Abstract
In Lebanon, approximately one in four adolescents suffers from a psychiatric disorder. Alarmingly, 94% of adolescents with a mental disorder have not sought any treatment. This study assessed the effectiveness of an evidence-based school-based universal mental health intervention (the FRIENDS program) in reducing depression and anxiety symptoms in middle school students in Lebanon. A total of 280 6th graders aged 11–13 years were recruited from 10 schools in Beirut. Schools were matched on size and tuition and randomly assigned to intervention or control groups. The FRIENDS program was translated into Arabic, adapted, and then implemented by trained mental health professionals during 10 classroom sessions over 3 months. We assessed sociodemographic and relevant psychological symptoms by self-report, using the Scale for Childhood Anxiety and Related Disorders (SCARED), Mood and Feelings Questionnaire (MFQ), and Strengths and Difficulties Questionnaire (SDQ), at baseline. We re-administered these scales at 3 months post-intervention. There was a significant time × group interaction for the SDQ emotional score (p = 0.011) and total MFQ score (p = 0.039) indicating significant improvement in depressive and emotional symptoms in the intervention group. Subgroup analysis by gender showed a significant time × group interaction for the total SCARED score (p = 0.025) in females but not in males (p = 0.137), consistent with a reduction of anxiety symptoms in this stratum of the intervention group as compared with the control group. The FRIENDS program was effective in reducing general emotional and depressive symptoms among middle school students in this Lebanese study population. This intervention provides an opportunity for promoting mental health in Lebanese schools and reducing the treatment gap in mental health care.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Ahlen, J., Breitholtz, E., Barrett, P. M., & Gallegos, J. (2012). School-based prevention of anxiety and depression: A pilot study in Sweden. Advances in School Mental Health Promotion, 5, 246–257. https://doi.org/10.1080/1754730X.2012.730352.
Almaqrami, M. H., & Shuwail, A. Y. (2004). Validity of the self-report version of the strengths and difficulties questionnaire in Yemen. Saudi Medical Journal, 25, 592–601.
Barrett, P., & Turner, C. (2001). Prevention of anxiety symptoms in primary school children: Preliminary results from a universal school-based trial. The British Journal of Clinical Psychology, 40, 399–410. https://doi.org/10.1348/014466501163887.
Barrett, P. M., Moore, A. F., & Sonderegger, R. (2000). The FRIENDS program for young former-Yugoslavian refugees in Australia: A pilot study. Behaviour Change, 17, 124–133. https://doi.org/10.1375/bech.17.3.124.
Barrett, P. M., Farrell, L. J., Ollendick, T. H., & Dadds, M. (2006). Long-term outcomes of an Australian universal prevention trial of anxiety and depression symptoms in children and youth: An evaluation of the friends program. Journal of Clinical Child and Adolescent Psychology, 35, 403–411. https://doi.org/10.1207/s15374424jccp3503_5.
BBC (2018 ). Lebanon profile - Timeline. Retrieved from https://www.bbc.com/news/world-middle-east-14649284
Beck, J. S. (2011). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford Press.
Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S. M. (1997). The screen for child anxiety related emotional disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 545–553. https://doi.org/10.1097/00004583-199704000-00018.
Central Administration of Statistics, L. (2012). Education in Lebanon. Retrieved from http://www.cas.gov.lb/images/PDFs/SIF/CAS_Education_In_Lebanon_SIF3.pdf.
Chan, K. S., Bird, C. E., Weiss, R., Duan, N., Meredith, L. S., & Sherbourne, C. D. (2006). Does patient–provider gender concordance affect mental health care received by primary care patients with major depression? Women's Health Issues, 16, 122–132. https://doi.org/10.1016/j.whi.2006.03.003.
Charara, R., Forouzanfar, M., Naghavi, M., Moradi-Lakeh, M., Afshin, A., Vos, T., . . . Mokdad, A. H. (2017). The burden of mental disorders in the eastern Mediterranean region, 1990-2013. PLoS One, 12, e0169575. https://doi.org/10.1371/journal.pone.0169575.
