Iván Fernández-Martínez, Alexandra Morales, José P. Espada, Cecilia A.

Essau, and Mireia Orgilés

ISSN 0214 - 9915 CODEN PSOTEG

Psicothema 2019, Vol. 31, No. 3, 298-304
Copyright © 2019 Psicothema
doi: 10.7334/psicothema2018.336 www.psicothema.com

Effectiveness of the program Super Skills For Life in reducing symptoms

of anxiety and depression in young Spanish children
Iván Fernández-Martínez1, Alexandra Morales1, José P. Espada1, Cecilia A. Essau2, and Mireia Orgilés1
1
Universidad Miguel Hernández and 2 University of Roehampton

Abstract Resumen
Background: Super Skills for Life (SSL) is a transdiagnostic Eficacia del programa Super Skills For Life para reducir síntomas de
prevention program designed for children with anxiety and depressive ansiedad y depresión en niños pequeños españoles. Antecedentes: Super
symptoms based on cognitive-behavioral therapy. This study is a trial Skills for Life (SSL) es un programa de prevención transdiagnóstico
of the efficacy of the SSL program to reduce anxiety and depression diseñado para niños con síntomas de ansiedad y depresión basado en la
symptoms in a representative sample of Spanish children aged 6 to 8. terapia cognitivo-conductual. Se presenta un ensayo sobre la eficacia del
Method: This cluster randomized controlled trial involved 123 Spanish- programa SSL en la reducción de los síntomas de ansiedad y depresión
speaking children recruited from 10 schools. Schools were the unit of en una muestra representativa de niños españoles de 6 a 8 años de edad.
randomization, and were randomly assigned to one of two experimental Método: este ensayo controlado aleatorio grupal incluyó a 123 niños
conditions: intervention group (SSL) and waiting list control (WLC) group. hispanohablantes reclutados en 10 colegios. Los colegios fueron la
Assessments were conducted before and after the 8-week intervention. unidad de aleatorización, siendo asignados aleatoriamente a una de dos
Results: Generalized estimating equations showed that, compared with condiciones experimentales: grupo de intervención (SSL) y grupo control
WLC, the intervention significantly reduced emotional symptoms of (GC). Las evaluaciones se realizaron antes y después de la intervención
anxiety and depression. Significant improvements were also found in de 8 semanas. Resultados: las ecuaciones de estimación generalizadas
specific symptoms of anxiety disorders, and in the interference of anxiety mostraron que, en comparación con el GC, la intervención redujo
in the child´s life. Conclusions: The findings of this study provide initial significativamente los síntomas emocionales de ansiedad y depresión.
support for the immediate effects of SSL, suggesting that it is a valuable También se encontraron mejorías significativas en síntomas de trastornos
resource for the early reduction of anxiety and depressive symptoms in de ansiedad específicos y en la interferencia de la ansiedad en la vida
young Spanish-speaking children. del niño. Conclusiones: los resultados de este estudio proporcionan
Keywords: Anxiety, depression, children, Super Skills for Life, apoyo inicial a los efectos inmediatos de SSL, sugiriendo que es un
transdiagnostic program. recurso valioso para la reducción temprana de los síntomas de ansiedad y
depresión en niños pequeños hispanohablantes.
Palabras clave: ansiedad, depresión, niños, Super Skills for Life, programa
transdiagnóstico.

