Abstract
Anxiety disorders in preschool-age children represent an important clinical problem due to high prevalence, substantial impairment, persistence, and associated risk for later emotional problems. Early intervention may mitigate these problems by capitalizing on a strategic developmental period. Elevated neuroplasticity, availability of screening tools, and the potential to modify parenting practices position anxiety as a good candidate for early intervention and preventive efforts. While some novel interventions show promise, the broad success of such programs will largely depend on parent engagement. Since parents are less likely to identify and seek help for anxiety problems compared to other childhood behavior problems, especially in a preventive manner, methods for understanding parents’ decisions to participate and enhancing levels of engagement are central to the success of early childhood anxiety prevention and intervention. Understanding these processes is particularly important for families characterized by sociodemographic adversity, which have been underrepresented in anxiety treatment research. This review summarizes the developmental phenomenology of early emerging anxiety symptoms, the rationale for early intervention, and the current state of research on interventions for young, anxious children. The roles of parent engagement and help-seeking processes are emphasized, especially among economically disadvantaged and ethnic minority communities who are acutely at risk. Evidence-based strategies to enhance parent engagement to facilitate the development and dissemination of efficacious programs are offered.
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References
Aisenberg, E. (2001). The effects of exposure to community violence upon Latina mothers and preschool children. Hispanic Journal of Behavioral Sciences, 23(4), 378–398.
Alegria, M., Canino, G., Lai, S., Ramirez, R. R., Chavez, L., Rusch, D., et al. (2004). Understanding caregivers’ help-seeking for Latino children’s mental health care use. Medical Care, 42(5), 447–455.
Allen, J. L., Rapee, R. M., & Sandberg, S. (2008). Severe life events and chronic adversities as antecedents to anxiety in children: A matched control study. Journal of Abnormal Child Psychology: An official publication of the International Society for Research in Child and Adolescent Psychopathology, 36(7), 1047–1056.
Bannon, W. M, Jr, & McKay, M. M. (2005). Are barriers to service and parental preference match for service related to urban child mental health service use? Families in Society, 86(1), 30–34.
Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study. Psychological Bulletin, 133(1), 1–24.
Barlow, D. H., Chorpita, B. F., & Turovsky, J. (1996). Fear, panic, anxiety, and disorders of emotion. In D. A. Hope (Ed.), Nebraska symposium on motivation, 1995: Perspectives on anxiety, panic, and fear (pp. 251–328). Lincoln, NE: University of Nebraska Press.
Bayer, J. K., Rapee, R. M., Hiscock, H., Ukoumunne, O. C., Mihalopoulos, C., & Wake, M. (2011). Translational research to prevent internalizing problems early in childhood. Depression and Anxiety, 28(1), 50–57.
Benham, A. L., & Slotnick, C. F. (2006). Play therapy: Integrating clinical and developmental perspectives. In J. L. Luby (Ed.), Handbook of preschool mental health: Development, disorders, and treatment (pp. 331–371). New York, NY: Guilford Press.
Biederman, J., Hirshfeld-Becker, D. R., Rosenbaum, J. F., Hérot, C., Friedman, D., Snidman, N., et al. (2001). Further evidence of association between behavioral inhibition and social anxiety in children. American Journal of Psychiatry, 158(10), 1673–1679.
Biederman, J., Petty, C. R., Hirshfeld-Becker, D. R., Henin, A., Faraone, S. V., Fraire, M., et al. (2007). Developmental trajectories of anxiety disorders in offspring at high risk for panic disorder and major depression. Psychiatry Research, 153(3), 245–252.
Bittner, A., Egger, H. L., Erkanli, A., Costello, E. J., Foley, D. L., & Angold, A. (2007). What do childhood anxiety disorders predict? Journal of Child Psychology and Psychiatry, 48(12), 1174–1183.
Bosquet, M., & Egeland, B. (2006). The development and maintenance of anxiety symptoms from infancy through adolescence in a longitudinal sample. Development and Psychopathology, 18(2), 517–550.
Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36(4), 376–390.
Briggs-Gowan, M. J., Carter, A. S., Moye Skuban, E., & McCue Horwitz, S. (2001). Prevalence of social-emotional and behavioral problems in a community sample of 1- and 2-year-old children. Journal of the American Academy of Child and Adolescent Psychiatry, 40(7), 811–819.
