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Clin Child Fam Psychol Rev (2014) 17:8596

DOI 10.1007/s10567-013-0152-0

Little Children with Big Worries: Addressing the Needs of Young,


Anxious Children and the Problem of Parent Engagement
Nicholas D. Mian

Published online: 15 August 2013


Springer Science+Business Media New York 2013

Abstract Anxiety disorders in preschool-age children Keywords Anxiety  Preschool  Early childhood 
represent an important clinical problem due to high preva- Parent engagement  Prevention  Early intervention
lence, substantial impairment, persistence, and associated
risk for later emotional problems. Early intervention may
mitigate these problems by capitalizing on a strategic Childhood anxiety disorders represent a major mental
developmental period. Elevated neuroplasticity, availability health problem, with lifetime prevalence estimates ranging
of screening tools, and the potential to modify parenting from 14 to 25 % for community samples of children and
practices position anxiety as a good candidate for early adolescents (Costello et al. 2004). Estimates for preschool-
intervention and preventive efforts. While some novel age children are approximately 9 % (Egger and Angold
interventions show promise, the broad success of such pro- 2006b), but younger children are less likely to receive
grams will largely depend on parent engagement. Since treatment (Egger and Angold 2006a). Anxiety symptoms
parents are less likely to identify and seek help for anxiety and disorders are often chronic and relatively stable across
problems compared to other childhood behavior problems, development if left untreated (Karevold et al. 2009; Mian
especially in a preventive manner, methods for understand- et al. 2011), and child anxiety predicts anxiety disorders as
ing parents decisions to participate and enhancing levels of well as other emotional disorders and negative sequelae,
engagement are central to the success of early childhood such as substance abuse, in adolescence (Bittner et al.
anxiety prevention and intervention. Understanding these 2007; Cole et al. 1998; Kendall et al. 2004).
processes is particularly important for families characterized While progress has been made in developing empirically
by sociodemographic adversity, which have been under- supported treatments and prevention programs for young
represented in anxiety treatment research. This review children, this research has tended to under represent eco-
summarizes the developmental phenomenology of early nomically disadvantaged and ethnic minority families
emerging anxiety symptoms, the rationale for early inter- despite higher risk for emotional problems in such popu-
vention, and the current state of research on interventions for lations (Aisenberg 2001; Allen et al. 2008; Copeland
young, anxious children. The roles of parent engagement and 2005). One of the greatest challenges to developing inter-
help-seeking processes are emphasized, especially among ventions to target these high-risk children is low rates of
economically disadvantaged and ethnic minority commu- parent engagement in early intervention programs (Prinz
nities who are acutely at risk. Evidence-based strategies to et al. 2001). There is reason to believe that this challenge is
enhance parent engagement to facilitate the development particularly salient for anxiety-focused interventions, as
and dissemination of efficacious programs are offered. parents are less likely to identify and seek help for anxiety
problems, compared with more disruptive behavior prob-
lems (Pavuluri et al. 1996). However, very little research
has investigated parent engagement in anxiety-focused
N. D. Mian (&)
intervention research.
Center for Anxiety and Related Disorders, Boston University,
648 Beacon Street, 6th Floor, Boston, MA 02215, USA This review summarizes relevant developmental factors
e-mail: nickmian@gmail.com and the current state of research on interventions for

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preschool-age children with elevated anxiety symptoms. context, and long-term memory of fear context, which are
The focus of the review is on children aged 26 years, but adult-like reactions to fear stimuli (Callaghan and
some interventions reviewed include children as old as Richardson 2011). Hence, early life stress may be associ-
9 years. In addition, this review emphasizes the importance ated with accelerated development of limbic structures and
of studying processes related to parent engagement in early pathways associated with fear acquisition and attentional
intervention, especially among economically disadvan- biases. This research highlights the potential role of neu-
taged and ethnic minority communities. The purpose of this roplasticity of structures related to anxiety and fear in
review is to synthesize research on the phenomenology of young children. From a theoretical perspective, if early life
anxiety in young children, intervention approaches, and stress can lead to changes in brain development, it is rea-
parent engagement to facilitate the development of inter- sonable to suspect that targeted interventions might have
vention research for young, anxious children, with the hope the potential to buffer such effects or alter brain develop-
that interventions can be designed to meet the needs of ment in a protective fashion at this stage.
diverse and underserved populations.
Developmental Issues