Anxiety disorders are among the most frequent mental also considerable (Canals, Voltas, Hernández-Martínez, Cosi, &
disorders and those with the earliest onset among children and Arija, 2019; Romero et al., 2010). Anxiety and depression disorders
tend to co-occur with depression, both disorders are associated also appear to interact negatively, as the presence of one may
with severe psychosocial impairment (Beesdo, Knappe, & Pine, increase the symptomatology of the other (Garber & Weersing,
2009; Merikangas et al., 2010; Polanczyk, Salum, Sugaya, Caye, 2010). Thus, the comorbidity of both conditions is associated with
& Rohde, 2015). International literature reported high rates of more severe symptoms, poorer treatment response, and increased
comorbidity between childhood anxiety and depression disorders, risk of other problems (e.g., physical problems, suicide attempts)
ranging between 10-50% (see Garber & Weersing, 2010). In compared to having either an anxiety or a depressive disorder
Spanish children, the estimated levels of comorbidity of anxiety (Melton, Croarkin, Strawn, & McClintock, 2016). Additionally,
symptoms of these internalizing problems appear to be present
and depressive symptoms (20-80%) and disorders (12-17%) are
and stable in children aged 2–11 years, with symptoms increasing
in late childhood if not treated (Sterba, Prinstein, & Cox, 2007).
Received: December 9, 2018 • Accepted: April 25, 2019 In this regard, the need for more research on prevention and early
Corresponding author: Iván Fernández-Martínez intervention programs for young children’s anxiety and depression
Facultad de Ciencias Sociosanitarias problems has been highlighted (e.g., Bayer & Beatson, 2013).
Universidad Miguel Hernández
03202 Elche (Spain) In this context and considering the supported efficacy of
e-mail: i.fernandez@umh.es cognitive-behavioral therapy (CBT) in treating childhood

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anxiety and depression (Hollon, Stewart, & Strunk, 2006), there have immediate positive effects on secondary outcome measures
has been an increasing interest in the development of CBT- such as interference of anxiety with children’s and parents’ life,
based transdiagnostic treatments addressing common factors hyperactivity, prosocial behavior, and conduct and peer problems.
of these comorbid disorders by applying a unified intervention Based on previous experience with SSL (Essau et al., 2014),
protocol (Clark & Taylor, 2009), and results have been promising it was hypothesized that in the short-term, there would probably
regarding their effectiveness (Bettis, Forehand, Sterba, Preacher, be effects on anxious symptoms, but not in the scores of other
& Compas, 2016; Craske, 2012; García-Escalera, Chorot, Valiente, secondary outcomes measured, as the original study reported either
Reales, & Sandín, 2016). A transdiagnostic perspective focuses no effects (e.g., anxiety-related interference, prosocial behavior) or
on the common mechanisms or processes underlying a range of that effects only occurred at follow-up (e.g., hyperactivity, peer
specific disorders that can be contributing to their development and conduct problems). Concerning symptoms of depression, this
or maintenance. Therefore, compared to specific-disorder CBT- outcome was not assessed in the original SSL study. However,
based treatments, those relying on a transdiagnostic CBT-based immediate effects were hypothesized in depression symptoms due
approach to anxiety and depressive disorders are designed to to the effectiveness shown by the transdiagnostic CBT protocols
target their commonalities (e.g., negative affectivity, negative in the pre-post reduction of anxiety and depressive symptoms, and
thoughts, interpretative and attentional biases, avoidance) through the commonalities and co-occurrence between the two conditions
a single protocol, thus allowing the treatment of participants with (e.g., Canals et al., 2019; García-Escalera et al., 2016; Melton et
anxiety and/or depression in the same intervention (Craske, 2012; al., 2016).
García-Escalera et al., 2016). This has been found to be an efficient
approach, with flexibility to incorporate effective disorder- Method
specific interventions, and easy to implement (Clark & Taylor,
2009; Craske, 2012). Therefore, the diagnostic commonalities of Participants
anxiety and depression and their shared risk factors could justify