Costello, E. J., & Angold, A. (1988). Scales to assess child and adolescent depression: Checklists, screens, and nets. Journal of the American Academy of Child & Adolescent Psychiatry, 27, 726–737. https://doi.org/10.1097/00004583-198811000-00011.
Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M., & Laurens, K. R. (1997). Prevention and early intervention for anxiety disorders: A controlled trial. Journal of Consulting and Clinical Psychology, 65, 627. https://doi.org/10.1037//0022-006x.65.4.627.
Davydov, D. M., Stewart, R., Ritchie, K., & Chaudieu, I. (2010). Resilience and mental health. Clinical Psychology Review, 30, 479–495. https://doi.org/10.1016/j.cpr.2010.03.003.
Dray, J., Bowman, J., Campbell, E., Freund, M., Wolfenden, L., Hodder, R. K., . . . Wiggers, J. (2017). Systematic review of universal resilience-focused interventions targeting child and adolescent mental health in the school setting. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 813–824. https://doi.org/10.1016/j.jaac.2017.07.780.
Erskine, H. E., Moffitt, T. E., Copeland, W. E., Costello, E. J., Ferrari, A. J., Patton, G., . . . Scott, J. G. (2015). A heavy burden on young minds: The global burden of mental and substance use disorders in children and youth. Psychological Medicine, 45, 1551–1563. https://doi.org/10.1017/S0033291714002888.
Fisak, B. J., Richard, D., & Mann, A. (2011). The prevention of child and adolescent anxiety: A meta-analytic review. Prevention Science, 12, 255–268. https://doi.org/10.1007/s11121-011-0210-0.
Gallegos, J., Rodríguez, A., Gómez, G., Rabelo, M., & Gutiérrez, M. F. (2012). The FRIENDS for life program for Mexican girls living in an orphanage: A pilot study. Behaviour Change, 29, 1–14. https://doi.org/10.1017/bec.2012.8.
Goodman, R. (1997). The strengths and difficulties questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581–586. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x.
Goodman, R., Ford, T., Simmons, H., Gatward, R., & Meltzer, H. (2018). Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. British Journal of Psychiatry, 177, 534–539. https://doi.org/10.1192/bjp.177.6.534.
Grills, A. E., & Ollendick, T. H. (2003). Multiple informant agreement and the anxiety disorders interview schedule for parents and children. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 30–40. https://doi.org/10.1097/00004583-200301000-00008.
Hanley, J. A., Negassa, A., Edwardes, M. D. D., & Forrester, J. E. (2003). Statistical analysis of correlated data using generalized estimating equations: An orientation. American Journal of Epidemiology, 157, 364–375. https://doi.org/10.1093/aje/kwf215.
Hariz, N., Bawab, S., Atwi, M., Tavitian, L., Zeinoun, P., Khani, M., ... & Maalouf, F. T. (2013). Reliability and validity of the Arabic Screen for Child Anxiety Related Emotional Disorders (SCARED) in a clinical sample. Psychiatry Research, 209, 222–228. https://doi.org/10.1016/j.psychres.2012.12.002.
Herrman, H., Stewart, D. E., Diaz-Granados, N., Berger, E. L., Jackson, B., & Yuen, T. (2011). What is resilience? The Canadian Journal of Psychiatry, 56, 258–265. https://doi.org/10.1177/070674371105600504.
Iizuka, C. A., Barrett, P. M., Gillies, R., Cook, C. R., & Miller, D. (2014). The FRIENDS emotional health program for minority groups at risk. The Journal of School Health, 84, 124–132. https://doi.org/10.1111/josh.12127.
Jackson, C., Geddes, R., Haw, S., & Frank, J. (2012). Interventions to prevent substance use and risky sexual behaviour in young people: A systematic review. Addiction, 107, 733–747.
Jamal, F., Fletcher, A., Harden, A., Wells, H., Thomas, J., & Bonell, C. (2013). The school environment and student health: A systematic review and meta-ethnography of qualitative research. BMC Public Health, 13, 798.