Briggs-Gowan, M. J., & Mian, N. D. (in press). Trauma and violence exposure in young children. In P. Clements, & S. Seedat (Eds.), Mental health issues of child maltreatment. Saint Louis, MO: STM Learning, Inc.
Callaghan, B. L., & Richardson, R. (2011). Maternal separation results in early emergence of adult-like fear and extinction learning in infant rats. Behavioral Neuroscience, 125(1), 20–28.
Cartwright-Hatton, S., McNally, D., Field, A. P., Rust, S., Laskey, B., Dixon, C., et al. (2011). A new parenting-based group intervention for young anxious children: Results of a randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 50(3), 242–251.
Cauce, A. M., Domenech-Rodriguez, M., Paradise, M., Cochran, B. N., Shea, J. M., Srebnik, D., et al. (2002). Cultural and contextual influences in mental health help seeking: A focus on ethnic minority youth. Journal of Consulting and Clinical Psychology, 70(1), 44–55.
Chavira, D. A., Stein, M. B., Bailey, K., & Stein, M. T. (2004). Child anxiety in primary care: Prevalent but untreated. Depression and Anxiety, 20(4), 155–164.
Chorpita, B. F., & Barlow, D. H. (1998). The development of anxiety: The role of control in the early environment. Psychological Bulletin, 124(1), 3–21.
Cole, D. A., Peeke, L. G., Martin, J. M., Truglio, R., & Seroczynski, A. D. (1998). A longitudinal look at the relation between depression and anxiety in children and adolescents. Journal of Consulting and Clinical Psychology, 66(3), 451–460.
Comer, J. S., Puliafico, A. C., Aschenbrand, S. G., McKnight, K., Robin, J. A., Goldfine, M. E., et al. (2012). A pilot feasibility evaluation of the CALM program for anxiety disorders in early childhood. Journal of Anxiety Disorders, 26(1), 40–49.
Copeland, V. C. (2005). African Americans: Disparities in health care access and utilization. Health and Social Work, 30(3), 265–270.
Costello, E. J. (1989). Child psychiatric disorders and their correlates: A primary care pediatric sample. Journal of the American Academy of Child and Adolescent Psychiatry, 28(6), 851–855.
Costello, E. J., Egger, H. L., & Angold, A. (2004). Developmental epidemiology of anxiety disorders. In T. H. Ollendick & J. S. March (Eds.), Phobic and anxiety disorders in children and adolescents: A clinician’s guide to effective psychosocial and pharmacological interventions (pp. 61–91). New York, NY: Oxford University Press.
Dadds, M. R., & Roth, J. H. (2008). Prevention of anxiety disorders: Results of a universal trial with young children. Journal of Child and Family Studies, 17(3), 320–335.
Day, J. C. (1996). Population projections of the United States by age, sex, race, and Hispanic origin: 1995 to 2050. US Bureau of the Census, Current Population Reports, P25-1130. Washington, DC: US Government Printing Office. http://www.census.gov/prod/1/pop/p25-1130.pdf.
Derryberry, D., & Reed, M. A. (1994). Temperament and the self-organization of personality. Development and Psychopathology, 6(4), 653–676.
Duncan, G. J., Brooks-Gunn, J., & Klebanov, P. K. (1994). Economic deprivation and early childhood development. Child Development, 65(2), 296–318.
Egger, H. L., & Angold, A. (2006a). Anxiety disorders. In J. L. Luby (Ed.), Handbook of preschool mental health: Development, disorders, and treatment (pp. 137–164). New York, NY: Guilford Press.
Egger, H. L., & Angold, A. (2006b). Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47(3), 313–337.
Eley, T. C., Bolton, D., O’Connor, T. G., Perrin, S., Smith, P., & Plomin, R. (2003). A twin study of anxiety-related behaviours in pre-school children. Journal of Child Psychology and Psychiatry, 44(7), 945–960.
Evans, D. W., Leckman, J. F., Carter, A., Reznick, J. S., Henshaw, D., King, R. A., et al. (1997). Ritual, habit, and perfectionism: The prevalence and development of compulsive-like behavior in normal young children. Child Development, 68(1), 58–68.
Garland, A. F., Lau, A. S., Yeh, M., McCabe, K. M., Hough, R. L., & Landsverk, J. A. (2005). Racial and ethnic differences in utilization of mental health services among high-risk youths. The American Journal of Psychiatry, 162(7), 1336–1343.