a transdiagnostic approach to prevention, which may increase the A cluster randomized controlled trial design was used in this
efficiency of current disorder-specific preventive interventions study, with schools being the unit of randomization, assigned to
(Dozois, Seeds, & Collins, 2009). However, transdiagnostic either the SSL or WLC experimental conditions. The present
prevention protocols targeting children with symptoms of anxiety cluster randomized controlled trial was conducted in 2017. The
and depression are still scarce, and few are available to date study involved an incidental sample of 123 Spanish-speaking
(e.g., García-Escalera et al., 2016; Martinsen, Kendall, Stark, & children ranging in age from 6 to 8 years (M age = 6.89 years,
Neumer, 2016). SD = .79; 44.7% female) and their parents. Children were
A recent and promising CBT-based transdiagnostic protocol enrolled in first (44.7%), second (34.1%), and third year (21.2%)
is the Super Skills for Life (SSL) program (Essau & Ollendick, of primary school at 10 schools, and were selected based on
2013), developed for children with anxiety and depressive the responses of their parents to a battery of questionnaires,
symptoms. This targeted prevention program integrates social who voluntarily agreed to participate in the study. Participants
skills training, behavioral activation, and video-feedback with came from families with a medium-high socio-economic level,
cognitive preparation as part of the intervention for the first time and 98.4% were born in Spain. Out of the 12 schools invited to
(Essau et al., 2014). Thus, based on its authors, the main core participate, a total of 10 were enrolled in the study, all of them
principles of the program involve targeting common risk factors from urban areas of the province of Alicante, in the southeast of
of comorbid disorders following a transdiagnostic approach, Spain. Primary schools were selected based on their potential to
developing children’s skills to deal with anxiety situations based represent the socio-economic structure of the Spanish population,
on the principles of CBT, and improving their mood and self- with the participation of public, private, and state-assisted private
esteem following the principles of behavioral activation. The schools. The schools were randomly assigned to one of the two
program also aims to enhance the social competence of children experimental conditions: SSL (n = 5) or non-intervention WLC (n
through the learning of social skills, and their self-perception by = 5). A total of 67 children (M age = 6.88 years, SD = 0.80; 50.7%
using video-feedback with cognitive preparation. The original female) were in the SSL group, and 56 (M age = 6.88 years, SD =
study by Essau et al. (2014) provided preliminary support for the 0.78; 37.5% female) in the WLC group. Table 1 shows the baseline
SSL applied in a school setting, demonstrating positive effects sociodemographic characteristics of the participating children and
with Anglo-Saxon children aged 8-10 years with significant their parents by intervention condition.
anxiety problems, as well as a positive impact on other symptoms The inclusion criteria were that participants a) were between
such as peer problems, conduct problems, and hyperactivity. Since 6 and 8 years of age and Spanish-speaking, b) presented
the original study did not use a control condition, further research emotional symptoms based on scores equal to or greater than
is needed to determine the effectiveness of SSL to reduce the 4 on the emotional symptoms subscale of the Strengths and
targeted emotional problems in children. However, it appears to Difficulties Questionnaire-Parent version (SDQ-P; Goodman,
be a short and cost-effective program. 2001) categorized as borderline or abnormal, respectively, c) did
The present study aimed to examine for the first time the not receive psychological or psychiatric treatment; and d) did not
immediate effectiveness of the Spanish-adapted version of the present developmental problems or severe learning difficulties.
SSL in reducing anxiety and depressive symptoms in European
Spanish-speaking children, aged 6-8 years, selected based on high Instruments
scores on a measure of emotional symptoms (i.e., anxiety and
depression), compared with a waiting list control (WLC) group. The Due to self-reports tend to show good properties as of 8-9
secondary aim of this study was to evaluate whether the SSL may years of age (e.g., Rapee, 2018) and the linguistic and cognitive

