preventie anxietate copii

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Clinical Psychology Review, Vol. 20, No. 4, pp. 509531, 2000Copyright 2000 Elsevier Science Ltd.Printed in the USA. All rights reserved

0272-7358/00/$see front matter

PII S0272-7358(99)00040-9

509

PREVENTION OF CHILDHOOD

ANXIETY DISORDERS

Caroline L. Donovan and Susan H. Spence

University of Queensland

ABSTRACT.

Anxiety disorders represent one of the most common and debilitating forms of psy-chopathology in children. While empirical research, mental health funding, and mental healthprofessionals continue to focus on the treatment rather than prevention of anxiety disorders inchildren, preliminary research presents an optimistic picture for preventative strategies in the fu-ture. Knowledge of the risk factors, protective factors, and treatment strategies associated withchildhood anxiety disorders, in conjunction with theories regarding the methods, timing, levels,and targets of prevention, equip us well for effectively preventing childhood anxiety disorders inthe future. 2000 Elsevier Science Ltd.

KEY WORDS.

Prevention, Anxiety, Children, Risk factors, Protective factors.

INTRODUCTION

THE ADAGE THAT prevention is better than cure would seem to make intuitive senseand is certainly a concept embraced by the medical profession. Immunisation, breastcancer screening, pap smear tests, and media campaigns aimed at decreasing skin can-cer, are but a few examples of the emphasis on prevention within the field of medicine.Prevention and treatment research within the medical domain are considered to be of

equal importance by researchers, funding bodies, and the general public. Furthermore,medical practitioners spend a significant proportion of their time engaged in preventa-tive strategies and in advocating preventative strategies to their patients.

In contrast, the mental health sector has not, until recently, shared the emphasis onprevention. Despite the enormous economic, personal and social costs of many men-tal health problems, and the vast number of people suffering from them, the focuswithin mental health has continued to be on treatment rather than prevention. Whilethere has been an encouraging increase in the number of psychological academic

Correspondence should be addressed to Susan H. Spence, School of Psychology, University ofQueensland, Brisbane, Queensland, 4072, Australia. E-mail: [email protected]


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510 C. L. Donovan and S. H. Spence

journal articles relating to prevention, the majority of papers have been theoretical innature rather than rigorous empirical tests of particular preventative strategies.

Children may suffer from a number of mental health problems, however anxietydisorders represent one of the most common forms of psychopathology in children.

In an epidemiological study of the prevalence of anxiety disorders in children, Ka-shani and Orvaschel (1990) found that 21% of children and adolescents demon-strated an anxiety disorder of some description. While separation anxiety disorder isthe only anxiety disorder categorised as typically beginning in childhood and adoles-cence according to the Diagnostic and Statistical Manual of Mental Disorders

, 4th ed.(American Psychiatric Association, 1994), children may also suffer from any of theanxiety disorders outlined for adulthood. From the following discussion it will be-come apparent that while the prevention of childhood anxiety remains in its infancy,preliminary research presents an optimistic picture for the future.

RISK AND PROTECTIVE FACTORS FOR ANXIETY DISORDERS

The risk factors, protective factors, and treatment strategies associated with a particu-lar disorder are important considerations when devising prevention strategies. En-quiry into the area of childhood anxiety has identified many risk factors, somewhatfewer protective factors, and a number of treatment strategies.

Risk Factors

Empirical psychological research investigating the aetiology of anxiety disorders inchildren has identified a number of risk factors associated with childhood anxiety dis-orders. Risk factors refer to variables, the presence of which predict the onset, sever-ity, and duration of psychopathology (Coie et al., 1993) and may be biological, envi-ronmental, or psychological in nature. Risk factors for anxiety disorders may (a) benonspecific and applicable to several mental health problems, (b) impact upon anxi-ety disorders in general, or (c) be specific to one particular anxiety disorder. In addi-tion, risk factors may or may not be causal and always precede the associated mentaldisorder. Furthermore, they may have a cumulative effect or a dosage effect so thatthe stronger the risk factor, the more severe the disorder (Coie et al., 1993; Mrazek &Haggerty, 1994). Moreover, risk factors may appear and disappear over time, emergedifferently at different times and may vary in importance at different developmentalstages (Coie et al., 1993; Mrazek & Haggerty, 1994).

The development of childhood anxiety disorders involves a complex interplay be-tween biological, psychological, and environmental factors. Implicated risk factors forchildhood anxiety problems include anxious-resistant attachment, parental anxiety, achild temperament style of behavioural inhibition, traumatic/negative/stressful lifeevents, and parenting style characteristics.

Anxious-resistant attachment.

Attachment theorists postulate that the quality of attach-ment between infants and primary caregivers is an important factor in the develop-

ment of childhood anxiety disorders (Erickson, Sroufe, & Egeland, 1985; Lewis, Fei-ring, McGafey, & Jaskir, 1984; Sroufe, Egeland, & Kreutzer, 1990). Unfortunately,much of the empirical support for this model is indirect and therefore somewhat lim-ited. A recent study, however, examined the role of attachment style on the later de-


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Prevention of Childhood Anxiety Disorders 511

velopment of anxiety disorders. Warren, Huston, Egeland, and Sroufe (1997) assessed172 children at 12 months and then later at 17.5 years of age. Results suggested that apattern of anxious/resistant attachment at 12 months predicted later anxiety disor-der, even after the effects of maternal anxiety and infant temperament were removed.

While further empirical testing of this model is necessary, it would seem that the qual-ity of infantcaregiver attachment has an effect on later anxiety development in thechild. Future research should attempt to uncover the mechanisms through which thisprocess occurs.

Parental anxiety.

Empirical research has implicated parental anxiety as being a riskfactor for childhood anxiety problems (Rosenbaum et al., 1988; Turner, Beidel, &Costello, 1987; Weissman, Leckman, Merikangas, Gammon, & Prusoff, 1984). For ex-ample, results of a study by Last, Hersen, Kazdin, Francis, and Grubb (1987) sug-gested that, compared to their nonanxious peers, anxious children were more likely

to have a parent suffering from anxiety. Furthermore, heritability estimates of approx-imately 4050% have been found for anxiety symptoms in children (Thapar & McGuf-fin, 1995).

Parental anxiety is an example of a risk factor that is not directly causal, but rather ismoderated or mediated through some other mechanism. Whether the mechanismthrough which this occurs is genetic, environmental, or represents an interplay be-tween the two, remains unclear. However, inherited child temperament and parent-ing characteristics are two mechanisms that have been suggested to account for the re-lationship between child anxiety and parental anxiety. Each of these mechanisms,therefore, represent further risk factors for the development of anxiety in children(see below).