Anxiety in Young Children Interesting advances have been made in the phenomenol-
ogy of early childhood anxiety. Multiple research groups
Rationale for Assessing Anxiety and Intervening have used factor analysis to identify patterns of symptom
in Early Childhood differentiation according to diagnostic profiles in pre-
schoolers. These have tended to reflect social phobia (or
Prevalence rates of anxiety disorders among preschool shyness), general anxiety, separation anxiety, obsessive
children are as high as 9.4 % (Egger and Angold 2006b). compulsive symptoms, and fears (Eley et al. 2003; Spence
Common, normative fears in young children are often et al. 2001). A similar model, supporting separation anxi-
transient and include fears of separation, the dark, and ety, social phobia, generalized anxiety, and obsessive
animals, but if they lead to significant impairment and/or compulsive symptoms, has also been supported in 2- to
distress or do not decline with age, they may be associated 3-year-olds (Mian et al. 2012). Of note, obsessivecom-
with severe irritability, mood swings, and worry (Egger and pulsive symptoms have been shown to further differentiate
Angold 2006a). Anxiety in preschool children interferes in young children, representing just right and repetitive
with development, family relationships, and learning. There behavior symptoms in children as young as 1 year of age
is also substantial evidence suggesting that young, anxious (Evans et al. 1997). Still, most early childhood research
children are likely to struggle with emotional problems later applies an undifferentiated construct that represents anxiety
in childhood and into adulthood if left untreated (Biederman symptoms as reflective of a single, diffuse, construct (e.g.,
et al. 2007; Bosquet and Egeland 2006; Cole et al. 1998; Marakovitz et al. 2011). If symptoms do reflect syndromes
Karevold et al. 2009). Hence, in addition to alleviating corresponding to psychiatric diagnoses, then applying an
current distress, intervening in early childhood provides a undifferentiated approach may mask differences in etiol-
developmentally strategic opportunity to improve long- ogy, risk, trajectories, and treatments for young children.
term emotional functioning. Theoretically, improving par- For example, Kendall et al. (1997) found that school-age
entchild transactional processes by teaching parenting children diagnosed with avoidant disorder improved less
skills has the potential to influence emotion regulation and than children with overanxious and separation disorders.
coping throughout childhood (Bayer et al. 2011; Hirshfeld- Weems (2008) offers a theoretical model that differen-
Becker and Biederman 2002). Intervening with young tiates between primary and secondary features of anxious
children shifts the primary agent of change from the child to emotion. Primary features represent the underlying dys-
the parent, thereby making successful parent engagement a regulation of the emotional response system that likely
crucial ingredient in early intervention. accounts for general risk for anxiety disorder, including
There is also reason to believe that early intervention physiological, cognitive, and behavioral symptoms. Sec-
may be more effective due to heightened neuroplasticity in ondary features represent symptoms that are disorder-spe-
young children, increasing the potential for changes in cific, such as fear of embarrassment in social anxiety
neural pathways related to attentional processes and disorder. The same underlying primary feature may man-
approach-avoidance behaviors thought to be biological ifest as different disorders at different developmental
precursors to anxiety (Bar-Haim et al. 2007; Derryberry periods, affecting whether any individual child remains on
and Reed 1994). Research with rodents has demonstrated a particular trajectory. Although differentiated symptoms
that early life stress increases fear relapse following are present in children as young as 2 years (Mian et al.
extinction, the relationship between fear response and 2012), primary features may still represent the main source