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 Iván Fernández-Martínez, Alexandra Morales, José P. Espada, Cecilia A. Essau, and Mireia Orgilés

development level of young children may affect their accuracy, compulsive disorder, and generalized anxiety disorder), and an
the evaluation in this study relied on parent reports, who are overall measure of anxiety can be obtained by summing all the
reliable and frequent informants of child mental health symptoms item scores (score range: 0-114). Parents respond to items using a
(Melton et al., 2016). Thus, parent-report measures with adequate 4-point rating scale, ranging from 0 (never) to 3 (always). Higher
psychometric properties were selected, including the parent version scores indicate more severe symptoms. The Spanish version of
of some scales used in the original SSL study (e.g., SDQ-P) (Essau the SCAS-P showed good convergent and divergent validity, a
et al., 2014). high internal consistency coefficient (.91), and adequate test-retest
Mood and Feelings Questionnaire-Parent version (MFQ-P). reliability (Orgilés, Rodríguez-Menchón, Fernández-Martínez,
The MFQ-P (Angold et al., 1995) is a unidimensional 34-item Morales, & Espada, 2019). In the current study, the ordinal alpha
screening tool for depression in children and young people. For for total score was .79, ranging from .65 (obsessive compulsive)
each item, parents rate their children’s feelings and actions over to .82 (physical injury fears and generalized anxiety disorder) for
the previous 2 weeks on a 3-point Likert scale: 0 (not true), 1 the subscales.
(somewhat true), and 2 (true). The MFQ-P total score is obtained Child Anxiety Life Interference Scale-Parent report (CALIS-P).
by summing the scores of all items (score range: 0-68). Higher The CALIS-P (Lyneham et al., 2013) is a 16-item scale assessing
scores indicate more severe symptoms of depression. The scale interference and impact associated with child anxiety on the life
yielded good criterion validity, high internal consistency (α = .96), of children and their parents in several domains from the parents’
and test-retest reliability (Daviss et al., 2006). Cronbach’s α was point of view. Items are divided into three subscales: child at home,
.90 in this study. child outside home, and parent life. The CALIS-P total score is
Spence Children’s Anxiety Scale-Parent version (SCAS-P). obtained by summing all item scores (range: 0-64). Items are rated
The SCAS-P (Nauta et al., 2004) is a 38-item parent-report on a 5-point Likert scale from 0 (not at all) to 4 (a great deal). The
questionnaire assessing the severity with which symptoms of original version of the scale by Lyneham et al. (2013) showed good
several anxiety disorders are present in children aged 6–18 validity and test-retest reliability, and high internal consistency for
years. It comprises six subscales (panic attack and agoraphobia, mother (α = .90) and father reports (α = .88). In the current study,
separation anxiety, physical injury fears, social anxiety, obsessive Cronbach’s α was .91 for total score and ranging from .75 (child at