Behavioural inhibition.

Parental anxiety may exert an influence on child anxietythrough an increased likelihood of offspring inheriting a temperament characteristicprone to the development of anxiety. Kagan and colleagues (Kagan, Reznick, & Gib-bons, 1989; Kagan & Snidman, 1991) have identified the relatively stable tempera-ment style of behavioural inhibition that manifests itself as timidity, shyness, andemotional restraint when exposed to unfamiliar people, places, or contexts (Asen-dorpf, 1993). Behavioural inhibition has been associated with elevated physiologicalindices of arousal and has been shown to have a strong genetic component (DiLalla,Kagan, & Reznick, 1994; Plomin & Stocker, 1989). It has been demonstrated that chil-dren exhibiting behavioural inhibition are more likely to develop an anxiety disorderduring childhood (Biederman et al., 1993; Kagan, 1997; Rosenbaum et al., 1993).However, as not all children displaying behaviourally inhibited tendencies have ananxious parent or proceed to develop an anxiety disorder (Biederman et al., 1993;Rosenbaum et al., 1993), other mechanisms or risk factors may be involved in the pro-cess. Parenting behaviour (see below) is one such mechanism proposed to be associ-ated with the stability of behavioural inhibition in children (Hirshfeld, Biederman,Brody, Faraone, & Rosenbaum, 1997a, 1997b).

Traumatic, negative, and stressful life events.

Traumatic, negative, and stressful life

events also represent risk factors for childhood anxiety problems. Following trauma,children have been found to demonstrate higher levels of fear relating to stimuli asso-ciated with the traumatic event. They may demonstrate avoidance behaviours, somaticcomplaints, depression, sleep disturbance, and intrusive experiences following the


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traumatic experience (Dollinger, 1986; Dollinger, ODonnell, & Staley, 1984). Fur-thermore, higher rates of anxiety disorders have been found following major naturaldisasters, such as earthquakes, bush fires, and storms (e.g., Dollinger et al., 1984; Terr,1981; Yule & Williams, 1990). For most children, these symptoms ameliorate relatively

quickly after the traumatic event. However, for many children experiencing trauma,anxiety tends to persist.While traumatic experiences are somewhat uncommon, children are more often

faced with a number of stressful or negative life events, such as parental separation, di-vorce, death of a family member, family conflict, and repeated moves of school. Re-search suggests that clinically anxious children have experienced a greater number ofsuch events compared to nonanxious children (Benjamin, Costello, & Warren, 1990;Goodyer & Altham, 1991), indicating that stressful life events may be a risk factor inthe development of anxiety disorders in children.

As not all children experiencing traumatic, negative, or stressful life events proceed

to develop anxiety problems, other variables or mechanisms must moderate the impactof negative life events upon the development of anxiety problems. Parental behaviouris one such variable that has been found to interact with traumatic, negative, and stress-ful life events in the development of anxiety in the child. For example, McFarlane(1987) found that mothers exhibiting high levels of anxiety and overprotectivenesstended to have children suffering from high levels of posttraumatic symptoms. Simi-larly, anxious parental behaviour has been found to affect child anxiety during pain-ful medical procedures (Jacobsen, Manne, Gorfinkle, & Schorr, 1990; Bush,Melamed, Sheras, & Greenbaum, 1986).

Parenting behaviour.

From the above discussion, it is evident that parenting character-istics have been suggested to interact with a number of other risk factors in the devel-opment of childhood anxiety. Studies that have examined the relationship betweenparental behaviour and childhood anxiety suggest that parents of anxious children of-ten behave in ways that increase the likelihood of their child responding in an anxiousmanner (Spence, in press). Different aspects of parenting style have been suggestedto effect the direction of anxiety problems in children. From a learning theory per-spective, parents of anxious children are proposed to model, prompt, and reinforceanxious behaviour in their children. A study by Barrett, Dadds, Rapee, and Ryan(1996) suggested that parents of anxious children differ from other parents in the waythey teach their children to interpret and respond to ambiguous threat cues. Theseauthors demonstrated that anxious children and their parents make relatively highnumbers of threat interpretations and, therefore, choose avoidant solutions whenfaced with ambiguous hypothetical social problems. Furthermore, when Barrett,Dadds, Rapee, and Ryan (1996) asked families to discuss with their child how theyshould deal with ambiguous situations, anxious children were more likely than con-trol children to devise an avoidant solution after family discussion. Dadds, Barrett,and Rapee (1996) analysed the contingent stream of family behaviours that had beenvideotaped during the family discussions in the Barrett, Dadds, Rapee, and Ryan(1996) study. Results indicated that parents of anxious children were more likely toreciprocate avoidant solutions and less likely to encourage pro-social solutions to am-

biguous social situations, compared to parents of nonclinical and aggressive children.Parental overcontrol, overprotection, and criticism represent additional parenting

characteristics that have been suggested as possible risk factors in the development ofchildhood anxiety (Krohne & Hock, 1991). As noted above, overprotection and over-


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control on behalf of the parent may be influential in the stability of behavioural inhi-bition (Hirshfeld et al., 1997a, 1997b) and in the effect of stressful and negative lifeevents (e.g., McFarlane, 1987). Krohne and Hock (1991) suggest that parental over-control tends to interfere with childrens acquisition of effective problem-solving

skills, resulting in a failure to learn to deal successfully with stressful life situations. Pa-rental overcontrol has also been suggested to undermine childrens belief in theirability to succeed in challenging situations, thus producing low expectancies for suc-cess and low self-efficacy for problem-solving (Khrone & Hock, 1991). Evidence sup-porting these suppositions has been produced in a number of studies (Krohne, 1990,1992; Khrone & Hock, 1991) suggesting that parenting style may effect the develop-ment of childhood anxiety either directly, or indirectly through the interaction withother risk factors.

Summary.

It is likely that risk factors other than those outlined above exist for the de-

velopment of childhood anxiety. For example, adverse sociocultural factors, such aslow socioeconomic status, poor housing conditions, large family size, and marital dis-cord have been associated with many psychological problems in children. In the caseof childhood anxiety disorders, however, the relationship with such variables remainsunclear (Gittleman, 1986). As many disorders share common risk factors, it is likelythat variables such as sociocultural characteristics may represent further anxiety riskfactors as yet unexplored.

