Summary of the impact

This case study describes how Prof Cecilia Essau's research into emotional and behavioural problems in children and adolescents has been of benefit to children and has helped parents and schools to provide them with better support. Essau has worked with a children's charity to use her externally funded research to contribute to public understanding through providing presentations and skills training and to underpin the development and implementation of an anxiety prevention programme, Super Skills for Life (SSL), which has had a demonstrable benefit on children's wellbeing. In addition, Essau's research has been of value in informing the development of DSM-5, in introducing a specifier to the diagnosis of conduct disorder using callous-unemotional traits, and in refining the diagnosis of somatic symptom disorder. It has also contributed to policies and interventions internationally.

Underpinning research

The research underpinning this case study involves both fundamental and applied research into anxiety, somatic symptoms and conduct disorders. Essau's (Professor, 2004 to date) research has demonstrated that anxiety disorders are among the most common mental health problems in children and adolescents in both community and clinical settings (Essau, 2005) and are often associated with significant distress and difficulties in personal, family, school, and social functioning. Anxiety disorders frequently co-occur (in more than 60% of cases) with other disorders, in particular depression and substance use disorder (Essau, 2007a, 2008; Essau et al., 2010). This research shows that the presence of comorbid disorders not only increases the level of psychological distress experienced but also the frequency with which mental health services are used. Some of the most consistently identified risk factors for anxiety disorders include daily hassles (e.g., school stress) and major life stress (e.g., changing from primary to secondary schools), cognitive dysfunction, low self-esteem, and parental psychopathology (Essau, 2008).

Despite the existence of effective interventions for childhood anxiety, fewer than 20% of children and adolescents in need of mental health services receive support (Essau, 2005). Treatments are typically carried out in outpatient settings with almost half of the adolescents seeking help from school psychologists. When left untreated, childhood anxiety tends to become chronic and can be associated with other negative outcomes (Essau, 2005). Cognitive behavioural therapy (CBT) is the treatment of choice, and has been established as an efficacious treatment for child anxiety. However, existing CBT-based programmes tend to produce variable outcomes and are associated with high attrition and moderate remission rates (Essau et al., 2012). There is, therefore, a need to refine existing treatment strategies through a wider integration of CBT techniques (e.g. video- feedback).

Essau's research on the Inventory of Callous-Unemotional (CU) Traits indicated three dimensions of behaviour (Essau, Sasagawa, & Frick, 2006): callousness (i.e., a lack of empathy, guilt, and remorse for misdeeds), uncaring (i.e., a lack of caring about one's performance in tasks and for the feelings of other people), and unemotional (i.e., an absence of emotional expression). CU traits are associated with severe conduct problems, antisocial behaviour and psychosocial impairment (Essau et al., 2006). The presence of CU traits also designates an important subgroup of antisocial youth.

Essau's research on somatoform disorders has indicated that a third of adolescents, diagnosed as such, continued to have the same disorders when re-interviewed about 15 months later. In other adolescents, the original somatoform disorder had been replaced with, for example, depression and substance abuse (Essau, 2007b). The adolescents with somatoform disorders were significantly more impaired in their interpersonal relationships, psychopathology, and leisure-time activities, compared to those in a control sample (i.e., who had never met criteria for any psychiatric disorders). Furthermore, Essau (2007b) demonstrated a strong association between health status and total somatic symptom scores.

References to the research

Indicators of Quality:
These indicative seven outputs have been cited a total of 220 times (SCOPUS). Since joining this UoA in May 2004 as a Professor of Developmental Psychopathology, Essau has published 28 articles which have been cited 350 times. Essau's research has benefited from funding from a range of sources, both from the UK and internationally (total grant income £136,826) such as the Higher Education Commission in Pakistan and the British Council; The Education, Children's and Cultural Services Directorate of the London Borough of Richmond upon Thames; American Psychiatric Association; Japan Society for the Promotion of Science. This research has benefitted from a number of international collaborations. (1) Essau et al. (2006) is in collaboration with the Waseda University (Japan) and the University of New Orleans (USA). (2) Essau et al. (2010) is in collaboration with Oregon Research Institute (USA) and Mejiro University (Japan). This research was funded by the National Institute of Mental Health awards MH40501 and MH50522 (Dr Lewinsohn). (3) Essau et al. (2012) is in collaboration with University of Bremen (Germany), Mejiro University (Japan), and Virginia Tech (USA). This research was funded by the Dr. Karl-Wilder Stiftung, Germany (Dr Essau). (4) Essau (2005, 2007a, 2007b) were funded by the German Research Council (Deutsche Forschungsgemeinschaft: PE 271/5-3 [Petermann, University of Bremen & Essau]).