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of distress for young children. As such, research that strongly recommended (Hirshfeld-Becker and Biederman
investigates whether treatments, such as exposures, have an 2002; Pincus et al. 2005; Suveg et al. 2006). Preschool-age
effect on primary versus secondary features of anxious children often spend far more time with their parents,
emotion could shed light on mechanisms for treatment. suggesting that parents have a stronger influence on their
A related developmental consideration is differentiating childrens behavior. Also, separating from parents, sleep-
between temperamental variations and symptoms, which ing alone or away from home, and approaching novel sit-
are difficult to disaggregate (Rapee and Coplan 2010). uations or people are among the most commonly reported
About 15 % of children present with behavioral inhibition, anxiety symptoms for young children (Spence et al. 2001),
a temperamental construct characterized by low levels of suggesting that symptoms often relate directly to parents.
approach behavior and higher autonomic reactivity in novel Lastly, parents of young children are more likely to
situations (Kagan 1984) and thought to be a risk factor for exclusively make decisions regarding treatment attendance,
later anxiety disorders (Biederman et al. 2001). However, highlighting the importance of parent engagement. Virtu-
some researchers now question whether this presentation is ally, all interventions described below emphasize parental
better thought of as an early sign of anxious symptomology involvement.
(e.g., Egger and Angold 2006a). Inhibited children can
present very similarly to those who are clinically anxious;
differentiation is most likely due to the degree of distress or Early Intervention Models for Preschool-Age Children
impairment. In one study, 90 % of children identified as
having behavioral inhibition were found to meet criteria for The term prevention is used broadly in this review to refer
anxiety disorder (Kennedy et al. 2009), suggesting signifi- to interventions that target children who are not yet expe-
cant overlap. These two constructs can be differentiated riencing an anxiety disorder (Mrazek and Haggerty 1994).
conceptually, particularly in that a substantial number of Prevention and treatment are thought to be part of the same
individuals have fearful temperaments without a history of continuum of providing care, and the distinction can be
anxiety disorder and that interventions tend to have stronger misleading, as treatment in early childhood is inherently
effects on symptoms than temperamental characteristics preventive if the effects reduce symptoms in the future.
(Rapee and Coplan 2010). However, challenges remain in However, the distinction is applied here because more
differentiating the two through measurement. One method severe symptomology is predictive of seeking clinical
may be by assessing functional impairment, which should services (Pavuluri et al. 1996). Hence, it is likely that
be more associated with disorders. engagement patterns may differ for prevention and treat-
ment approaches.
Implications for Family Involvement in Treatment
Prevention Approaches
Research on the impact of parental behaviors on childrens
anxiety symptoms and the high likelihood that parents will There is a growing interest in the cost-effectiveness of
also be anxious suggest that including parents in treatment providing mental health services in a preventive fashion
will help to reduce parenting behaviorssuch as modeling (Mrazek and Haggerty 1994). Anxiety has been presented
anxious behaviors or reinforcing avoidancethat have as a good candidate for selective (targeted) prevention due
been implicated in anxiety disorders (Ginsburg and Sch- to its prevalence, developmental stability, known risk fac-
lossberg 2002). Hence, early, family intervention could tors, and availability of screening tools (Bayer et al. 2011;
help to foster healthier, active coping from a young age. Hirshfeld-Becker and Biederman 2002; Rapee 2002). The
With school-age children, family-based cognitive-behav- risk factors that have received the most support are
ioral therapy (CBT), which provides parents with infor- behavioral inhibition and parental anxiety disorder
mation on contingency management, personal anxiety (Hirshfeld-Becker and Biederman 2002; Rapee 2002), but
management, and how to respond to the child, has been early manifestations of anxiety symptoms (Mian et al.
shown to be as effective or more effective than standard 2011) and attention bias to threat (Bar-Haim et al. 2007)
CBT (for a review, see Ginsburg and Schlossberg 2002). may also represent good candidates. More research is
Parent involvement is thought to facilitate the transfer of needed on the sensitivity and specificity of using risk fac-
knowledge and skills from therapist to parent and from tors to identify at-risk children and identifying the optimal
parent to child (see Ginsburg and Schlossberg 2002). This developmental period for prevention. While some
model suggests that if these processes are successful, par- researchers have targeted pre-adolescence (Ginsburg
enting changes can continue to lead to positive effects long 2009), earlier intervention may be preferable to decrease
after formal treatment ends (e.g., Rapee 2013). With anxiety symptoms throughout childhood (Rapee et al.
younger children, including parents in therapy has been 2005).

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The most highly developed and tested prevention pro- marginal, non-significant improvements, suggesting that
grams for young children have been conducted in Australia this intervention was not powerful or targeted enough to
by Rapee et al. (2005), who designed a selective prevention change anxious/withdrawn behaviors.
intervention (Cool Little Kids) for young children at risk Other examples of prevention-based approaches have
for anxiety by virtue of being behaviorally inhibited (Rapee focused on universal prevention, which strives to provide
2002). The 146 children (aged 36 to 62 months) who met an intervention for all children in a particular population.
criteria were randomly assigned to either a monitoring Pahl and Barrett (2010) designed a school-based program
group or a 6-session parent education group that focused on for preschool-age children (aged 4 to 6 years), also in
CBT strategies, including psychoeducation, use of fear Australia, called the Fun FRIENDS program. This CBT-
hierarchies, the relationship between overprotection and based program was delivered directly to children in a
anxiety, and cognitive restructuring for parents own wor- preschool classroom over nine one-hour sessions. It
ries (children did not directly receive services). At includes developmental modifications of CBT strategies,
12-month follow-up, the intervention led to a decrease in including relaxation, active coping, thought monitoring,
the development of an anxiety disorder, but did not affect and self-talk. In addition, parents were offered three
temperamental inhibition. Interestingly, girls in the inter- information sessions on psychoeducation about anxiety and
vention group were assessed to have fewer internalizing session content. The RCT conducted with this intervention
problems 11 years later, at age 15, compared to the control demonstrated feasibility of providing an intervention in this
group (this effect was not found for boys), suggesting that format, but did not achieve significant effects for symptoms
even a brief, parenting-focused program can have long- across intervention groups. Notably, effects of this inter-
lasting preventive effects (Rapee 2013). vention were undermined by high levels of attrition and
The same research group later targeted children at even low levels of parent participation (discussed in more detail
higher risk by including children who were inhibited and below). Dadds and Roth (2008) also conducted a universal
had a parent with an anxiety disorder (Kennedy et al. prevention study in Australia that was designed to prevent
2009). The intervention was also enhanced by adding two the development of anxiety disorders, but with limited
additional parent sessions. Seventy-one children (mean of success. This study included 734 parents of children aged 3
47 months old) were randomly assigned to a parent edu- to 6 years. Parents participated in a six-session CBT-based
cation group or a 6 months waitlist. At post-intervention, training program, which specifically targeted the develop-
there were significant treatment effects for both maternal- ment of positive encouragement, positive self-talk, and
reported and observational measures of inhibition, and strength-based coping. Although anxiety symptoms
more children in the intervention group were free of anx- decreased, these effects were small and only evident in
iety disorders compared to those in the control group (46.7 teacher reports; they were also no longer present at
vs. 6.7 %, respectively). The results of this study are 7-month follow-up, suggesting this universal intervention
impressive because changes were observed in diagnostic may have been too general to address anxiety symptoms.
status, symptom severity, and level of inhibition, a tem-
peramental construct that is thought to be relatively stable Treatments for Anxiety with Young Children
over time. A translational randomized controlled trial
(RCT) is now under way, which will test the intervention It has been documented for decades that specific phobias (or
without previous limitations, such as research university fears) can be treated in preschool-age children with operant
location, self-selection of participants, and laboratory approaches (for a review, see Ollendick and King 1998),
assessment methods (Bayer et al. 2011). As described, this suggesting that such interventions (i.e., exposures and
trial will include participants from low, medium, and high modeling) are effective with young children. However, most
socioeconomic levels. of these studies preceded the advent of current methodo-
Another prevention approach was conducted in Canada logical recommendations for empirically supported treat-
by Lafreniere and Capuano (1997). This study included ments, including maximizing the representativeness of
children (mean age of 4.5 years) identified by an elevated clinical samples (Weisz et al. 2005). These treatments were
anxious-withdrawn score on a parent-report measure. designed to treat specific phobias, and it is unclear whether
Half the children were randomly assigned to a series of 19 addressing the underlying features of anxious emotion (e.g.,
individual parent meetings (mostly home visits). This cognitive distortions, stimulus generalization, attention
intervention was aimed at addressing general social-emo- biases), found in more complex anxiety disorders, requires a
tional development by improving developmental under- treatment that goes beyond behavioral techniques, such as
standing, parent competence, parent stress, and social cognitive restructuring does with older children. Specific
support. Although there were positive results in this study, phobias have also been shown to be easier to treat, with
changes on the anxious-withdrawn subscale indicated only school-age children benefitting from single-session exposure