As noted above, risk factors are often common to a number of disorders. To compli-cate matters further, a particular disorder (such as anxiety) may have a number of riskfactors. That these risk factors act upon disorders in isolation is unlikely, and thereforethe risk factors outlined above are not to be viewed as mutually exclusive or indepen-dent. From the above discussion, it is not only evident that a number of risk factors areimplicated in the development of childhood anxiety, but also that complex interac-tions and associations exist between the various risk factors. Surprisingly little researchhas been conducted on the interactive effects of risk factors in the development ofchild anxiety. Future research should attempt to examine both the combinations ofrisk factors and the processes involved in order to achieve a more holistic understand-ing of the etiological processes involved in childhood anxiety disorders.

Protective Factors

It is clear that not all children exposed to the risk factors outlined above, proceed todevelop anxiety disorders. This has led researchers to explore the possibility of protec-tive factors that improve resilience to both risk factors and psychological disorder(Coie et al., 1993). Protective factors may be either intrinsic to the child or be part oftheir environment (Coie et al., 1993; Cowen, 1985; Garmezy, 1985; Rutter, 1985).They may protect against a disorder by directly affecting the disorder, decreasing thelikelihood of negative chain reactions, or preventing a risk factor occurring alto-gether. In addition, they may be protective by providing a buffer against a risk factor,or affecting the mediational link through which a risk factor operates (Coie et al.,1993; Dignam & West, 1988; Wheaton, 1986).

Unfortunately, the search for protective factors involved in childhood anxiety hasnot been as intensive as the search for risk factors. For anxiety disorders, enquiry intoprotective factors has been very much limited to the areas of social support and childcoping skills.


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Social support.

It has been proposed that social support is an important protective fac-tor with respect to a number of behavioral and emotional problems in children (Com-pas, 1987). For example, when negative, traumatic, or stressful life events occur in thepresence of positive social support, the risk of psychosocial disorders is reduced (Mur-

ray, 1992). A number of empirical findings suggest that social support may play a rolein the development of anxiety. For example, Quamma and Greenberg (1994) foundthat family social support was a significant moderating variable between stressful lifeevents and the self-reported anxiety problems of special-education children. In a lon-gitudinal study investigating the moderating effects of family social support in the rela-tionship between exposure to community violence and anxiety in 11- to 14-year-olds,White, Bruce, Farrell, and Kliewer (1998) found a strong negative relationship betweenanxiety level and family social support. In this study, children who initially demonstratedlow levels of worry anxiety and who possessed low social support, showed a greater in-crease in worry anxiety during follow-up. Similarly, in another study investigating the ef-

fects of exposure to community violence on 4th to 6th graders, trait anxiety was foundto be negatively correlated with social support, and state anxiety was found to be nega-tively correlated with family social support (Hill, Levermore, Twaite, & Jones, 1996).

Further evidence for the protective value of social support on the development ofchild anxiety was found in a study examining risk factors for internalizing and exter-nalizing problems of 11- to 18-year-old girls referred to therapy following sexualabuse. Spaccarelli and Fuchs (1997) found that self-reports of depression and anxietywere associated with lower perceived support from the parent not involved in theabuse, higher levels of cognitive-avoidance coping, and more negative appraisals ofthe abuse. In addition, in a study of 49 children aged 823 years with congenital/ac-quired limb loss, perceived social support by classmates significantly predicted depres-sive symtomatology, trait anxiety, and general self-esteem (Varni, Setoguchi, Rappa-port, & Talbot, 1992). Similarly, in a study of 102 4th6th grade children whoseparents had been divorced, subjects with a higher self-rating of overall support, mani-fested lower postdivorce difficulties, anxiety, and worry (Cowen, Pedro-Carroll, & Al-pert-Gillis, 1990).

The existing evidence provides strong support for the notion that higher levels ofsocial support are associated with lower levels of anxiety, in the presence of stressful ortraumatic life events. Future research should further explore the relationship betweensocial support and childhood anxiety and the mechanism(s) through which this pro-tective effect occurs.

Coping skills.

The type of responses that children use to cope with unpleasant experi-ences may greatly influence the degree of fear, anxiety, and distress they experience(Spence, in press). Coping skills

is a generic term that includes a variety of methods in-dividuals employ in an attempt to cope with negative or aversive situations. Copingstrategies may be categorized as either problem-focussed, avoidant, or emotion-focussed (Billings & Moos, 1981; Carver, Scheier, & Weintraub, 1989; Endler &Parker, 1990a, 1990b; Folkman & Lazarus, 1980, 1985). Problem-focussed coping re-fers to strategies that directly address, or minimize, the effect of the problem and in-clude such strategies as positive self-talk and seeking out information. Alternatively,

emotion-focussed coping strategies focus on the level of distress associated with theproblem while avoidant coping strategies focus on avoiding or escaping the problem.

Empirical evidence suggests that for adults, emotion-focussed and avoidant copingstrategies are associated with higher levels of anxiety in response to stressful life events


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(Carver et al., 1989; Edwards & Trimble, 1992). While empirical enquiry into the roleof coping strategies in the development of child anxiety is not as plentiful as that foradults, there is some evidence to suggest that emotion-focussed and avoidant copingstrategies may be associated with higher levels of anxiety in children and adolescents.

For example, when dealing with interpersonal stressors, it has been demonstrated thatchildrens ability to use problem-focussed rather than emotion-focussed coping strate-gies is associated with more positive psychological adjustment in children (Compas,Malcarne, & Fondacaro, 1988). In addition, emotion-focussed coping has been associ-ated with higher levels of emotional and behavioural problems in adolescence (Com-pas et al., 1988) and avoidant coping has been associated with higher levels of anxietyand depression (Ebata & Moos, 1991). While further research is necessary, the use ofproblem-focussed rather than emotion-focussed or avoidant coping strategies mayrepresent an important protective factor for anxiety disorders in children.

From the above discussion, it is clear that our knowledge of protective factors is sig-

nificantly less that our knowledge regarding risk factors in the development of child-hood anxiety disorders. Future research investigating the role of protective factors inthe development of anxiety disorders should focus on a number of areas. First, furtherinvestigation needs to be conducted with respect to the role of social support and cop-ing skills in the resilience to anxiety. Second, the possibility of additional protectivefactors needs to be explored. Third, enquiry must be made into the possible interac-tions that protective factors may have with the many anxiety risk factors in the devel-opment of childhood anxiety.