Details of the impact

The underpinning research has had a significant impact through (1) its direct use by Essau in supporting the work of the Catholic Children's Society-Westminster (CCSW) to provide training for their staff and to develop an intervention programme, (2) contribution to the DSM-5, and (3) through its utilisation by international research councils and researchers internationally.

Essau was approached by the CCSW in late 2009 to develop a school-based intervention programme to prepare children for the transition of primary to secondary school. This resulted in a long-term partnership during which Essau developed Continuing Professional Development (CPD) for CCSW staff and designed and implemented an anxiety prevention programme for school children.

1. Contribution to public understanding and skills through presentations and training, and the development Super Skills for Life, an anxiety preventing programme for children:

Essau's research underpinned the CPD that she developed and provided for approximately 40 staff of the CCSW (February and July 2010). Underpinned by Essau, 2005, 2007a, 2008, the CPD initially focused on developing knowledge of the frequency of anxiety disorders in children and the risk factors and comorbid patterns, as well as mental health service utilisation. The CPD then focused on CBT-based intervention for childhood anxiety (e.g., effectiveness of CBT-based intervention in reducing anxiety disorders symptoms in children; factors that moderate the intervention outcome) which was underpinned by Essau et al. (2012). This CPD has increased staff skills, knowledge and experience, and as such it has enabled CCSW (a) to offer an increased range of solutions to a variety of problems, including emotional and behavioural problems among children; (b) to reduce costs and enable a wider reach; and (c) to increase capacity to deliver training. This CPD complements the work of CCSW, which provides a counselling service in over 30 schools in 11 London boroughs [1].

Essau contributed to the development of a survey of approximately 220 head teachers to establish relevant training needs. Essau was a partner in a successful bid that the CCSW won from a London borough which supported the development of Super Skills for Life (SSL; Essau & Ollendick, 2013) an evidence-based prevention programme to help children cope with anxiety- provoking situations and to counteract anxiety disorders. The SSL has three key features, each underpinned by Essau's research. Firstly, it focuses on children at Key Stage 2 to provide invaluable support as they approach the often-difficult transition to secondary school. This feature is underpinned by the finding that stressful life events are associated with emotional problems (Essau, 2007a). Secondly, it was designed for delivery in a group format in schools in order to maximize access, prevent anxiety disorders (Essau et al., 2012), and help to reduce stigmatization. This feature is based on the low utilisation rate of mental health services among adolescents with anxiety disorders (Essau, 2005). Thirdly, SSL teaches children generic skills (e.g. social skills, cognitive restructuring) that help to promote psychological wellbeing. This feature is underpinned by the finding that cognitive dysfunction is linked with emotional problems (Essau et al., 2012). Finally, SSL also includes three group sessions for parents, which are conducted at separate times from the child sessions. These sessions provided parents the opportunity to learn about the SSL programme and to discuss parenting and reinforcement strategies such as praise for facing feared situations. This feature is underpinned by the finding that parent's participation in the CBT plays an important role in children's therapeutic outcome (Essau et al., 2012). Before delivering the SSL, Essau conducted a workshop for selected teachers from the participating schools (Autumn 2011) in order to develop their understanding of childhood anxiety and to explain the basic components of SSL.

The SSL programme was delivered in 12 London primary schools, reaching 190 children and 24 teachers (between September 2011 - October 2012). Results showed that anxiety symptoms were significantly reduced at post-test and follow-up assessments. SSL also had a positive effect on hyperactivity, conduct, and peer problems although it took longer for these effects to occur. Behavioural indicators of anxiety during the 2-minute speech task decreased, indicating that the independent raters noticed behavioural change in the children from pre-treatment to follow-up [2]. The programme has been endorsed by teachers [3, 4] and parents [5, 6]. As schools continue to deliver the SSL, the reach and significance of SSL's impact continues to expand. Following a visit by Essau to the Fatima Jinnah Women's University, in Rawalpindi, Pakistan, the SSL has been adopted by a team for delivery in Spring 2014 [7]. SSL has also been adopted as the first choice of treatment for children with an anxiety disorder at the Psychiatry and Mental Health Department of Centro Hospitalar do Algarve - Portimão, a unit with which Essau has had links since 2005.

In addition to the impacts that Essau has achieved through partnerships which she has developed, her work has also been a resource for others, and has had an impact in two areas (1) through its contribution to DSM-5, and (2) through its contribution to the development of policies and interventions on adolescent behaviour internationally.

