Is It Possible To Effectively Reduce Anxiety In Children Through School Screening? An Analysis of iCATSi2i

by Fude YANG

Introduction

Child anxiety is easy to underestimate because it often presents quietly. A child may still attend school, follow classroom routines, and avoid drawing concern from adults while carrying substantial fear, worry, or distress. Yet anxiety disorders are among the most prevalent mental disorders in childhood, have a very early peak age of onset, and account for a large share of disease burden in children aged 5 to 9.

That is why the basic question behind the iCATSi2i trial matters far beyond school psychology: can schools become a meaningful entry point for effective early intervention, rather than simply a place where problems are noticed too late?

The Lancet Psychiatry trial did not test screening in isolation. It tested a screening-to-intervention pathway in 84 primary and junior schools in England. That distinction is crucial. Screening alone can identify need without guaranteeing help. iCATSi2i asked a more demanding question: if schools identify children with likely anxiety problems and connect families to a structured, evidence-based response, do outcomes actually improve?

The answer from this trial was yes, at least within the system in which it was studied. More children who screened positive at baseline later screened negative at 12 months in the intervention group than in the control group.

That result deserves attention, but so do the details. The study sits at the intersection of psychiatry, education, and public mental health. Its importance lies not only in the positive outcome, but in the way it tries to solve a practical problem that many child mental health systems have not solved well: how to reduce the gap between effective treatment in principle and actual access in real life.

Why School-Based Anxiety Identification Matters

The service gap in child mental health is not only a question of treatment supply. It is also a question of timing, recognition, and navigation. Many children and adolescents worldwide do not receive the mental health care they need, and anxiety disorders are especially important because they begin early. If intervention is delayed until symptoms become more visible, more impairing, or formally referred, the opportunity for earlier support may already have narrowed.

There is another reason schools matter. Cognitive behavioral therapy is an effective first-line treatment for child anxiety, and for primary-school-aged children it can be delivered via parents with outcomes similar to child-directed intervention and less therapist time. Digital delivery can further reduce barriers linked to face-to-face attendance.

The problem, then, is not that there is no evidence-based treatment model for this age group. The problem is that families often struggle to identify anxiety difficulties in children and to navigate a complex route into services. That is the logic behind school-based identification. Schools are one of the few systems that routinely reach large numbers of children at the age when anxiety disorders are already common and when intervention may still be relatively efficient.

But school-based screening has often raised a justified concern: what happens after identification? If screening only produces a list of children with possible difficulties and no accessible pathway to care, it may add administrative burden without changing outcomes. The iCATSi2i study is important precisely because it did not stop at detection. It was designed around identification plus feedback plus intervention.

What The Screening-To-Intervention Pathway Actually Is

The most important feature of iCATSi2i is that it is a pathway, not a single tool. In intervention schools, all parents in sampled classes were invited to complete a two-item parent questionnaire, the iCATS-2, at baseline. Parents then received feedback on the screening outcome. If a child screened positive for anxiety problems, the parents were offered a parent-led CBT intervention delivered through the Online Support and Intervention for Child Anxiety (OSI) platform, with online materials and telephone support. A single whole-class session on identifying and managing fears and worries was also delivered.

Schools in both groups continued their usual provision, and assessments were completed in both arms.

That structure is important, since each element addresses a different barrier. The screening step addresses recognition. Feedback addresses the problem of families not knowing how results should be interpreted. The parent-led CBT offer addresses access. And the whole-class session appears to have been included partly because earlier development work and stakeholder feedback suggested some universal support should accompany the targeted intervention.

OSI itself is a parent-led CBT intervention in which parents complete seven online modules, each around 20 to 30 minutes, with a short call of approximately 20 minutes with a children’s wellbeing practitioner after each module and again several weeks after the final intervention content. The modules provide strategies around exploring and testing anxious thoughts through exposure, problem-solving, and encouraging independence.

The support component was also relatively structured. Eight trial therapists, mostly children’s wellbeing practitioners, received training in OSI delivery and weekly supervision from a clinical psychologist with expertise in child anxiety treatment and OSI. Adherence was closely monitored.

How The Trial Was Designed And Why That Design Matters

iCATSi2i was a pragmatic, parallel-group, superiority, cluster-randomized controlled trial in 84 primary and junior schools in England with at least two year-4 classes. Children aged 8 to 9 in participating classes were eligible unless opted out by a parent. Schools, not individual children, were randomized 1:1 either to screening, feedback, and intervention alongside usual school practice or to assessment and usual school practice only. Randomization was stratified by school-level deprivation.

The cluster design mirrors how a school-based mental health pathway would actually be introduced. The primary outcome was whether children in the target population who screened positive at baseline later screened negative at 12 months.

What The Study Found

The trial recruited baseline participants between January and November 2022. Parents of 1,459 children completed the screening questionnaire. Of those screened, 409 children screened positive and formed the target population.

At 12 months, more children in the target population screened negative for anxiety problems in the intervention group than in the control group: 89 of 145 (61%) versus 62 of 163 (38%). The adjusted odds ratio was 2.32 (95% CI 1.41–3.81, p=0.0009). No serious adverse events related to trial procedures or the intervention were reported.

The authors conclude that an integrated screening-to-intervention pathway in primary schools reduced parent-reported child anxiety problems compared with assessment and usual provision only, and may offer a promising way to improve access to effective early intervention.

What Makes iCATSi2i Stronger Than A Simple School Screening Program

The main strength of iCATSi2i is that it tested a full pathway — identification, feedback, and intervention — rather than screening alone. It was pragmatic, conducted in ordinary schools, and used an evidence-based parent-led CBT model (OSI) with structured support and supervision.

The Limits Of Transfer To Other Education Systems

Uptake was only 27% of eligible children, which raises questions about reach and representativeness. The model also depended on digital infrastructure, trained practitioners, and school willingness. The single whole-class session raised concerns about possible unintended effects on child-reported outcomes, and the authors recommend it should not be used in future implementations without further study.

What This Trial Means For Psychiatry, Schools, And Public Mental Health

The iCATSi2i trial matters because it demonstrates that schools can host a structured early-intervention pathway that improves outcomes. It links evidence-based treatment to a real-world access problem and offers a model in which early identification is tied to actual intervention rather than left as an administrative endpoint.

Conclusion

The iCATSi2i trial does not prove that school screening is a universal solution to childhood anxiety. What it does show is more specific and more valuable: a well-designed screening-to-intervention pathway can improve outcomes in a real primary school setting.

Its wider lesson is that early intervention becomes more credible when systems solve the route from recognition to care. In that sense, iCATSi2i is not just a trial about schools. It is a trial about how public mental health can become operational rather than aspirational.

References

1. Reardon, T., Ukoumunne, O. C., Taylor, L., Ball, S., Violato, M., Larkin, M., Fisk, J., Halliday, G., Yu, S., Williamson, V., Ford, T., Gray, A., Hill, C., Jasper, B., Macdonald, I., Morgan, F., Pollard, J., Sancho, M., Sniehotta, F. F., Spence, S. H., Stainer, J., Stallard, P., iCATS Team, & Creswell, C. (2026). Screening-to-intervention pathway for child anxiety problems alongside usual school practice versus usual school practice only (iCATSi2i): A cluster-randomised, controlled trial in primary schools in England. The Lancet Psychiatry, 13(5), 396–412. https://doi.org/10.1016/S2215-0366(26)00064-7