PREVENTION

While many effective treatment approaches to child anxiety exist and are highly effec-tive for the majority of children (Barrett, Dadds, & Rapee, 1996; Cobham, Dadds, &Spence, in press; Kendall, 1994), there are a number of reasons why prevention ofanxiety disorders is preferable to treatment. Prevention can be defined as interven-tions that occur before the onset of a clinically diagnosable disorder that aim to re-duce the number of new cases of that disorder (Munoz, Mrazek, & Haggerty, 1996).In order to prevent a disorder such as anxiety, preventative methods must be viewedas any attempt to prevent entry to, or progression along, the pathway towards a severe,debilitating psychological disorder (Mrazek & Haggerty, 1994).

There are several reasons why prevention is more desirable than relying on treat-ment. First, teachers and parents are often not aware that a child is suffering with anx-iety problems due to the compliant and nondisruptive nature of anxious children.Even when awareness of anxiety problems exists, teachers and parents tend to mini-mize the seriousness of the affliction. Thus, it is not surprising that the majority ofchildren with anxiety disorders do not receive the treatment they need (Esser,Schmidt, & Woerner, 1990; Zubrick et al., 1997). It is also of concern that anxiety disor-ders may become chronic or may reoccur if left untreated (Mental Health WorkingGroup on Prevention Research, 1995; Munoz et al., 1996). In addition, recent evidencehas emerged to suggest that child anxiety may play a causal role in the development of

depression among young people (Cole, Peeke, Martin, Truglio, & Seroczynski, 1998).Second, in cases where children are referred for treatment, the disorder is often wellestablished and many of the adverse effects upon school performance and peer rela-tionships have already occurred and are difficult to reverse. Third, anxiety treatments


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have been found to be ineffective for many children with empirical evidence suggest-ing that 3040% of children continue to meet criteria for a clinically significant anxietydisorder following treatment (Barrett, Dadds, Rapee, & Ryan, 1996; Kendall, 1994).

The costs of anxiety, both personal and economic, are manifold. Anxiety problems

are associated with a range of debilitating social, emotional, and academic conse-quences for the child and their families. Those suffering with anxiety have been foundto leave school early, marry early, underachieve, and be less active in the workforcecompared to their nonanxious peers (Mental Health Working Group on PreventionResearch, 1995). Economically, clinic-based interventions are expensive, even whenconducted on a group basis. Costs such as unemployment, days lost from work, hospi-talization, medication, and pension payments must be considered in the calculationof economic cost if childhood anxiety persists into adulthood. Furthermore, the de-mand for mental health services far exceeds supply (Winett, 1998). Community men-tal health services are overburdened and alternative private mental health facilities

are often too costly for those most in need. The current situation is that there are in-sufficient mental health resources for an ever-increasing demand.Due to the problems associated with treatment of child anxiety disorders and the

personal and economic costs involved, it is important that researchers, clinicians,community health organizations, and governments emphasize and work towards theprevention of anxiety disorders in children. A large knowledge base exists regardingeffective treatment, risk factors and protective factors associated with childhood anxi-ety. Strategies aimed at preventing child anxiety may utilize this knowledge in order toeliminate risk factors and to provide children with protective factors.

A number of elements are important when developing prevention strategies. Themethods through which prevention is to occur, the timing of the strategy, the level atwhich the strategy is pitched and the individuals targeted, are important consider-ations when developing an effective preventative program. These important elementsare outlined and discussed below in terms of their relevance to the prevention ofchildhood anxiety.

Methods of Prevention

Drawing upon the evidence discussed above, and the literature concerning effectivecognitive-behaviour therapy in the treatment of anxiety disorders (for reviews seeDadds & Roth, in press; Rapee, in press), we are armed with a number of child-, par-ent-, and environment-focussed strategies for preventing childhood anxiety. Spence(in press) proposed a number of child, parent, and environmental methods that arelikely to be valuable in preventative strategies (see Figure 1).

Timing of Prevention

The timing of prevention strategies is an important consideration in the implementa-tion of prevention programs. It is evident from the above discussion that many riskfactors exist for the development of anxiety disorders. A number of risk factors such astraumatic, negative, and stressful life events, influence a child throughout their life-

time. Preventative strategies targeting these risk factors may, therefore, be of assis-tance throughout a childs life. While some risk factors have a continuing influence, itis also clear that other risk and protective factors manifest themselves and become im-portant only at certain times in a childs development. Preventative strategies aimed at


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these risk factors should be carefully timed and directed more specifically towards cer-tain points in a childs development. For both continual and more time-specific riskfactors, it is necessary to tailor the presentation of the prevention strategy to the devel-opmental level of the child in order for the strategy to be effective.

Spence (in press) outlined an integrated developmental model for prevention.While this model is theoretical in nature, and is presented only tentatively whilst await-ing testing and empirical validation, it represents a potentially useful way to view pre-vention methods across the lifespan. The model outlined developmental levels, riskfactors for anxiety evident at those levels, and preventative methods that may be em-ployed during these stages. A number of anxiety risk factors including genetic predis-position for anxiety and traumatic, negative, and stressful life events, were identifiedas exerting an influence upon an individual across their life-span. The model pro-posed that preventative methods that may be of use throughout a childs development

FIGURE 1. Child, parent, and environmental methods of prevention.


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in order to address these risk factors, include child coping skills training, traumacounseling, parent skills training, and divorce counseling.

While some risk factors may exert an influence throughout a childs life, other riskfactors may effect the individual at more specific developmental levels. For example,

the model proposed by Spence (in press) suggests that a genetic history of anxiety dis-order and parental psychopathology may be risk factors that are particularly relevantduring the prenatal period. Therefore, it was proposed that preventative strategies,such as parenting skills training and the treatment of parental anxiety, may be particu-larly useful during this time. Similarly, the model proposed that during infancy, riskfactors such as insecure attachment, behavioural inhibition, parental anxiety, andanxious parenting are influential. Preventative strategies that may be useful duringthis developmental stage may, therefore, include parenting skills training and thetreatment of parental anxiety. A number of anxiety risk factors including overprotec-tive and critical parenting style, behavioural inhibition, starting school, parental anxi-

ety, and early symptoms of anxiety, were proposed by the model as being of particularimportance during the childhood years. It was, therefore, suggested that appropriatepreventative methods during this developmental phase may include parenting skillstraining, treatment of parental anxiety and child coping skills training. Finally, duringadolescent years, the transition to high school, parental anxiety and symptoms of anx-iety may constitute risk factors for childhood anxiety. Preventative methods duringthis phase may, therefore, include adolescent coping skills training, parenting skillstraining, and the treatment of parental anxiety.

While this model requires empirical validation, it highlights the importance ofchild developmental level in terms of both the content and presentation of preven-tion material. The importance of parenting skills training and child coping skills train-ing is highlighted through their repeated potential use as preventative strategies ateach developmental level. Early acquisition of these skills by both parents and chil-dren is likely to assist in the prevention of anxiety at multiple points in a childs life.