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treatments (Ollendick et al. 2009). Differences between sample appeared to represent mostly White, middle, and
fearan autonomic response to present threatand anxi- upper-middle class families.
etya multi-faceted, future-oriented response of apprehen- Two research groups are adapting parentchild interac-
sion (Barlow et al. 1996)suggest that treatments that tion therapy (PCIT), an empirically supported treatment for
address both will be most useful. preschool-age children with behavior problems, for use
Recent advances have been made in developing treat- with young, anxious children (Comer et al. 2012; Pincus
ments for young children diagnosed with an anxiety disorder. et al. 2008; Puliafico et al. 2012). Unlike the treatments
Targeting children with clinically severe symptomology described above, PCIT is not a downward extension of an
avoids the major challenge of engaging parents who may not intervention designed for older children, but was originally
be highly motivated, a significant problem for preventive designed for preschool-age children and their parents.
approaches. Hirshfeld-Becker et al. (2010, 2008) conducted Pincus et al. (2008) tailored PCIT for children with sepa-
a RCT for CBT targeting 4- to 7-year-old children with ration anxiety disorder (SAD) based on the importance of
anxiety disorders. This group employed developmental parents unique involvement in the maintenance of SAD. A
adaptations to develop Being Brave: A Program for Coping new phase was added to the PCIT protocol: the bravery-
with Anxiety for Young Children and Their Parents. This directed interaction (BDI). Parents receive psychoeduca-
program includes 20 sessions reflecting four modules: parent tion about anxiety and relevant maintaining factors (i.e.,
anxiety management (sessions 13), coaching the child in avoiding feared situations) and are coached to guide the
anxiety management (46), child anxiety management child through exposure exercises and reinforce bravery.
(719), and relapse prevention (20). The first six sessions Coaching parents to conduct the exposures without the
involve parents only, allowing parents to learn the content therapist visible may increase portability beyond the ther-
before assisting the child. Content includes psychoeduca- apy office. The first RCT for this treatment (with nine
tion, parental modeling, cognitive restructuring (for parents), sessions) is being conducted with children ages 4 to 8 years
dangers of overprotection, exposure exercises, relaxation with a principle diagnosis of SAD (Pincus et al. 2008).
exercises, and maintenance strategies. Developmental Preliminary findings are encouragingclinician-reported
adaptations include relaxation techniques designed for measures of symptom severity decreased from 5.54 to 2.80
younger children, self-instructive strategies (rather than on a scale of 08. Parents reported the intervention
cognitive restructuring), inclusion of games in exposure increased their confidence. Another research group has
exercises, and immediate positive reinforcement. After developed the CALM Program, which is an adaptation of
treatment, 59 % of children receiving the intervention were PCIT for a range of anxiety disorders (Comer et al. 2012;
free of anxiety diagnosis, compared to 18 % of controls. Puliafico et al. 2012). In addition to the core PCIT skills,
Gains were largely maintained at 1-year follow-up. Inter- this program employs CBT principles, such as teaching
estingly, children who were rated as behaviorally inhibited parents to selectively attend to children to reinforce brave
were less likely to benefit. As with many treatment studies, behavior during in vivo exposures. Unlike standard PCIT
this sample represented low levels of sociodemographic risk and the modification by Pincus et al. (2008), the CALM
(despite high levels of psychiatric risk): 80 % of children program does not address child discipline, as in the parent
identified as European American, 88 % were from intact directed interaction phase. A small, pilot trial with 12
families, and the sample was largely middle class and well- sessions has provided encouraging results, with 86 % no
educated. While this study provides good evidence that CBT longer meeting criteria for anxiety disorder. Since PCIT
can be effectively adapted for young children, it is unclear has been used with younger children (Schuhmann et al.
whether similar protocols would be effective with more 1998), these treatments may be useful for children younger
disadvantaged or diverse samples. than 4 as well.
Cartwright-Hatton et al. (2011) also developed a CBT- These examples of CBT and PCIT mark important pro-
focused intervention, Timid to Tiger, for young children gress in developing treatments for young, anxious children.
(aged 2.79 years; mean = 6.6 years) with anxiety disor- Both approaches have produced encouraging preliminary
ders. Most children (64 of 74) were self-referred. Parents results and reflect rigorous methodology. These approaches
were invited to 10 group sessions (children did not attend) are theoretically and empirically derived and represent
that focused on maintaining a warm, predictable home adaptations of existing empirically supported approaches.
environment and teaching parents how to manage child However, only one of the studies above (Cartwright-Hatton
anxiety by applying CBT strategies. Even with this brief et al. 2011) included children younger than age 4, and they
intervention, results were similar to the CBT study above; all include children of school age. Including separate
57 % of children were free of their primary anxiety diag- analyses for younger children or testing age as a moderator
nosis, compared to 15 % of controls. Gains were also (as in Hirshfeld-Becker et al. 2010) can help demonstrate if
demonstrated for anxiety symptom levels. Again, this the intervention works equally well across ages. Studies

