Preventing anxiety and promoting social and emotional strength in early childhood

241 Pages·2009·1.08 MB·English

Preventing anxiety and promoting social and emotional strength in early childhood: An
investigation of aetiological risk factors
Kristine Marie Pahl

A thesis submitted for the degree of Doctor of Philosophy in Clinical Psychology

The University of Queensland in February 2009

School of Psychology
To my mom and dad
Preventing anxiety and promoting social and emotional strength
Declaration by author

This thesis is composed of my original work, and contains no material previously published
or written by another person except where due reference has been made in the text. I have clearly
stated the contribution by others to jointly-authored works that I have included in my thesis.
I have clearly stated the contribution of others to my thesis as a whole, including statistical
assistance, survey design, data analysis, significant technical procedures, professional editorial
advice, and any other original research work used or reported in my thesis. The content of my thesis
is the result of work I have carried out since the commencement of my research higher degree
candidature and does not include a substantial part of work that has been submitted to qualify for
the award of any other degree or diploma in any university or other tertiary institution. I have
clearly stated which parts of my thesis, if any, have been submitted to qualify for another award.
I acknowledge that an electronic copy of my thesis must be lodged with the University
Library and, subject to the General Award Rules of The University of Queensland, immediately
made available for research and study in accordance with the Copyright Act 1968.
I acknowledge that copyright of all material contained in my thesis resides with the
copyright holder(s) of that material.

Statement of Contributions to Jointly Authored Works Contained in the Thesis

Pahl, K.M., & Barrett, P.M. (in press). Interventions for Anxiety Disorders in Children using Group
CBT with Family Involvement. In J. Weisz, & A. Kazdin (Eds.) Evidence-Based
Psychotherapies for Children and Adolescents, Second Edition. New York: Guildford
Publications.
Pahl was responsible for writing the book chapter and Barrett was responsible for reviewing the
book chapter and providing feedback.

Pahl, K.M., & Barrett, P.M. (submitted). Examining Potential Risk Factors for
Anxiety and Behavioural Inhibition in Preschool Aged Children. Manuscript submitted for
publication.
Pahl was responsible for writing the article and conducting the statistical analyses. Barrett was
responsible for assisting with conceptualisation and providing feedback.

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Preventing anxiety and promoting social and emotional strength
Pahl, K.M., & Barrett, P.M. (submitted). Preventing anxiety and promoting social and emotional
strength in preschool children: A universal evaluation of the Fun FRIENDS program.
Manuscript submitted for publication.
Pahl was responsible for writing the article and conducting the statistical analyses. Barrett was
responsible for assisting with conceptualisation and providing feedback.

Statement of Contributions by Others to the Thesis as a Whole
No contributions by others.

Statement of Parts of the Thesis Submitted to Qualify for the Award of Another Degree
None.

Published Works by the Author Incorporated into the Thesis

Pahl, K.M., & Barrett, P.M. (in press). Interventions for Anxiety Disorders in Children using Group
CBT with Family Involvement. In J. Weisz, & A. Kazdin (Eds.) Evidence-Based
Psychotherapies for Children and Adolescents, Second Edition. New York: Guildford
Publications. Incorporated as Chapter Four

Pahl, K.M., & Barrett, P.M. (submitted). Examining Potential Risk Factors for
Anxiety and Behavioural Inhibition in Preschool Aged Children. Manuscript submitted for
publication. Incorporated as Chapter Seven.

Pahl, K.M., & Barrett, P.M. (submitted). Preventing anxiety and promoting social and emotional
strength in preschool children: A universal evaluation of the Fun FRIENDS program.
Manuscript submitted for publication. Incorporated as Chapter Eight.

Additional Published Works by the Author Relevant to the Thesis but not Forming Part of it
None.

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Preventing anxiety and promoting social and emotional strength
Acknowledgements
I would like to sincerely thank my principal supervisor, mentor, and friend, Professor Paula
Barrett for her constant support, encouragement, and positive guidance over the past four years.
Thank you for sharing your knowledge with me and for providing me with so many wonderful
opportunities, both personally and professionally. Thanks to my secondary supervisor, Associate
Professor Ken Packeham for his assistance during beginning stages of this thesis.
I would like to thank my partner Andrew for being a constant ray of sunshine and for
standing by my side throughout every step of this long process. Thank you for always being
optimistic and wonderful - I have grown tremendously from your strength and from your love.
A special thanks to my mom for her unconditional love and support. Thanks for instilling
me with the skills, values, and resilience needed to achieve. Thanks to my brother Jeff for always
believing in me, for being a great cure for homesickness, and for making every Canadian vacation
special, filled with all of my favourite things. Thanks to my brother Jay and my sister-in-law Elske
for being a source of positive support, for believing in my ability to achieve, and for giving me the
most adorable nieces and nephew.
A special thank you to my dear friend Meike who worked on this project with me during its
beginning stages and who helped me remain positive and hopeful when things seemed impossible.
Thanks for always listening, always caring, and for always being a wonderful friend.
I would also like to thank some very special friends who have provided incredible support to
me over the past four years - Leah, Glynis, Kirsty, and Katherine. I do not know what I would have
done without our monthly dinners, weekend workouts, and intimate conversations. I am a better
person for having you all in my life.
Thanks to my fourth year Honours supervisor and mentor, Professor Michael Ashton (Brock
University, Canada) for peaking my interest in research and for encouraging me to apply to
graduate school.
A very special thank you to all of the schools, teachers, children, and families who
participated in this research project. It was a pleasure working with each and every one of you.