Levels of Prevention

The level or levels at which preventative strategies are targeted is an important yetscarcely researched aspect of preventative programs. Winett (1998) has proposed aproactive-developmental-ecological prevention paradigm over different levels ofanalyses. Winett (1998) and Spence (in press) share the developmental perspectivethat prevention strategies should not only be appropriately tailored for different agegroups in terms of content, but they must also recognise that different issues andproblems are evident for children and their families at various time points.

The ecological perspective within Winetts (1998) model emphasises the impor-tance of the environment. In his review of various prevention studies, Winett (1998)suggests that the majority of prevention studies have focussed primarily on factors re-lating to the individual, such as cognitions and behaviours, to the exclusion of envi-ronmental and community change. He suggests that infrastructures must be put inplace, within which more personal changes such as behaviours and cognitions, areable to occur over time. To this end, community systems and political action must be

engaged in order to encourage change. Thus, Winett (1998) shares the view of manyother prevention theorists, that multi-level prevention strategies are necessary if realchange is to occur (Mental Health Working Group on Prevention Research, 1995;Munoz et al., 1996). Winett (1998) suggests that adequate prevention requires strate-


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gies aimed at four levels: personal, interpersonal, organisational/environmental andinstitutional. Within each of these four levels, prevention strategies require the appro-priation of adequate: competencies (knowledge and skills); resources, both tangible(such as time and money) and intangible (such as respect and caring from others)

and; settings (environments in which prevention strategies may be implemented).Table 1 outlines the way in which Winetts (1998) model can be applied to the pre-vention of anxiety disorders in children.

Targets of Prevention

In addition to the levels and categories suggested by Winett (1998), much of the recentliterature regarding prevention distinguishes between universal, selected, and indicatedprevention (Mrazek & Haggerty, 1994). These three levels of prevention differ in termsof their target populations. Universal prevention strategies are provided to entire popu-

lations that have not been identified on the basis of risk factors. Selective preventionstrategies are targeted towards subgroups or individuals who are assumed to have a highlifetime or imminent risk of developing a problem as the result of exposure to some bio-logical, psychological, or social risk factor(s). Finally, indicated prevention strategies fo-cus on high-risk individuals who demonstrate minimal but detectable symptoms of amental disorder, or biological markers suggestive of a predisposition towards the devel-opment of a clinical-level mental disorder (Mrazek & Haggerty, 1994).

Below are examples of prevention studies in the area of childhood anxiety that havebeen categorised in terms of their universal, selective, and indicated status. Twopoints will become evident from the review below. The first is the low number of pre-vention studies aimed specifically at reducing childhood anxiety. The second is thatthe vast majority of child anxiety prevention studies employ selective prevention strat-egies and focus on the acquisition of personal competencies.

Universal prevention strategies.

One of the few studies to take a universal prevention ap-proach was reported by Dubow, Schmidt, McBride, Edwards, and Merk (1993). Thisstudy aimed to provide fourth-grade children with protective factors for dealing withstressful situations using the I CAN DO program. The I CAN DO program con-sisted of 13, 45-minute sessions, presented by researchers within a classroom setting.The first three sessions focussed on teaching children general coping skills, such asproblem-solving, social-support seeking, and strategies to increase positive affect inuncontrollable situations. The remaining sessions were devoted to the practice ofthese coping skills within each of five common stressful situations: parental separa-tion/divorce; loss of a loved one; move to a new home/school; spending time in self-care (home alone) and; feeling different. Students were also instructed in ways to as-sist peers experiencing these negative life events and feelings. Results suggested thatthe program had no effect in changing the childrens social support network size or inchanging their knowledge and attitudes regarding the negative life events. However,compared to children not receiving the program, children participating in the I CANDO program demonstrated higher levels of self-efficacy in their ability to deal withthe stressors and a greater problem-solving ability. Unfortunately, at 6-month follow-

up, control group data was unavailable. However, for children participating in theprogram, no change in knowledge and attitudes, social support size, or problem-solv-ing ability was evident at follow-up. Participants continued to improve however, intheir self-efficacy scores.


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TABLE 1. Proactive-Developmental-Ecological Prevention Paradigm

a

as Applied to

Childhood Anxiety

Competencies Resources Settings

Personal Child coping skills Time and access Adequate home

Skills to overcome to preventative environment

a

parental anxiety mechanisms, suchas schools,community healthcentres, and preventioncentres

Time and access to clinicsto reduce parental anxiety

Interpersonal Parenting skills Adequate social support Adequate homeInterpersonal skills for parents and children environment

for the acquisition Time and access to Adequate clinicof adequate social community health and environment for

support prevention centres overcomingparental anxiety

Organisational Teachers adequately School time and money Adequate schooland trained to instruct allocation to coping skills environment forEnvironmental children in child programs the teaching of

coping skills Schools emphasising the coping skillsCommunity health importance of testing for Prevention and

staff adequately risk factors and subclinical mental healthtrained in symptomatology, etc. centresteaching effective Adequate tools forparenting skills identifying the existence

of risk factors and sub-clinical symptomatologyAvailability of approved

coping skills curriculumwithin schools

Institutional Government and Government and funding Government leg-funding body bodies allocating sub- islation promot-policies emphasising stantial funding towards ing mentalthe importance of mental health preven- health, e.g. legis-childrens mental tion, e.g., bodies regulat- lation ensuringhealth ing curriculum so that that adequate

Government schools teach approved mental health

knowledge child coping skills pro- and preventionof information re- grams, e.g., mental health centres are avail-garding successful policies ensuring that all able and acces-mental health strat- mental health and pre- sible by allegies e.g., legislation vention strategies are of a peopleensuring that all high standard and areteachers and mental equipped with thehealth professionals relevant preventativeare adequately strategiestrained in the teach-ing of parenting and

child coping skills

a

From Prevention: A Proactive Developmental-Ecological Perspective, by R. A. Winett in

Handbook of Child Psychology

, 3rd ed., edited by T. H. Ollendick and M. Hersen, 1998, New York:Plenum Press.


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While the program was aimed at providing children with resources to deal effec-tively with stressful situations, measures of stress and anxiety were not included in thestudy. Replications of this study incorporating longer follow-up periods, control-groupfollow-up, measures of anxiety, and real life events are necessary. The program may

well succeed in providing children with adequate self-efficacy for coping with stressfulhypothetical situations, however, it remains to be seen whether this increase in self-efficacy will result in the desired effect of reducing stress for children when faced withreal-life events.