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with children under age 4 have generally taken the form of academic failure. In addition, parents may be more likely
parent trainings (Cartwright-Hatton et al. 2011; Rapee et al. to see anxiety as something that will get better by itself, a
2005), reflecting the difficulty of implementing individual barrier to help seeking that was endorsed by 79 % of
treatments in this age group as well as evidence that parents in one study (Pavuluri et al. 1996).
changing parenting alone can lead to improvements. One theoretical model for parents help-seeking behav-
However, treatments that include both child and parent iors for young childrendrawn from the health beliefs and
components have been implemented for behavior problems pediatric mental health service literaturesidentifies
(Webster-Stratton and Reid 2003). While the studies cited behaviors necessary for receiving help: recognizing that a
above provide encouraging progress, they are limited by problem exists, deciding to seek help, identifying an action
low clinical representativeness of samples and settings, like plan, and taking action (Godoy and Carter 2013). Many
much efficacy research (Weisz et al. 2005). factors, such as feedback from family members and pro-
Finally, there is a dearth of research from different fessionals or parents own anxiety, can affect parental
theoretical orientations in the child anxiety literature. Play motivation at each step and move a parent toward or away
therapy, which reflects a psychodynamic framework, uses from taking action. One of the most important influences
play to encourage emotional expression, learning, and on this process is the parents appraisal of the childs
integration of feelings (Benham and Slotnick 2006). While problem, which encompasses explanatory models, per-
widely practiced with young children, empirical outcome ceived severity, and worry about the problem. When sta-
data are conspicuously lacking, especially for specific tistically modeled among low-income parents, parental
problems. Bratton et al. (2005) analyzed results from 94 appraisals have predicted parents considering seeking help,
studies that included a broad range of diagnostic problems which then predicted service receipt (Godoy et al. 2013).
and approaches. Only 43 had been published, of which According to this model, parents would be expected to be
only seven included an outcome measure for anxiety or less motivated to participate in the prevention programs
fear. The effect size for these studies was 0.69, one of the because they target children who are not yet experiencing
lowest investigated. Despite difficulties related to measur- clinical problems (Mrazek and Haggerty 1994). Unlike
ing, standardizing, and quantifying this treatment, its preventive medicine, such as vaccines and regular check-
developmental appropriateness for young children suggests ups, the benefits of prevention programs for mental health
it may inform interventions for preschool-age children. concerns are virtually unknown. Hence, understanding
parents decisions related to participation and identifying
ways to change parent appraisals or attitudes are
The Challenge of Parent Engagement paramount.
In Rapee et al. (2005) prevention study described above,
The Importance of Parent Engagement 1,647 of 5,609 (29.4 %) screening packets were returned.
In addition, 73 children were self-referred by parents. Of
The greatest challenges to dissemination and establishing the 1,720 children, 285 scored above a behavioral inhibi-
effectiveness of early childhood anxiety interventions for tion cut score and were invited to attend a laboratory
high-risk children will likely be related to parents interest, assessment and 180 (63 %) attended. Of the 180, 148 met
willingness, or ability to engage in these programs. In the laboratory-based assessment for behavioral inhibition, and
general population, the vast majority of children in need of 146 (aged 36 to 62 months) agreed to participate. It is not
mental health services do not receive them (Horwitz et al. clear how many of the 73 self-referred children are repre-
2003; Pavuluri et al. 1996), and rates of unmet need are sented in the 146 participants. This study illustrates some
highest among children younger than age 6, uninsured challenges with conducting this type of prevention pro-
children, and children of color (Kataoka et al. 2002). Low gram. First, this sample included predominantly Anglo-
rates of professional service utilizationas low as 3 % Saxon or European participants (approximately 85 % of
have been found for 4-year-olds with clinical diagnoses the final sample), potentially limiting generalizability of
(Lavigne et al. 2009). Low rates are also seen in prevention both results and engagement to other ethnic groups (it
program participation (Prinz et al. 2001). This problem is would be interesting to compare this proportion to the
particularly important for anxiety intervention, as parents areas population to assess for different engagement pat-
are generally less likely to recognize there is a problem and terns across groups). Second, only 146 of 5,682 potential
seek help for internalizing symptoms compared to prob- participants met criteria and agreed to participate. Since an
lematic externalizing or hyperactive behaviors (Chavira 85th percentile cut score was used for the initial screening,
et al. 2004; Pavuluri et al. 1996; Wu et al. 1999). Parents it could be expected that approximately 852 children would
may perceive behavior problems as having more severe have met initial criteria for participating if all packets were
consequences such as school expulsion, social isolation, or returned. Of that estimated number, 146 (17 %) actually