Jansen, M., Bodden, D. H. M., Muris, P., van Doorn, M., & Granic, I. (2017). Measuring anxiety in children: The importance of separate mother and father reports. Child & Youth Care Forum, 46, 643–659. https://doi.org/10.1007/s10566-017-9402-5.
Karam, E. G., Fayyad, J., Nasser Karam, A., Cordahi Tabet, C., Melhem, N., Mneimneh, Z., & Dimassi, H. (2008). Effectiveness and specificity of a classroom-based group intervention in children and adolescents exposed to war in Lebanon. World psychiatry : official journal of the World Psychiatric Association (WPA), 7, 103–109. https://doi.org/10.1002/j.2051-5545.2008.tb00170.x.
Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among US children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159, 1548–1555. https://doi.org/10.1176/appi.ajp.159.9.1548.
Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., . . . Rahman, A. (2011). Child and adolescent mental health worldwide: Evidence for action. Lancet, 378(9801), 1515–1525. https://doi.org/10.1016/s0140-6736(11)60827-1.
Lendrum, A., Humphrey, N., & Wigelsworth, M. (2013). Social and emotional aspects of learning (SEAL) for secondary schools: Implementation difficulties and their implications for school-based mental health promotion. Child and Adolescent Mental Health, 18(3), 158–164. https://doi.org/10.1111/camh.12006.
Lipsitz, S. R., Molenberghs, G., Fitzmaurice, G. M., & Ibrahim, J. (2000). GEE with Gaussian estimation of the correlations when data are incomplete. Biometrics, 56, 528–536. https://doi.org/10.1111/j.0006-341X.2000.00528.x.
Lock, S., & Barrett, P. M. (2003). A longitudinal study of developmental differences in universal preventive intervention for child anxiety. Behaviour Change, 20, 183–199. https://doi.org/10.1375/bech.20.4.183.29383.
Lowry-Webster, H. M., Barrett, P. M., & Lock, S. (2012). A universal prevention trial of anxiety symptomology during childhood: Results at 1-year follow-up. Behaviour Change, 20, 25–43. https://doi.org/10.1375/bech.20.1.25.24843.
Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543–562. https://doi.org/10.1111/1467-8624.00164.
Maalouf, F. T., Ghandour, L. A., Halabi, F., Zeinoun, P., Shehab, A. A., & Tavitian, L. (2016). Psychiatric disorders among adolescents from Lebanon: Prevalence, correlates, and treatment gap. Social Psychiatry and Psychiatric Epidemiology, 51, 1105–1116. https://doi.org/10.1007/s00127-016-1241-4.
Maalouf, F. T., Alamiri, B., Atweh, S., Becker, A. E., Cheour, M., Darwish, H., Ghandour, L. A., Ghuloum, S., Hamze, M., Karam, E., Khoury, B., Khoury, S. J., Mokdad, A., Meho, L. I., Okasha, T., Reed, G. M., Sbaity, E., Zeinoun, P., & Akl, E. A. (2019). Mental health research in the Arab region: Challenges and call for action. Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(19)30124-5.
Maggin, D. M., & Johnson, A. H. (2014). A meta-analytic evaluation of the FRIENDS program for preventing anxiety in student populations. Education and Treatment of Children, 37, 277–306. https://doi.org/10.1353/etc.2014.0018.
Matsumoto, Y., & Shimizu, E. (2016). The FRIENDS cognitive behavioral program in Japanese schools: An examination of the treatment effects. School Psychology International, 37, 397–409. https://doi.org/10.1177/0143034316649639.
Murphy, J. M., Abel, M. R., Hoover, S., Jellinek, M., & Fazel, M. (2017). Scope, scale, and dose of the world’s largest school-based mental health programs. Harv Rev Psychiatry, 25, 218–228. https://doi.org/10.1097/hrp.0000000000000149.