Because universal studies, by definition, target an entire population including thosenot at risk, they require large sample sizes and long-term follow-up to enable discern-ible differences between groups. Such large samples sizes and lengthy follow-ups re-quire substantial funding and resources. Analyses must be conducted on the relativebenefits and costs associated with providing an intervention to a majority of childrenwho are not at risk. Calculating the relative benefit of prevention for mental health is

difficult as the associated benefits are often not as tangible or immediate as those asso-ciated with medical strategies. In calculating the benefit/cost ratio, considerationmust be given to variables such as costs of mental health consultations, time off work,hospitals, and pension payments. Less tangible considerations such as personal and fa-milial distress, the likelihood of relapse, and the social stigma associated with mentaldisorder must also be considered. Other problems associated with universal preven-tion studies also exist. For example, in gaining access to entire populations of chil-dren, the school system is often utilised. This process requires ongoing support byprincipals, teachers, parents, and children. Time is required for training teachers ineffective delivery of programs, parental consent is often difficult to achieve for non-risk children, and attrition is a continuing problem due to the mobility of families.

Despite the associated difficulties however, universal studies have the potential tobe of enormous benefit in terms of reducing the prevalence of mental disorders. Asall children are targeted, those who may otherwise slip through the net in terms ofrisk identification, receive assistance. In addition, comorbidity between mental disor-ders is high and protective factors are common to many disorders. The teaching of ge-neric child and parent skills may therefore be useful in the prevention of many disor-ders both within and between subjects. Acquisition of such skills is useful even forchildren and parents who are not at risk, as they may be employed successfully in anumber of everyday occurrences. Programs such as the I CAN DO program also havethe advantage of developing protective factors that are likely to impact on a range ofbehavioural and emotional problems, in addition to anxiety.

Before large-scale universal studies become commonplace, the infrastructure forpreventative research discussed by Winett (1998) must be in place. Schools, communi-ties, and government departments must perceive the prevention of mental disordersas a priority so that co-operation with researchers is enhanced. Encouragement forfunding bodies to sponsor such large-scale, time- and labour-intensive projects mustalso be given.

Selective prevention strategies.

Selective prevention targeting those at risk for a particu-lar disorder as the result of exposure to some biological or psycho-social risk factor, is

the most common type of strategy employed in the field of prevention research.Within the domain of childhood anxiety, the occurrence of traumatic/stressful/nega-tive life events is the most common risk factor upon which prevention researchershave selected their populations for intervention.


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In terms of traumatic life events, large-scale disasters are unpredictable and limitthe possibility of well-designed empirical studies. For large-scale disasters therefore,prevention research has been very much limited to case studies and theoretical propo-sitions (e.g., Sugar, 1989). Significantly greater empirical interest, however, has been

demonstrated in the area of more common negative and stressful life events. For ex-ample, parental divorce is one of the most common and serious negative life eventsconfronting children and adolescents (Hetherington, Bridges, & Insabella, 1998;Hightower & Braden, 1991; Hodges, 1991) and has been found to have many detri-mental effects, including anxiety (Hess & Camara, 1979). Many programs have beendesigned to provide children with coping skills for effectively dealing with parental di-vorce (e.g., Hodges, 1991; Pedro-Carroll & Cowen, 1985; Short, 1998). One such pro-gram was the Children of Divorce Intervention Project conducted by Hightower andBraden (1991). The program was conducted in small groups within the school settingand aimed to prevent academic, behavioural, and emotional problems. The program

attempted to develop a supportive group environment and facilitate the identificationand expression of divorce-related feelings. In addition, it strived to promote under-standing of divorce-related concepts and rectify misconceptions, teach coping skills,and enhance positive self and family perceptions. Results suggested that the programwas effective in reducing anxiety, decreasing behavioural problems, and producinggains in school competencies. Further, the program was successful in decreasing feel-ings of self-blame and increasing the ability to solve divorce-related problems. At2-year follow-up, these benefits were maintained for the majority of children. How-ever, at 3-year follow-up, only half the children continued to demonstrate the gains ev-ident at post-treatment and 2-year follow-up.

Another stressful life event with which children are required to cope, is that of tran-sition to a new school (Soussignan, Koch, & Montagner, 1988). A change in school isassociated with a range of emotional and behavioural difficulties, including peer rela-tionship problems, school refusal, somatic complaints, academic failure, increasedsubstance abuse, delinquency, and school drop out (Hightower & Braden, 1991). Pro-grams have therefore been developed to facilitate the transition between schools andprevent the distress and anxiety associated with it. For example, the School TransitionEnvironment Project (STEP) program developed by Felner and Adan (1988) is an at-tempt to facilitate the transition between primary and secondary school. It was envis-aged that by increasing personal relationships between pupils and staff and creatingsubenvironments within the larger school environment, the distress associated withchanging schools would be decreased. One of the major aims of the project was to re-duce the physical plan of the large school environment into smaller and more man-ageable units. The STEP program, therefore, constitutes a unique attempt to direct apreventative strategy towards an environmental setting. The physical plan of theschool was decreased through the creation of home-rooms in which students wereinstructed in their core academic subjects. In this way, students were allowed to be-come more familiar with the school environment while enjoying the stability of a reg-ular classroom and classmates. In addition, each class was appointed a home-roomstaff member who was responsible for taking class attendance, following up nonatten-dance, and counselling pupils regarding academic or school adjustment problems. Fi-

nally, coordinated liaison between teaching and school counselling staff was organ-ised. Results suggested that, compared to children not participating in the STEPprogram, children involved in the program demonstrated higher levels of academicperformance and self-esteem, better school attendance and lower school drop-out


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rates (Felner & Adan, 1988). Replications of this study, in various school settings withchildren from a variety of social backgrounds, have continued to demonstrate thebenefits of the STEP program. Although the study was not designed specifically to pre-vent anxiety, it provides a good example of organisational/environmental level pre-

vention through the promotion of an adequate setting.The prevention of anxiety and distress induced through medical procedures is aprolific area of research and represents another example of selective prevention usinga stressful life event as the risk criteria. Medical procedures are often novel, stressful,unpleasant, and sometimes painful, thus inducing fear among children. Children mayalso find other aspects related to the procedures, such as separating from parents, ill-ness, and unfamiliar surroundings equally as fear-provoking (Melamed, 1998; Traugh-ber & Cataldo, 1983). Due to the importance of many medical procedures and themedical professions emphasis on prevention, a great deal of research has been con-ducted into the development of methods to minimise childrens anxiety during medi-

cal procedures. Many techniques for helping children cope with injections, bone mar-row aspirations, and changing of burns dressings are now widely used throughout themedical profession (Jay, Elliott, Fitzgibbons, Woody, & Siegel, 1995; Melamed, 1998).