2. Contribution to DSM-5
Essau's research has contributed to two new features of the fifth edition of the key international reference work — the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Firstly, supported by Essau's research in callous-unemotional traits (CU; Essau et al., 2006), the DSM-5 has integrated CU traits into its criteria for the diagnosis of conduct disorder by including the specifier "With Limited Prosocial Emotions". This specifier applies to individuals whose behaviour pattern is characterized by a callous and unemotional interpersonal style across multiple settings/relationships. Secondly, supported by Essau's work on somatoform disorders, the DSM-5 section on somatic symptom disorders has moved away from "medically unexplained" symptoms as the core diagnostic feature to "any severely distressing somatic symptoms".[8]

3. Contribution to policies and interventions on adolescent behaviour internationally.
Essau's work has been of practical benefit internationally. For example, a South African Medical Research Council report on adolescents' behaviours (Morojele et al., 2013) draws on Essau et al. (2010) in order to understand gender differences in behavioural problems [9]. Two additional international interventions draw specifically on Essau's research: (1) Calear et al. (2013; Australia National University) reports a trial involving 30 schools with approximately 1500 students and 60 teachers (`Y-Worri') [10]. The `Y-Worri' project drew on Essau (2008) to establish that anxiety disorders are amongst the most common psychological problems in adolescents which can lead to depression, and Essau (2005) to establish that low rates of help-seeking behaviour by adolescents underpin the importance of school-based anxiety intervention programmes. The Internet-version of `Y-Worri' (i.e., "e-couch Anxiety and Worry module") is part of the e-hub Online Self-help Programmes for Mental Health, which can be accessed, free of charge, from anywhere and has over 3000 registered users. (2) Stephan et al. (2012; USA) draws on Essau (2005) to argue for the need to enable evidence-based practice to be more accessible in school mental health (SMH) programmes [11]. One hundred clinicians participate formally in the SMH programme to deliver empirically supported interventions to students in general, and special education programmes, and it is estimated that more than 5000 students are benefitting (Weist: personal communication).

Sources to corroborate the impact

5.1. Contribution to public understanding and skills through presentations and training

[1] Testimonial: CEO, Catholic Children Society - Westminster (CCSW; http://www.cathchild.org.uk/).

5.2. Developing Super Skills for Life, an anxiety preventing programme for children

[2] An evaluation of the SSL is provided: Essau et al. (manuscript in review), Integrating video- feedback and cognitive preparation in a cognitive-behaviour therapy in the treatment of childhood anxiety.

[3] [4] Feedback from a teacher and a Special Educational Needs Co-ordinator (SENCO) Communications from two contacts at two primary schools (a SENCO and a Deputy Head Teacher) are provided. They give information on the positive impact that SSL has on children's targeted behaviour, and in enhancing teacher's knowledge of childhood anxiety.

[5] [6] Feedback from parents of children
Communications from the parents of two children who participated in the SSL are provided. They provide information about how the SSL has helped their children to increase their self-confidence and social skills, as well as to cope with anxiety-provoking situations. Parents also described the SSL as a powerful tool to support their children outside school.

[7] The partnership with the Fatima Jinnah Women University in Pakistan is described in the following British Council Pakistan posting:
http://ihe-pakistan.blogspot.co.uk/2012/05/treating-anxiety-among-adolescents-in.html

5.3. Contribution to DSM-5

[8] ADHD and Disruptive Behavior Disorders: Prof Paul Frick, University of New Orleans, USA.

5.4. Contribution to policies and interventions internationally

[9] Morojele, N., Myers, B., Townsend, L., Lombard, C., Plüddemann, A., Carney, T., Petersen Williams, P., Padayachee, T., Nel, E. & Nkosi, S. (2013). Survey on Substance Use, Risk Behaviour and Mental Health among Grade 8-10 Learners in Western Cape Provincial Schools, 2011. Cape Town: South African Medical Research Council. Retrieved from http://www.mrc.ac.za/adarg/SurveySubstanceUseRiskBehaviours8-10LearnersWCprovince%202011.pdf

[10] Calear, A.L., Christensen, J., Griffiths, K.M. and Mackinnon, A. (2013). The Y-Worri Project: study protocol for a randomised controlled trial. Trials,14:76. Doi:10.1186/1745-6215-14- 76. http://www.trialsjournal.com/content/14/1/76

[11] Stephan, S., Westin, A., Lever, N., Medoff, D., Youngstrom, E., & Weist, M. (2012). Do school- based clinicians' knowledge and use of common elements correlate with better treatment quality? School Mental Health, 4, 170-180. DOI 10.1007/s12310-012-9079-8