Garvey, C., Julion, W., Fogg, L., Kratovil, A., & Gross, D. (2006). Measuring participation in a prevention trial with parents of young children. Research in Nursing & Health, 29(3), 212–222.
Ginsburg, G. S. (2009). The child anxiety prevention study: Intervention model and primary outcomes. Journal of Consulting and Clinical Psychology, 77(3), 580–587.
Ginsburg, G. S., & Schlossberg, M. C. (2002). Family-based treatment of childhood anxiety disorders. International Review of Psychiatry, 14(2), 143–154.
Godoy, L., & Carter, A. S. (2013). Identifying and addressing mental health risks and problems in primary care pediatric settings: A model to promote developmental and cultural competence. American Journal of Orthopsychiatry, 83(1), 73–88.
Godoy, L., Mian, N. D., Eisenhower, A. S., & Carter, A. S. (2013). Pathways to service receipt: Modeling parent help-seeking for childhood mental health problems. Administration and Policy in Mental Health and Mental Health Services Research. doi:10.1007/s10488-013-0484-6.
Gross, D., Julion, W., & Fogg, L. (2001). What motivates participation and dropout among low-income urban families of color in a prevention intervention? Family Relations, 50(3), 246–254.
Harachi, T. W., Catalano, R. F., & Hawkins, J. D. (1997). Effective recruitment for parenting programs within ethnic minority communities. Child and Adolescent Social Work Journal, 14(1), 23–39.
Harari, N., Davis, M., & Heisler, M. (2008). Strangers in a strange land: Health care experiences for recent Latino immigrants in Midwest communities. Journal of Health Care for the Poor and Underserved, 19(4), 1350–1367.
Heinrichs, N., Bertram, H., Kuschel, A., & Hahlweg, K. (2005). Parent recruitment and retention in a universal prevention program for child behavior and emotional problems: Barriers to research and program participation. Prevention Science, 6(4), 275–286.
Hirshfeld-Becker, D. R., & Biederman, J. (2002). Rationale and principles for early intervention with young children at risk for anxiety disorders. Clinical Child and Family Psychology Review, 5(3), 161–172.
Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely, L. R., Pollock-Wurman, R. A., McQuade, J., et al. (2010). Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 78(4), 498–510.
Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely, L. R., Rettew, D. C., Dufton, L., et al. (2008). Cognitive-behavioral intervention with young anxious children. Harvard Review of Psychiatry, 16(2), 113–125.
Horwitz, S. M., Gary, L. C., Briggs-Gowan, M. J., & Carter, A. S. (2003). Do needs drive services use in young children? Pediatrics, 112, 1373–1378.
Huey, S. J, Jr, & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic minority youth. Journal of Clinical Child and Adolescent Psychology, 37(1), 262–301.
Kagan, J. (1984). Behavioral inhibition to the unfamiliar. Child Development, 55(6), 2212–2225.
Karevold, E., Roysamb, E., Ystrom, E., & Mathiesen, K. S. (2009). Predictors and pathways from infancy to symptoms of anxiety and depression in early adolescence. Developmental Psychology, 45(4), 1051–1060.
Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among US children: Variation by ethnicity and insurance status. The American Journal of Psychiatry, 159(9), 1548–1555.
Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65(3), 366–380.
Kendall, P. C., Safford, S., Flannery-Schroeder, E., & Webb, A. (2004). Child anxiety treatment: Outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up. Journal of Consulting and Clinical Psychology, 72(2), 276–287.
Kendall, P. C., & Sugarman, A. (1997). Attrition in the treatment of childhood anxiety disorders. Journal of Consulting and Clinical Psychology, 65(5), 883–888.
Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009). A selective intervention program for inhibited preschool-aged children of parents with an anxiety disorder: Effects on current anxiety disorders and temperament. Journal of the American Academy of Child and Adolescent Psychiatry, 48(6), 602–609.
LaFreniere, P. J., & Capuano, F. (1997). Preventive intervention as means of clarifying direction of effects in socialization: Anxious-withdrawn preschoolers case. Development and Psychopathology, 9(3), 551–564.