A number of strategies have been employed to assist in preventing child anxietyduring medical procedures. Coping skills training (cue-controlled relaxation, distract-ing mental imagery, and comforting self-talk) combined with modelling has beenfound to be superior in reducing anxiety due to tonsillectomy procedures comparedto either modelling or information alone (Peterson & Shigetomi, 1981). Similarly,during bone marrow aspirations, modelling plus coping strategies (breathing exer-cises, imagery, positive self-statements, reinforcement, and role-play rehearsal using adoll) have been shown to significantly lower behavioural distress, lower pain ratingsand lower pulse rates, as compared to Valium or attention control procedures (Jay, El-liott, Katz, & Siegel, 1987).

A related area of enquiry is the prevention of dental phobia, a problem that hasbeen estimated to effect between 1020% of children and adolescents (Milgrom,Vignehsa, & Weinstein, 1992). Due to the high prevalence rate of this disorder, theemphasis on prevention within the medical profession, and the importance of dentalprocedures, prevention of dental phobia represents an extensive area of research.Weinstein (1990) reviewed the literature relating to the prevention of dental fears inchildren and suggested that methods found to be beneficial in reducing child anxietyabout dental procedures include (a) providing the child with as much control overthe procedure as possible, (b) giving children nontraumatic, pre-exposure prior to in-vasive treatment, and (c) allowing children to view videotaped modelling of anotherchild coping with the same procedure.

It is evident from the above discussion that the majority of selective prevention stud-ies have focussed on stressful or negative life events as the risk criteria. There are mul-titudes of stressful life events that children must unfortunately endure in addition tothe ones detailed above which may be targeted in prevention programs. Indeed, pro-grams to prevent anxiety have been developed for children who face a wide range oflife stressors, in addition to those outlined above. Children who have chronically illsiblings; children undergoing tests; and children performing music, sport, and other

public exhibitions are other examples of those targeted for anxiety prevention (e.g.,Tryon, 1980; Williams et al., 1997). In addition, many other risk factors are associatedwith childhood anxiety, thus opening up further avenues for selective prevention re-search. For example, as discussed, parental anxiety is a risk factor for anxiety prob-


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lems in children (Mattison, 1992). It has been found that the treatment of parentalanxiety may enhance the effectiveness of cognitive-behavioural treatment on clinicallysignificant child anxiety disorders (Cobham et al., in press). To date, there do not ap-pear to be any controlled evaluations of the effectiveness of parental anxiety reduc-

tion programs in the prevention of childhood anxiety. However, reducing parentalanxiety would seem an important research direction, as early detection and treatmentof parental anxiety may reduce the likelihood of the child developing an anxiety dis-order later on. Parental over-control, overprotection and criticism are also suggestedto be risk factors for child anxiety. Parents exhibiting these characteristics may betaught effective parenting strategies that reduce their maladaptive parenting stylesand promote non-anxious behaviour in their child. Teaching appropriate parentingstrategies has been shown to reduce and prevent anxiety when children are subjectedto other risk factors. It seems likely, therefore, that early detection of inappropriateparenting strategies and the teaching of appropriate parenting strategies prior to neg-

ative life events, may be of benefit to the child.Future selective prevention research may also investigate the risk factors of childtemperament and attachment style. To date, controlled outcome studies have notbeen reported in which behavioural inhibition or anxious resistant attachment havebeen used as a criteria for inclusion in prevention programs. Like other risk factors,there is likely to be a complex interplay between behaviourally inhibited temperamentstyle or anxious-resistant attachment style, the environment, and other risk and protec-tive factors. However, early detection of a behaviourally inhibited temperament andanxious-resistant attachment may allow early intervention and thus change a trajectorythat may otherwise lead to an anxiety disorder. Preventative methods directed at chil-dren may include the teaching of relaxation skills and cognitive self-instruction. Paren-tal instruction may focus on teaching parents to model, prompt, and reinforce nonanx-ious behaviour and to encourage independent problem-solving in their children.

There are a number of benefits associated with selective prevention procedures.When compared to universal prevention procedures, selective prevention strategiesare more time, cost, and labour efficient, and the benefit/cost ratio is more easily cal-culated. Funding bodies are, therefore, more likely to perceive the benefits of spon-soring selective endeavours rather than universal strategies.

There are a number of difficulties that selective prevention researchers must over-come. Children at risk of anxiety due to the experience of negative life events are rel-atively easy to identify. However, selective prevention procedures based on biological,or other psycho-social risk factors require the development of appropriate means ofidentification. If selective prevention procedures are to become commonplace andwidespread, then brief, cheap, reliable, and valid mechanisms must be developed andused to identify those at risk. Methods to efficiently and adequately detect risk factorssuch as behavioural inhibition, anxious-resistant attachment, parental anxiety andmaladaptive parenting style must therefore be devised.

As noted above, risk factors may become more important at different times in achilds life, thus presenting a further challenge for selective prevention research. It isnecessary to determine at which points in the developmental trajectory it is most effi-cient to evaluate relevant risk factors and subsequently provide intervention. Should

identification and subsequent intervention occur at certain points in a childs devel-opment, or should they continue throughout the lifespan? If identification and inter-vention is targeted at only certain points in a childs life, how many children are likelyto slip through the net? There are many such questions that remain to be answered.


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In summary, many risk factors remain unexplored and the use of existing cognitive-behavioural change techniques within a preventative context must be investigated.Furthermore, the development of efficient risk identification procedures is necessary,and the optimal timing of intervention must be determined. Research possibilities

therefore abound in the area of selective prevention, and future research should aimto explore these avenues and expand them into the wider prevention framework pro-posed by Winett (1998).

Indicated prevention strategies.