home) to .87 (parent life) for the subscales.
Table 1 Strengths and Difficulties Questionnaire-Parent version
Sociodemographic characteristics of baseline participating children and their (SDQ-P). The SDQ-P (Goodman, 2001) is a 25-item questionnaire
parents by intervention condition assessing emotional and behavioral difficulties and positive
Control
behaviors in children aged 3-16 years, and includes the five
SSL group Total following subscales: emotional symptoms (i.e., anxiety and
Characteristics group p value
(n = 67) (N = 123)
(n = 56) depressive symptoms), conduct problems, hyperactivity/
inattention, peer relationship problems, and prosocial behavior.
Children
Items are rated from 0 (not true) to 2 (certainly true), with total
Female, N (%) 34 (50.7) 21 (37.5) 55 (44.7) .14 scores in each subscale ranging from 0 to 10. The total difficulties
Mean age (SD), years 6.88 (.80) 6.88 (.78) 6.89 (.79) .80 score (range: 0-40) is obtained by summing all subscales scores
6 years 25 (37.3) 21 (37.5) 46 (37.4) excluding the prosocial behavior subscale. Higher scores indicate
7 years 23 (34.3) 21 (37.5) 44 (35.8) .89 more difficulties; the prosocial subscale is interpreted inversely.
8 years 19 (28.4) 14 (25) 33 (26.8) Psychometric properties and internal consistency (Cronbach’s
School grade alpha was .76 for the total score) of the Spanish SDQ-P were
1 27 (40.3) 28 (50) 55 (44.7) good (Rodríguez-Hernández et al., 2012). In the current study, the
2 25 (37.3) 17 (30.4) 42 (34.1) .55 ordinal alpha for the total score was .74, ranging from .77 (conduct
3 15 (22.4) 11 (19.6) 26 (21.2) problems) to .87 (peer problems) for the subscales, except for
emotional symptoms (α = .54).
Nationality
Spanish 65 (97) 56 (100) 121 (98.4)
Other 2 (3) 0 (0) 2 (1.6)
.19 Procedure

Mean number (SD) of siblings 1 (.81) .91 (.61) .96 (.72) .50 The present study was approved by the Ethics Committee of
Parents
(Miguel Hernández) University (Spain). The schools distributed
a letter to parents with information about the study; parents (i.e.,
Female, N (%) 54 (80.6) 43 (76.8) 97 (78.9) .60
only mother or father) who were interested accessed an online
Family situation form where they completed the first evaluation of the study, which
Married 57 (85.1) 49 (87.5) 106 (86.2) in turn served as screening. Parents were previously informed of
Separated or divorced 9 (13.4) 7 (12.5) 16 (13) .64 the objectives and procedure of the research, the confidentiality
Single 1 (1.5) 0 (0) 1 (0.8) of their data, and that participation was voluntary. Children
Education
who met the inclusion criteria were selected and parents were
Primary education 16 (23.9) 7 (12.5) 23 (18.7)
informed via e-mail. Those parents whose children were assigned
Secondary education 12 (17.9) 26 (46.4) 38 (30.9) .003 to the intervention condition attended a meeting where the SSL
Higher education 39 (58.2) 23 (41.1) 62 (50.4) intervention was explained and parents provided their informed
consent. For both experimental conditions, fathers or mothers
Note: SSL = Super Skills for Life
who had completed the first assessment (pre-test) were asked