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attended, and this likely includes self-referred children. Paradoxically, these high-risk samples are under-repre-
Although participating parents benefited substantially, sented in treatment studies, including those described in
programs like this must reach more parents to achieve this review. Huey and Polo (2008) identified only three
large-scale societal impact. Further, since 90 % of partic- controlled studies addressing anxiety among minority
ipants had an anxiety disorder at the study onset (see (school-age) youth. These are increasingly important
Kennedy et al. 2009), it is likely that parents with children problems, as ethnic minority individuals are estimated to
with relatively severe anxiety self-selected to participate. represent half of the US population by 2050, with half
The translational RCT that is currently under way (Bayer being Hispanic (Day 1996). Moreover, families character-
et al. 2011) will likely be crucial in assessing feasibility for ized by low socioeconomic status benefit less from parent
large-scale dissemination. Challenges related to engaging training programs (Leijten et al. 2013).
families were found across many studies in this review; Focusing on families characterized by sociodemographic
Dadds and Roth (2008) invited a potential 1,646 parents; adversity may be particularly important for anxiety inter-
734 consented to participate, but only 107 parents (30 % of ventions due to the relationship between uncontrollability in
the intent-to-treat group) actually attended sessions. the environment and anxiety (Chorpita and Barlow 1998).
Retention has also been a problem. In the Fun FRIENDS Young children living in poor, urban communities are more
study (Pahl and Barrett 2010), a high level of initial likely to be exposed to potentially traumatic experiences,
engagement was successfully achieved by offering the ranging from parental conflict to domestic and community
program through a public preschool, but 41 % of partici- violence (for reviews, see Briggs-Gowan and Mian in press;
pants failed to complete the post-treatment assessments. Margolin and Gordis 2000; Osofsky 1999). In a study by
Another important consideration is the relationship Aisenberg (2001), 26 % of young, poor, Latino children had
between parent engagement and effectiveness. Pahl and experienced violence toward themselves and 45 % had
Barrett (2010) reported low levels of parent participation at witnessed violence in their lifetime. Not surprisingly,
information sessions, which was thought to reduce overall exposure to trauma, violence, or family conflict is associ-
intervention effects. Also, those with higher levels of pre- ated with elevated anxiety symptoms in young children
treatment anxiety symptoms were more likely to complete (Marakovitz et al. 2011; Margolin and Gordis 2000;
the program, suggesting that parents for whom the program McDonald et al. 2007), suggesting exposure may be a
was most relevant were more engaged with it. Similarly, mechanism through which sociodemographic adversity can
Dadds and Roth (2008) found that more highly stressed lead to anxiety. This could be due to associated increases in
parents tended to remain in the intervention. Such results feelings of insecurity or uncontrollability (Chorpita and
highlight the importance of tracking engagement as it can Barlow 1998), affecting the development of brain structures
relate to statistical power, effects, and generalizability. associated with fear responses (Callaghan and Richardson
These results are consistent with the finding that parents of 2011). Research investigating the relationship between
low socioeconomic status benefit less from parent training potentially traumatic experiences and anxiety is needed.
programs, except when problems are severe (Leijten et al.
2013). As suggested by the authors, this moderation effect Patterns of Service Use and Factors Associated
is most likely due to lower levels of parent engagement with Parent Engagement
among this population. This effect is especially problem-
atic for prevention programs and may also be more prob- There is a dearth of research on treatments for ethnic
lematic for interventions targeting anxiety if such minority and high-risk children, which is partly explained by
symptoms are perceived as less severe. service use patterns that differ from White, European fami-
lies and reflect disparities in access to care and variations in
Rationale for Focusing on Families with High attitudes regarding the cause, meaning, and treatment for
Sociodemographic Adversity psychological problems (Alegria et al. 2004; Cauce et al.
2002; Copeland 2005; Garland et al. 2005; Harari et al.
Achieving long-term societal benefit by helping young, 2008). Consistent with this concept, single mothers and
anxious children necessitates being able to reach the chil- ethnic minority children are more likely to drop out of CBT
dren who are most in need. Research suggests that children for child anxiety (Kendall and Sugarman 1997). Similar
from families characterized by sociodemographic risk sociodemographic trends can be seen in rates of accessing
including poverty, minority ethnicity, immigration, stress- community child mental health services (Garland et al. 2005;
ful life events, single-parent households, and low parent Pavuluri et al. 1996). However, once parents engage initially,
education are at higher risk for mental health problems higher symptom levels and lower stress have been associated
(Allen et al. 2008; Briggs-Gowan et al. 2001; Costello with retention in prevention programs (Dadds and Roth
1989; Duncan et al. 1994; McLeod and Shanahan 1993). 2008; Pahl and Barrett 2010).