As noted earlier, indicated prevention involves target-ing those individuals who exhibit subclinical symptoms or biological markers of a dis-order. Early symptoms of anxiety have been found to predict later childhood anxietydisorders, with mental health problems suggested to develop in a gradual progressionor trajectory. For example, Dadds, Spence, Holland, Barrett, and Laurens (1997)found that approximately 50% of children who demonstrated symptoms of anxiety

but did not yet meet diagnostic criteria, were diagnosed as meeting the criteria for ananxiety disorder 6 months later if left untreated.To date, two studies have attempted indicated-level preventative strategies within

the area of childhood anxiety. LaFreniere and Capuano (1997) conducted an indi-cated prevention program with preschool children exhibiting anxious-withdrawn be-haviour. Forty-three anxious-withdrawn children were randomly assigned to either theintervention or nonintervention groups. The intervention group received an intensive6-month program consisting of four phases. Assessment comprised the first phasewhile the second phase concentrated on educating the parent on their childs devel-opmental needs. The determination of specific objectives for the family constitutedthe third phase and the fourth phase involved implementing the intervention during11 home visits. The intervention phase concentrated on principles of child-directedinteraction, the modification of behaviour problems, training in parenting skills, andincreasing the effectiveness of social support systems. Results suggested a number ofencouraging findings. Compared to mothers in the control group, mothers in thetreatment group demonstrated lower levels of intrusive, overcontrolling behaviour,while children demonstrated an increase in co-operation and enthusiasm during aproblem-solving task. In addition, teacher ratings for treatment group children indi-cated significant improvement in child social competence at pre-school. However, sig-nificant reductions in the anxious-withdrawn behaviour of the child and maternalstress were found for both the control and intervention groups. Future replications ofthis study require long-term controlled follow-up in order to determine whether pro-viding a prevention strategy at preschool-age produces a reduction in the number ofchildren who later go on to develop an anxiety disorder. The study provides an impor-tant starting point however, for further indicated prevention research.

A second indicated prevention study relating to childhood anxiety was conductedby Dadds et al. (1997) in what became known as the Queensland Early Interventionand Prevention of Anxiety Project. Children identified as at risk were involved in ei-ther a control or intervention group. Seventy-five percent of subjects met diagnosticcriteria (at a very mild level) for an anxiety disorder while the remaining 25% demon-strated subclinical symptomatology. Given that the majority of subjects involved in the

Dadds et al. (1997) study already met diagnostic criteria for an anxiety disorder at thecommencement of intervention, the study represents a combination of early interven-tion and indicated prevention. True indicated prevention involves intervention withsymptomatic, but as yet subclinical, populations.


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The intervention consisted of 10 child sessions and 3 parent sessions and was basedon an Australian modification of Kendalls (1994) Coping Cat anxiety program. Im-mediately following completion of the program, no significant differences were evi-dent between the control and intervention groups. However, by 6-month follow-up a

difference emerged, with 27% of children in the intervention group and 57% of chil-dren in the control group demonstrating an anxiety disorder diagnosis. By 12-monthfollow-up, diagnosis rates for the two groups converged (37% vs. 42%), but at 2-yearfollow-up, a significant difference between groups was again evident with 20% of theintervention group and 39% of the control group demonstrating an anxiety disorder.The benefits of the intervention were strongest for those children who initially had amoderate to severe severity clinical diagnosis, with approximately 50% of these chil-dren retaining a clinical diagnosis at the 2-year follow-up if they did not receive the in-tervention (Dadds et al., 1999).

The benefits of the program were less impressive for those children who initially

showed symptoms of anxiety but who did not actually have a clinically significant anxi-ety disorder. At 6-month follow-up, the program appeared to be producing markedbenefits for these children, with 54% of these children meeting criteria for an anxietydisorder if left untreated, compared to 16% in the intervention group. However, at the2-year follow-up there was minimal difference between the preventive intervention andmonitoring-only conditions in terms of the percentage of children who showed an anx-iety disorder diagnosis (around 11% vs. 16%, respectively). Thus, children with subclin-ical anxiety problems do not appear to be at high risk of developing a more severe anx-iety disorder in the longer term if left untreated, and the benefits of the interventionare minimal. These findings suggest that preventive efforts and early intervention in thearea of child anxiety disorders may be best targeted towards children who show moder-ate to severe anxiety symptoms, rather than those with subclinical anxiety problems.

Indicated prevention shares many of the benefits associated with selective preven-tion in terms of cost-efficiency and greater likelihood of attracting finance from fund-ing bodies. However, indicated prevention also shares some of the difficulties associ-ated with selective prevention research. Identification mechanisms of sufficientsensitivity to reliably detect children who demonstrate subclinical symptoms requirefurther development if indicated prevention is to become commonplace. Of most dif-ficulty will be determining appropriate cut-off scores so that intervention can be pro-vided most effectively and efficiently. In addition, a timing issue is relevant for indi-cated prevention strategies as to when and how often children should be assessed foranxiety symptoms. It also remains to be determined whether brief interventions aresufficient to produce long-term change over 5- to 10-year periods, or whether recur-rent interventions are required. To date, the minimal evidence available cannot an-swer these questions.

CONCLUSIONS

The above discussion has highlighted the debilitating consequences of childhoodanxiety disorders and the benefits of prevention. Our knowledge of the many risk fac-

tors, protective factors, and effective treatment strategies for anxiety, equips us wellfor effectively preventing childhood anxiety disorders. It is evident that while furtherresearch is necessary, models already exist regarding the timing of preventative efforts(Spence, in press) and the different levels at which prevention should be aimed (per-


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sonal, interpersonal, organisational/environmental, and institutional; Winett, 1998).Furthermore, models exist regarding the type of resources into which preventative ef-forts should be channelled and the different target groups and design strategies forintervention (universal, selective, and indicated). It seems likely that universal preven-

tion methods that teach a broad spectrum of protective factors and focus on entirepopulations are most sensibly directed towards the prevention of a broad spectrum ofmental disorders, given that many disorders share common risk and protective fac-tors. In contrast, selective and indicated prevention strategies may be used effectivelyto target more specific disorders for which the presence of clear-cut risk factors can beused to identify children at risk for the disorder concerned.

Given the knowledge and theoretical underpinnings relating to the prevention ofanxiety disorders in children, the above discussion also highlights the infancy of ourempirical inquest into this area. The majority of studies investigating anxiety preven-tion have tended to be selective and aimed at the acquisition of personal competen-

cies. While this is likely to be an important first step, multidimensional preventativestrategies taking into account multiple risk and protective factors, aimed at differentlevels, and involving a number of preventative strategies are likely to be more effectivein the prevention of childhood anxiety. Futhermore, enquiry into the outcome of pre-ventative strategies requires the use of robust, controlled epidemiological methodsand the use of long-term follow-up.

The research possibilities in the area of prevention are enormous. However, preventionresearch will only be possible and useful if the prevention of mental disorders as a conceptis perceived as important by government, communities, funding bodies, clinicians, andthe general public. Prevention strategies must be conducted on a wide-scale basis beforesignificant reductions in the prevalence of disorders are demonstrated. Researchers, clini-cians, and society as a whole must therefore value and embrace the concept of preventionin the area of mental health before effective prevention can be achieved.

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