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to complete the online form again (post-test) after 8 weeks (i.e., within school. Cluster-randomized control trials are commonly
immediately after the eight-session SSL intervention). evaluated using GEE because it presents several advantages. GEE
The eight-session SSL program was implemented weekly, controls for correlations between responses when participants are
with one session per week, after school hours at participants’ clustered in centers, it increases the power of analyses in studies
schools as an extracurricular activity, and was facilitated by seven using small samples and a large number of repeated measures,
psychologists with a Master’s degree in Psychology, mostly in it estimates changes over time in main outcomes, and it allows
therapy with children and adolescents. The facilitators completed the use of incomplete data (e.g., follow-up assessments) without
an intensive 1-day SSL training at the authors’ institution, in excluding the participants from the analyses (El Rafihi-Ferreira,
which the objectives and contents of each session of SSL were Silvares, Asbahr, & Ollendick, 2018; Liang & Zeger, 1986).
thoroughly reviewed. In addition, weekly follow-up facilitator The effectiveness of the program was tested by comparing
meetings were held to resolve questions, deliver materials, both experimental conditions. Each variable was tested using
highlight important aspects of each session, and monitor the independent analyses. Individuals were the unit of analysis, while
adequacy of implementation. The facilitators also registered centers were the unit of randomization. Only cases including pre-
relevant data in each session (e.g., attendance, content covered), and post-test data were analyzed. Analyses were conducted using
which enabled verifying that the program was implemented as SPSS V25.
planned. The sessions were delivered to small groups of 4 to 6
children, with one facilitator per group. There was a total of 13 Results
groups, an average of 2.6 groups per school participating in the
intervention condition. Figure 1 illustrates the flow of participants during the trial.
Prior to conducting the current research, two bilingual Regarding external validity, there were no differences in age (p
psychologists at the authors’ institution translated the original SSL = .42) or gender (p = .50) between participants who were lost
program from English into European-Spanish. Subsequently, five to follow-up at post-test and those who provided the post-test
psychologists participated in an expert focus group in order to ensure evaluation data. Moreover, no differences were found in the main
an adequate cultural adaptation of the program. Additionally, the outcome variables, including scores on SCAS-P (p = .89), SDQ-P
program was pilot-tested with a focus group of six children aged (p = .47), CALIS-P (p = .35), and MFQ-P (p = .68) between
6-8 years old, participation was voluntary and parents gave their these groups. Regarding internal validity, statistically significant
informed consent. As a result, the original content and components differences were found in the retention rate of children at post-test
of the program were maintained, while slight modifications were between the SSL and WLC conditions (p = .03). The retention
made (e.g., names of characters, language expressions, examples, rate was higher for the intervention group (89.6%) compared to the
and pictures) in order to facilitate understanding and improve the WLC group (75%), as shown in Figure 1. However, differences in
adaptation to Spanish culture. the loss to follow-up rate between both conditions were not related
Intervention. The SSL program consists of eight weekly 45- to age, gender, or main outcome variables, including SCAS-P (p
minute sessions, which can be delivery in schools by experts. The = .82), SDQ-P (p = .40), CALIS-P (p = .10), and MFQ-P (p = .42)
sessions are designed for groups containing a maximum of 6 to 8 scores.
children. The intervention is provided through different activities On average, children’s attendance to SSL sessions was high (M
such as simple explanations of key concepts, readings, games, role- sessions attended = 7; SD = 1). Of the children who received the
playing, speech tasks, video-feedback with cognitive preparation, intervention, 82.1% (n = 55) attended 7 or 8 sessions (almost all or
and small group or individual exercises. The main components of all sessions).
this program are relaxation strategies, self-monitoring, behavioral At baseline, the experimental and control groups were
activation, cognitive reappraisal, emotional education, and training equivalent in terms of sociodemographic variables, except for
in social skills and problem solving. After each session, children parental level of study (X2 = 11.92, p < .01). In the SSL group,
are asked to do some homework to practice and reinforce what there was a higher percentage of parents with higher education
they learned in the session. A more detailed explanation of the than in the WLC group (58.2% vs. 41.1%); whereas in the WLC
program can be found in the original study (Essau et al., 2014). group there was a higher percentage of parents with secondary
education compared to the SSL group (46.4% vs. 17.9%) (Table
Data analysis 1). The two experimental conditions did not differ in the outcome
variables in the pre-test, except for emotional symptoms (t =
The baseline equivalence between the experimental and control 2.52, p = .01, d = .51), anxiety interference at home (t = 2, p =
groups was determined using t Student (quantitative variables) or .04; d = .40), and depressive symptomatology (t = 2.28, p =
crosstabulation (qualitative variables). Cohen’s (1988) effect size .02, d = .46). The children in the SSL group had higher scores
was estimated for statistically significant differences. Attrition on emotional symptoms (SDQ-P subscale), greater interference
was analyzed through logistic regression to identify the profile of anxiety at home (CALIS-P subscale), and greater depressive
of participants lost to follow-up in this study (i.e., those whose symptomatology (MFQ-P total score) than did those in the control
parents did not complete the post-test assessment when required) group. Although the effect size of these differences was moderate
from the SSL (n = 7) and WLC (n = 14) groups. Missing data at (Cohen, 1988), the variables were controlled for in the efficacy
post-test in this study was due to loss to follow-up, but not to other analysis of the intervention. Regarding anxiety scores (SCAS-P
factors (e.g., withdrawal). The effects of the SSL on the outcomes total score), moderated-to-elevated mean scores were reached in
were evaluated using generalized estimating equations (GEE) both experimental conditions, although slightly higher in the SSL
adjusting for baseline measures of the outcome, variables that group (p = .20). Table 2 shows the means and standard deviations
differed between conditions at baseline, age, gender, and clustering before and after the intervention by experimental condition.