Pahl, K. M., & Barrett, P. M. (2010). Preventing anxiety and promoting social and emotional strength in preschool children: A universal evaluation of the Fun FRIENDS program. Advances in School Mental Health Promotion, 3, 14–25. https://doi.org/10.1080/1754730X.2010.9715683.
Patel, V., Kieling, C., Maulik, P. K., & Divan, G. (2013). Improving access to care for children with mental disorders: A global perspective. Archives of Disease in Childhood, 98, 323–327.
Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56, 345–365. https://doi.org/10.1111/jcpp.12381.
Rahman, A., Hamoda, H. M., Rahimi-Movaghar, A., Khan, M., & Saeed, K. (2019). Mental health services for youth in the eastern Mediterranean region: Challenges and opportunities (editorial). Eastern Mediterranean Health Journal, 25, 80–81. https://doi.org/10.26719/2019.25.2.80.
Rose, H., Miller, L., & Martinez, Y. (2009). “Friends for life”: The results of a resilience-building, anxiety-prevention program in a Canadian elementary school. Professional School Counseling, 12, 400–407. https://doi.org/10.1177/2156759X0901200612.
Shortt, A. L., Barrett, P. M., & Fox, T. L. (2001). Evaluating the FRIENDS program: A cognitive-behavioral group treatment for anxious children and their parents. Journal of Clinical Child Psychology, 30, 525–535. https://doi.org/10.1207/S15374424JCCP3004_09.
Suldo, S. M. (2016). Promoting student happiness: Positive psychology interventions in schools. New York: Guilford Publications.
Tavitian, L., Atwi, M., Bawab, S., Hariz, N., Zeinoun, P., Khani, M., & Maalouf, F. T. (2014). The Arabic Mood and Feelings Questionnaire: psychometrics and validity in a clinical sample. Child Psychiatry and Human Development, 45, 361–368. https://doi.org/10.1007/s10578-013-0406-6.
UNHCR. (2018). Situation Syria regional refugee response. Retrieved from: https://data2.unhcr.org/en/situations/syria/location/71
Wang, M. (2014). Generalized estimating equations in longitudinal data analysis: A review and recent developments (Vol. 2014).
Warnick, E. M., Bracken, M. B., & Kasl, S. (2008). Screening efficiency of the Child Behavior Checklist and Strengths and Difficulties Questionnaire: A systematic review. Child and Adolescent Mental Health, 13, 140–147. https://doi.org/10.1111/j.1475-3588.2007.00461.x.
World Health Organization (WHO). (2004). Prevention of mental disorders: Effective interventions and policy options. Geneva: Author.
Zeger, S. L., Liang, K.-Y., & Albert, P. S. (1988). Models for longitudinal data: A generalized estimating equation approach. Biometrics, 44, 1049–1060. https://doi.org/10.2307/2531734.
Funding
This study was funded by the Harvard Medical School Center for Global Health Delivery–Dubai.
Author information
Authors and Affiliations
Corresponding authors
Ethics declarations
Conflict of Interest
Dr. Anne Becker reports the following: “Routledge/Taylor & Francis; anticipated royalties for edited book on global mental health training under contract.” Dr. Paula Barrett is the Director of Friends Resilience Pty Ltd. and Author of Friends Programs. She reports the following: “The research is Not for Profit based so no conflict of interest exists.” All other authors declare no conflict of interest.
Ethical Approval
The study was approved by the Institutional Review Boards of the American University of Beirut (AUB) and the Harvard Medical School (HMS). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (AUB IRB Protocol ID: PSY.FM.11 and HMS IRB Protocol ID: IRB17-0374) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed Consent
Participants’ parents signed written informed consent and participants signed written assent.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic Supplementary Material
ESM 1
(DOCX 26 kb)
Rights and permissions
About this article
Cite this article
Maalouf, F.T., Alrojolah, L., Ghandour, L. et al. Building Emotional Resilience in Youth in Lebanon: a School-Based Randomized Controlled Trial of the FRIENDS Intervention. Prev Sci 21, 650–660 (2020). https://doi.org/10.1007/s11121-020-01123-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11121-020-01123-5