Lavigne, J. V., LeBailly, S. A., Hopkins, J., Gouze, K. R., & Binns, H. J. (2009). The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. Journal of Clinical Child and Adolescent Psychology, 38(3), 315–328.
Leijten, P., Raaijmakers, M. A. J., Orobio de Castro, B., & Matthys, W. (2013). Does socioeconomic status matter? A meta-analysis on parent training effectiveness for disruptive child behavior. Journal of Clinical Child and Adolescent Psychology, 42(3), 384–392.
Linfoot, K., Martin, A. J., & Stephenson, J. (1999). Preventing conduct disorder: A study of parental behaviour management and support needs with children aged 3 to 5 years. International Journal of Disability, Development and Education, 46(2), 223–246.
Marakovitz, S., Wagmiller, R. L., Mian, N. D., & Carter, A. S. (2011). Lost toy? Monsters under the bed? Contributions of temperament and family factors to early internalizing problems in boys and girls. Journal of Clinical Child and Adolescent Psychology, 40(2), 233–244.
Margolin, G., & Gordis, E. B. (2000). The effects of family and community violence on children. Annual Review of Psychology, 51, 445–479.
McCabe, K. M., & Yeh, M. (2009). Parent–child interaction therapy for Mexican Americans: A randomized clinical trial. Journal of Clinical Child and Adolescent Psychology, 38(5), 753–759.
McCabe, K. M., Yeh, M., Garland, A. F., Lau, A. S., & Chavez, G. (2005). The GANA program: A tailoring approach to adapting parent child interaction therapy for Mexican Americans. Education & Treatment of Children, 28(2), 111–129.
McDonald, R., Jouriles, E. N., Briggs-Gowan, M. J., Rosenfield, D., & Carter, A. S. (2007). Violence toward a family member, angry adult conflict, and child adjustment difficulties: Relations in families with 1- to 3-year-old children. Journal of Family Psychology, 21(2), 176–184.
McKay, M. M., Hibbert, R., Hoagwood, K., Rodriguez, J., Murray, L., Legerski, J., et al. (2004). Integrating evidence-based engagement interventions into ‘real world’ child mental health settings. Brief Treatment and Crisis Intervention, 4(2), 177–186.
McKay, M. M., McCadam, K., & Gonzales, J. J. (1996a). Addressing the barriers to mental health services for inner city children and their caretakers. Community Mental Health Journal, 32(4), 353–361.
McKay, M. M., Nudelman, R., McCadam, K., & Gonzales, J. (1996b). Evaluating a social work engagement approach to involving inner-city children and their families in mental health care. Research on Social Work Practice, 6(4), 462–472.
McLeod, J. D., & Shanahan, M. J. (1993). Poverty, parenting, and children’s mental health. American Sociological Review, 58(3), 351–366.
Mian, N. D., Godoy, L., Briggs-Gowan, M. J., & Carter, A. S. (2012). Patterns of anxiety symptoms in toddlers and preschool-age children: Evidence of early differentiation. Journal of Anxiety Disorders, 26(1), 102–110.
Mian, N. D., Wainwright, L., Briggs-Gowan, M. J., & Carter, A. S. (2011). An ecological risk model for early childhood anxiety: The importance of early child symptoms and temperament. Journal of Abnormal Child Psychology, 39(4), 501–512.
Mrazek, P. J., & Haggerty, R. J. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press.
Ollendick, T. H., & King, N. J. (1998). Empirically supported treatments for children with phobic and anxiety disorders: Current status. Journal of Clinical Child Psychology, 27(2), 156–167.
Ollendick, T. H., Öst, L.-G., Reuterskiöld, L., Costa, N., Cederlund, R., Sirbu, C., et al. (2009). One-session treatment of specific phobias in youth: A randomized clinical trial in the United States and Sweden. Journal of Consulting and Clinical Psychology, 77(3), 504–516.
Osofsky, J. D. (1999). The impact of violence on children. The Future of Children, 9(3), 33–49.
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(3), 14–25.
Pavuluri, M. N., Luk, S.-L., & McGee, R. (1996). Help-seeking for behavior problems by parents of preschool children: A community study. Journal of the American Academy of Child and Adolescent Psychiatry, 35(2), 215–222.
Pincus, D. B., Eyberg, S. M., & Choate, M. L. (2005). Adapting parent–child interaction therapy for young children with separation anxiety disorder. Education and Treatment of Children, 28(2), 163–181.