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 Iván Fernández-Martínez, Alexandra Morales, José P. Espada, Cecilia A. Essau, and Mireia Orgilés

10 schools
randomly distributed to conditions

1,400 parents of children aged 6-8 were

invited to participate
The parents of 1,218 (87%) children did
not respond the screening survey to
identify those with emotional symptoms
182 participants’ parent completed the
screening survey (pre-test assessment)

123 children met the criteria to participate

and were included in the study

Received Super Skills for Life: Waiting list control group:

(n = 67) (n = 56)

Loss to follow-up at post-test Loss to follow-up at post-test

n = 7 (10.4%) n = 14 (25%)

Analyzed in the post-test: Analyzed in the post-test

5 schools (n = 60; 89.6%) 5 schools (n = 42; 75%)

Figure 1. Progress of participating children throughout the trial

Table 2
Effect of Intervention
Preintervention and Postintervention Means (SD) of the Outcomes
Table 3 shows the post-intervention effects of the SSL program
SSL group Control group on the considered outcomes. After the intervention, children in
Pre Post Pre Post the SSL group showed significantly higher reductions in scores on

Anxiety (SCAS total score) 28.89 (12.96) 22.81 (13.84) 26.66 (10.38) 25.88 (12.56) Table 3
Panic/agoraphobia 1.77 (2.47) 1.41 (2.51) 1.66 (2.06) 2.07 (3.25) Generalized linear model-based estimates 95% Confidence Intervals (CI), and
Separation anxiety 7.04 (3.67) 5.28 (3.85) 6.90 (2.78) 6.02 (3.32) significance tests for intervention effect on the outcomes
Physical injury fears 4.77 (2.95) 3.70 (2.70) 4.23 (2.90) 4.64 (3.03)
Estimates (95% CI) p value
Social anxiety 7.20 (3.56) 5.45 (3.25) 6.23 (3.15) 5.97 (3.22)
Obsessive compulsive 2.19 (2.45) 1.86 (2.51) 1.52 (1.51) 1.66 (1.80) Anxiety (SCAS total score) 4.40 (.72, 8.08) .01
Generalized anxiety 5.89 (2.86) 5.10 (3.50) 6.09 (2.84) 5.50 (2.78) Panic/agoraphobia .69 (-.19, 1.57) .12
Separation anxiety .78 (-.21, 1.77) .12
Total difficulties (SDQ
16.43 (6.58) 13.53 (6.45) 14.21 (5.85) 13.57 (7.43) Physical injury fears 1.16 (.36, 1.97) .005
total score)
Social anxiety 1.08 (.10, 2.06) .03
Emotional symptoms 5.31 (2.15) 3.85 (2.19) 4.33 (1.64) 4.17 (2.20)
Obsessive compulsive .15 (-.43, .73) .61
Conduct problems 3.07 (2.11) 2.62 (1.86) 2.86 (1.71) 2.71 (2.04)
Generalized anxiety .24 (-.50, 1) .51
Hyperactivity/inattention 4.99 (2.74) 4.53 (2.66) 4.86 (2.63) 4.67 (3.05)
Peer problems 3.06 (2.53) 2.53 (2.25) 2.17 (2.45) 2.02 (2.32) Total difficulties (SDQ total score) 1.55 (-.73, 3.83) .18
Prosocial behavior 7.12 (2.15) 7.47 (2.25) 7.67 (1.90) 7.57 (1.87) Emotional symptoms .85 (.009, 1.69) .04
Conduct problems .22 (-.36, .80) .45
Anxiety Life Interference
17.64 (12.70) 14.86 (13.31) 14.50 (9.54) 15.35 (11.42) Hyperactivity/inattention .10 (-.51, .73) .73
(CALIS total score)
Outside home 5.31 (4.81) 4.31 (4.97) 4.40 (3.91) 4.57 (4.13) Peer problems .05 (-.70, .81) .88
At home 5.80 (3.71) 4.70 (3.55) 4.50 (2.52) 5.07 (3.31) Prosocial behavior -.17 (-.92, .57) .64
Parent life 6.52 (5.97) 5.85 (6.38) 5.59 (5.62) 5.71 (5.51) Anxiety Life Interference (CALIS total score) 2.48 (-1.30, 6.28) .19
Depression (MFQ total Outside home .90 (-.60, 2.42) .24
13.44 (9.88) 7.43 (7.39) 9.42 (7.18) 9.45 (9.30) At home 1.14 (.24, 2.04) .01
score)
Parent interference .30 (-1.49, 2.09) .74
Note: SSL = Super Skills for Life; CI = Confidence Interval. Higher scores denote greater
symptomatology; except for Prosocial behavior Depression (MFQ total score) 3.94 (1.42, 6.47) .002