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No known studies have specifically investigated factors services, such as lack of childcare or transportation. Training
related to engagement in programs targeting early childhood providers in specific strategies aimed at improving parent
anxiety; hence, research cited below relates to engagement in engagement improved rates of attending first appointments by
programs targeting externalizing problems. While it may be 30 % in low-income, urban samples (McKay et al. 1996a).
more challenging to engage parents in interventions for Szapocznik et al. (1988) also investigated an engagement
anxiety, it is unclear whether these programs will require strategy, but among families with adolescent drug users. This
different engagement practices. Some barriers to treatment protocol used a family-based, strategic structural-systems
relate directly to the situational difficulties that characterize engagement method that employed family therapy techniques
many families living in disadvantaged communities, (joining and restructuring) according to different types of
including poverty, healthcare, transportation, and scheduling patient resistance. The therapist strived to join the family in a
(Linfoot et al. 1999). Time demands and scheduling issues way that did not threaten family structure (e.g., aligning with a
are often the most import barriers cited by parents (Gross particular parent based on which was ambivalent or disengaged
et al. 2001; Spoth and Redmond 2000). Spoth and Redmond in seeking treatment). Hence, the engagement strategy used
(2000) found that more highly educated parents of school- varied according to the type of family resistance (for a detailed
age children were more interested in participating and description, see Szapocznik et al. 1988). This technique suc-
reported higher perceived benefits. Another barrier they cited cessfully engaged 93 % of families compared to 42 % in the
was not wanting to be a research subject, suggesting parents control condition (Szapocznik et al. 1988). However, it is
may experience mistrust of research institutions. important to note that these studies aimed at engaging parents of
Heinrichs et al. (2005) investigated parent recruitment school-age children in community clinics, to which they had
rates and barriers to attendance in a two-phase study that already been referred. Early intervention and prevention pro-
involved completing assessments (phase 1) and then grams may require more powerful methods of engaging parents,
attending a 4-week parenting program. Targeted children since parents will be introduced earlier in the help-seeking
aged 36 years were recruited through preschools in Ger- process (Godoy and Carter 2013). However, both protocols
many. Parents from low SES neighborhoods were recruited could theoretically be adapted for early intervention. Rather
at a rate of 23 %, with these families being four times less than clarifying the need for clinical services in McKays pro-
likely to participate than parents from high SES neighbor- tocol, the potential benefit of preventive services could be
hoods. Regarding participation in the parenting program, emphasized. Szapoczniks protocol identifies family barriers to
77 % of parents who completed assessments in phase 1 engagement before the first session, which could be very useful
participated in the program. Again, parents from lower SES for engaging parents of young children.
neighborhoods, as well as single parents, were less likely to The Guiando a Ninos Activos (Guiding Active Children;
participate. Another research group that investigated parent GANA) program, an adaptation of PCIT for Mexican
engagement in early childhood prevention trials (in the American families, is an example of a cultural adaptation
United States) for low-income parents achieved rates of of an empirically supported treatment that includes a parent
35 % for project enrollment, as defined by parents agreeing engagement module (McCabe et al. 2005). The module is
to participate (Garvey et al. 2006). However, 33 % of parents based on McKays engagement strategies (McKay et al.
who enrolled never attended sessions and 8 % attended only 1996b), but include cultural variations, such as removing
one. Hence, only 23 % (196/858) of targeted families terms such as therapy or mental health from protocols
attended, despite strong and impressive results for those who to reduce stigma, increasing contact with family members
did. Thus, parent engagement rates in programs targeting beyond the parentchild dyad and explicitly addressing
early childhood behavior problems are often lower than 30 % preconceptions of treatment. Despite these efforts, a RCT
within high-risk communities. It is reasonable to expect that with 37-year-old children did not demonstrate better
rates for programs targeting anxiety would be even lower. engagement rates compared to PCIT-as-usual (McCabe and
Yeh 2009), suggesting that more research may be needed to
Enhancing Parent EngagementWhat Can Be Done? enhance engagement for this group.
Many research studies on parent engagement in pre-
McKay et al. (2004, 1996a) have developed the most widely vention include school-age children, but it is likely that
implemented strategies to enhance initial parent engagement such research can inform engagement procedures for
for child mental health services. The parent engagement inter- younger children. Spoth and Redmond reported in a series
vention strives to: (a) clarify the need for mental health services, of prevention studies with sixth graders that perceived
(b) maximize the caregivers investment and efficacy related to benefits about a program predicted reported inclination to
help seeking, (c) identify attitudes about seeking services participate, and this predicted actual participation (Spoth
including negative attitudes based on previous experiences, and and Redmond 2000). Parents also emphasized meeting
(d) develop strategies to overcome concrete obstacles to seeking location, program duration, evidence of efficacy, and the