Pincus, D. B., Santucci, L. C., Ehrenreich, J. T., & Eyberg, S. M. (2008). The implementation of modified parent–child interaction therapy for youth with separation anxiety disorder. Cognitive and Behavioral Practice, 15(2), 118–125.
Prinz, R. J., Smith, E. P., Dumas, J. E., Laughlin, J. E., White, D. W., & Barrón, R. (2001). Recruitment and retention of participants in prevention trials involving family-based interventions. American Journal of Preventive Medicine, 20(Suppl 1), 31–37.
Puliafico, A. C., Comer, J. S., & Pincus, D. B. (2012). Adapting parent–child interaction therapy to treat anxiety disorders in young children. Child and Adolescent Psychiatric Clinics of North America, 21(3), 607–619.
Rapee, R. M. (2002). The development and modification of temperamental risk for anxiety disorders: Prevention of a lifetime of anxiety? Biological Psychiatry, 52(10), 947–957.
Rapee, R. M. (2013). The preventative effects of a brief, early intervention for preschool-aged children at risk for internalising: Follow-up into middle adolescence. Journal of Child Psychology and Psychiatry, 54(7), 780–788.
Rapee, R. M., & Coplan, R. J. (2010). Conceptual relation between anxiety disorder and fearful temperament. In H. Gazelle & K. Rubin (Eds.), Social anxiety in childhood: Bridging developmental and clinical perspectives New directions for child and adolescent development. San Francisco: Jossey-Bass.
Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L. (2005). Prevention and early intervention of anxiety disorders in inhibited preschool children. Journal of Consulting and Clinical Psychology, 73(3), 488–497.
Schuhmann, E. M., Foote, R. C., Eyberg, S. M., Boggs, S. R., & Algina, J. (1998). Efficacy of parent–child interaction therapy: Interim report of a randomized trial with short-term maintenance. Journal of Clinical Child Psychology, 27(1), 34–45.
Spence, S. H., Rapee, R. M., McDonald, C., & Ingram, M. (2001). The structure of anxiety symptoms among preschoolers. Behaviour Research and Therapy, 39(11), 1293–1316.
Spoth, R., & Redmond, C. (2000). Research on family engagement in preventive interventions: Toward improved use of scientific findings in primary prevention practice. The Journal of Primary Prevention, 21(2), 267–284.
Suveg, C., Roblek, T. L., Robin, J., Krain, A., Aschenbrand, S., & Ginsburg, G. S. (2006). Parental involvement when conducting cognitive-behavioral therapy for children with anxiety disorders. Journal of Cognitive Psychotherapy, 20(3), 287–299.
Szapocznik, J., Perez-Vidal, A., Brickman, A. L., Foote, F. H., Santisteban, D., Hervis, O., et al. (1988). Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach. Journal of Consulting and Clinical Psychology, 56(4), 552–557.
Webster-Stratton, C., & Reid, M. J. (2003). Treating conduct problems and strengthening social and emotional competence in young children: The dina dinosaur treatment program. Journal of Emotional and Behavioral Disorders, 11(3), 130–143.
Weems, C. F. (2008). Developmental trajectories of childhood anxiety: Identifying continuity and change in anxious emotion. Developmental Review, 28(4), 488–502.
Weisz, J. R., Doss, A. J., & Hawley, K. M. (2005). Youth psychotherapy outcome research: A review and critique of the evidence base. Annual Review of Psychology, 56, 337–363.
Westra, H. A., & Dozois, D. J. A. (2006). Preparing clients for cognitive behavioral therapy: A randomized pilot study of motivational interviewing for anxiety. Cognitive Therapy and Research, 30(4), 481–498.
Wu, P., Hoven, C. W., Bird, H. R., Moore, R. E., Cohen, P., Alegria, M., et al. (1999). Depressive and disruptive disorders and mental health service utilization in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38(9), 1081–1090.
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I would like to thank Dr. Alice S. Carter for her guidance and support of this project.
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Mian, N.D. Little Children with Big Worries: Addressing the Needs of Young, Anxious Children and the Problem of Parent Engagement. Clin Child Fam Psychol Rev 17, 85–96 (2014). https://doi.org/10.1007/s10567-013-0152-0
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DOI: https://doi.org/10.1007/s10567-013-0152-0