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measures of anxiety (p = .01), physical injury fears (p < .01), social yet modified over the 8 weeks, and in turn, this did not allow
anxiety (p < .05), emotional symptoms (p < .05), interference of parents to perceive changes in their daily life.
anxiety at home (p = .01), and depression (p < .01) than did children We found no differences in other secondary measures as well.
of WLC group. The GEE analyses also revealed a positive impact In the original study by Essau et al. (2014), improvements were
of the SSL intervention on measures of panic/agoraphobia and found in some of these measures at 6-month follow-up compared
separation anxiety compared to WLC group, although the effect to pre-test (i.e., conduct and peer problems, hyperactivity), as well
only approached significance (p = .12). as in other anxiety symptoms on which this study failed to find an
immediate impact of the SSL program (e.g., generalized anxiety,
Discussion separation anxiety). This suggests the need to track symptoms for
a longer time, after which it is expected that more positive effects
Overall, the results indicated that the intervention had a could be identified at follow-up, as found in similar studies (Essau
significant immediate positive impact on 6 out of 18 analyzed et al., 2012).
symptoms. Regarding the aim objective of this study, compared Some study limitations should be considered when interpreting
to the WLC group, children who participated in the SSL program the results. First, the sample size in this study was small and
showed significant reductions in symptoms of depression, anxiety, geographically located in the Southeast of Spain. Future studies
social anxiety, physical injury fears, and emotional problems (i.e., should try to replicate our results with more representative
both anxiety and depression). These results confirm the hypothesis samples in order to be able generalize the findings. Second,
that this program could be effective in the immediate reduction only parent-report measures (from either mother or father) were
(i.e., in post-intervention assessment) of anxiety and depression utilized in assessments. This was due to the scarcity of measures
symptoms. These outcomes are in line with international studies available for younger children, a fact that other authors have
that evaluated the efficacy of preventive programs for childhood highlighted, for example, with regard to anxiety measures (Rapee,
anxiety and depression (e.g., Bettis et al., 2016) and found 2018). Given the low-to-moderate agreement between parents and
immediate effects in younger children (e.g., Essau, Conradt, children when measuring internalizing problems, future studies
Sasagawa, & Ollendick, 2012). should be performed following a multi-informant perspective,
In addition, these findings are consistent with studies that using measures from both parents and teachers, and appropriate
support the efficacy of transdiagnostic interventions for anxiety self-report measures for early ages (e.g., Izquierdo-Sotorrío,
and depression in children and adolescents (García-Escalera et al., Holgado-Tello, & Carrasco, 2016). Third, despite that the baseline
2016), and suggest the usefulness of a transdiagnostic approach for differences between the two conditions were controlled in all
the prevention of anxiety and depression disorders (Dozois et al., analyses, the lack of balance in randomization for parental level of
2009). It is also noteworthy that the program is effective in reducing studies and baseline differences in the main outcomes may have
specific symptoms such as physical injury fears, considering that influenced the results. Fourth, the control group did not receive an
specific phobias are one of the most frequent anxiety disorders in intervention equivalent to that implemented in the experimental
children and adolescents (Canals et al., 2019; Muris, 2017) and group, which may have increased the effect size of the intervention
show the earliest onset (Beesdo et al., 2009), with some phobic according to the Hawthorne effect (McCarney et al., 2007).
fears (e.g., animals) appearing in an age range similar to that of This study only provided results related to the immediate post-
our study participants (Rapee, 2018). Moreover, the positive impact test effects of the SSL program. Future randomized controlled
of the SSL program on symptoms of social anxiety is consistent trials should involve follow-up assessments in order to examine
with those reported in the original study (Essau et al., 2014), which the long-term effectiveness of the program. An additional line
was particularly expected given that the SSL program has a strong to be developed in the future would be to analyze the mediators
component of social skills training and uses several strategies as and moderators of the effectiveness of the SSL program. Also,
part of the treatment that may contribute to this reduction (e.g., role- dismantling studies of SSL are needed in order to examine the
playings, speech tasks, video feedback with cognitive preparation). efficacy of each component (e.g., social skills training) and
Regarding the secondary objective, compared to the WLC whether the outcomes are equivalent to those yielded using the
condition, the intervention showed a significant reduction in full program with young children.
symptoms related to the interference of anxiety with children’s In conclusion, despite the above-mentioned limitations, this
life at home, but not outside home. The reason for this result study has some strengths that must be highlighted. First, this is
could be that assessments were carried out by parents. That the first study examining the SSL program with young Spanish-
is, children outside home spend much time in contexts where speaking children aged 6-8 years. The current research provides
parents are not present, for example, at school; therefore, parents initial support for the immediate effectiveness of SSL in reducing
may not be able to observe or assess certain behavior changes internalizing symptoms of anxiety and depression, suggesting that
properly (e.g., performance in the classroom); reports from it could be a valuable resource for researchers and clinicians. This
teachers could provide more valuable information in this regard study also extends the evidence supporting the efficacy of the SSL
in future studies. Besides, the short 8-week period between pre- program by examining it for the first time with a control condition.
and post-test assessments could have been not long enough for
parents’ to perceive significant changes in the interference of their Acknowledgements
child’s anxiety in different areas of their own life (e.g., work or
relationships with family and friends); another explanation could This research was supported by the Ministry of Education,
be that certain parenting practices or strategies developed by Culture and Sport of Spain [Reference: FPU14/03900], and the
parents to deal with children’s anxiety (e.g., over-involvement or Ministry of Economy and Competitiveness (MINECO) of Spain
anxious behavior) (Beato, Pereira, & Barros, 2017) had not been [Reference: PSI2014-56446-P].

303
 Iván Fernández-Martínez, Alexandra Morales, José P. Espada, Cecilia A. Essau, and Mireia Orgilés

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