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Clin Child Fam Psychol Rev (2014) 17:8596 93

background of the program leader. Other research has engagement is much needed, and multi-dimensional parent
indicated that parents are more likely to attend sessions if anxiety measures that differentiate between subtypes (i.e.,
they perceive them to be aligned with their own prefer- social anxiety) may prove particularly useful.
ences for type of clinical service (Bannon and McKay
2005). Gross et al. (2001) investigated the role of incen-
tives for participating parents of preschool-age parents. The Conclusions
incentive most often endorsed was that the program be
offered on-site (at the childs day-care setting; 93 %), This review orients the present state of research at an
followed by the personality of the recruiter (88 %), free exciting moment in the development of interventions for
childcare (86 %), a copy of an assessment video (83 %), young children. Anxiety in preschool-age children is rec-
and offering the program on weekday evenings (79 %). ognized as a serious issue, but interventions are relatively
Another engagement strategyaimed at reducing stigma nascent. Empirical bases for treatments for school-age child
involves advertising the program in terms of the advanta- anxiety, preschool externalizing behavior, and adapted
ges of participating rather than the clinical need for ser- treatments for ethnic minority populations can inform the
vices, consistent with research indicating that parents development of interventions. It is advised that researchers
participate in programs to become better parents rather than acknowledge and measure the role of parent engagement,
to reduce problematic behaviors (Gross et al. 2001). particularly as it relates to reaching anxious children from
Some research on specific recommendations for recruit- diverse and high-risk backgrounds. While challenges rela-
ment among ethnic minority populations has emphasized ted to parent engagement are not unique to early childhood
active, community-based recruitment, including: (1) using anxiety, they may be particularly salient for this population.
participants native language, (2) recruitment in community Furthermore, these challenges represent a significant barrier
settings, and (3) recruitment through trusted community to developing treatment and prevention programs for
leaders (Harachi et al. 1997). This study, which included underserved populations and for wide-scale dissemination.
immigrant, non-English speaking parents of 67th graders, Demonstrating that prevention programs will reach parents
used non-traditional methods, such as recruiting at church and in need is important for the community partnerships and
community events, using social networks, and going door-to- funding agencies that make such research possible.
door in nearby neighborhoods. Another strategy is linking the The development of effective interventions for young,
research project with known and trusted community institu- anxious children represents an opportunity to ameliorate
tions, leaders, or providers, referred to as community suffering for children and families as well as the potential to
endorsement, which is thought to mitigate the barrier of mis- improve the course of emotional functioning across the life
trust or not wanting to be a research subject (McCabe et al. span. Extending such services to children in the most vul-
2005; Prinz et al. 2001). One example is including a letter from nerable communities and addressing barriers to treatment
the school principal (Prinz et al. 2001) or director of a childcare represent important ethical and public health responsibili-
program inviting parents to participate. ties. As the field develops treatments and preventive
There is reason to believe that enhancing recruitment approaches for this population, it is hoped that program
strategies for programs addressing anxiety in young children development is informed by research related to engaging
are particularly important due to the likelihood that partici- parents from hard-to-reach families.
pating parents will be anxious as well. As such, inviting
parents to groups may be anxiety provoking, especially if Acknowledgments I would like to thank Dr. Alice S. Carter for her
guidance and support of this project.
parents are anxious about how their parenting strategies will
be perceived. Recruitment methods aimed at reducing anx-
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