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Preventing anxiety and promoting social and emotional strength
Abstract
Anxiety disorders are among the most prevalent psychiatric disorders in children and
adolescents, with ten to fifteen percent of young children experiencing internalising problems
(Briggs-Gowan, Carter, Irwin, Wachtel, & Cicchetti, 2004; Egger & Angold, 2006). Researchers
have indicated that clinically significant anxiety can exist in preschool aged children and can be
sub-typed into patterns similar to that of older children. This early identification of anxiety has lead
researchers to recommend that prevention efforts occur early in the life course (Beinvenu &
Ginsburg, 2007), before the onset of disorder(s). Research remains scarce as to when the ultimate
time to intervene would be, as anxiety research with young children is minimal. The studies
presented in this thesis attempt to expand the current literature within in the area of early childhood
anxiety.

The first objective of this thesis was to extend the literature in the field of early childhood
anxiety by examining the aetiology of anxiety and behavioural inhibition (BI) through the
investigation of potential risk factors. This study (Study One) represents one of the first
investigations within the research to examine risk factors for early childhood anxiety. Two hundred
and thirty-six children aged four to six years participated in this study. Parents of the children
completed self-report questionnaires at one time point. Results revealed that BI did not
significantly predict anxiety, nor did any of the risk factors significantly predict BI. Significant
predictors of anxiety included mother’s negative affect and mother’s parenting stress. Father’s
parenting stress was found to play a mediating role between mother’s parenting stress and child
anxiety. Overall, the findings highlight the importance of both parents (directly or through
mediation) in the aetiology of early childhood anxiety. The findings of Study One provide
important information regarding the aetiology of early childhood anxiety and provide important
implications for the development of preventative intervention programs.

Study Two sought to examine the efficacy of a preventative intervention program (Fun
FRIENDS; Barrett, 2007a) for preschool aged children, delivered as a school- based, universal
intervention. This was the first study conducted evaluating the Fun FRIENDS program and was one
of only a few prevention trials cited within the literature examining early childhood anxiety. The
study involved a cohort of 263 children enrolled in one of 16 preschool classes. Children were aged
between four and six years. Schools were randomly allocated to either an intervention group (IG)
or a waitlist control group (WLG). Parents of the children and teachers completed self-report
questionnaires at preintervention, postintervention, and at 12-month follow-up (parents in the IG
only).
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Preventing anxiety and promoting social and emotional strength
Parent report data revealed no significant differences between intervention conditions on
anxiety at postintervention, although participants in the IG experienced larger reductions in anxiety
than participants in the WLG. Children in both conditions decreased in BI symptoms at
postintervention, except for boys in the IG. Significant increases in social-emotional strength were
found for girls in both conditions, but not for boys. When examining the IG only over the long-
term (pre, post, 12 month follow-up), nearly significant decreases in anxiety were found at
postintervention and significant decreases were found again at 12-month follow-up. Improvements
in BI were found at all time points for girls but not for boys and improvements on social-emotional
strength were found from preintervention to 12-month follow-up, with girls scoring significantly
higher than boys.

For teacher report, children in the IG improved significantly more on BI compared to the
WLG at postintervention indicating that the intervention program may have had a positive impact
on these children in learning strategies to manage BI symptoms. However, at pr-intervention,
scores on BI were significantly different between the IG and the WLG. Similar to parent report,
girls in the IG experienced the largest decrease in BI symptoms at postintervention. On social-
emotional strength, children in the IG improved significantly more than children in the WLG at
postintervention with girls in the IG experiencing the largest improvement from pre to
postintervention. Overall, these findings suggest that the intervention program had a positive
impact on some children as evidenced by improvements in anxiety, BI, and social-emotional
strength at postintervention and at 12-month follow-up. Parent report indicated that children in the
WLG also improved on these measures, making it difficult to contribute positive changes solely to
the program. However, teacher report did indicate that children in the IG improved significantly
more than children in the WLG. The improvements gained at 12-month follow-up highlight the
potential long-term impact of the program although, without a comparison group, it is unknown
whether significant differences would exist between both conditions. Implications of these results
are discussed along with limitations and directions for future research.

Keywords
anxiety, prevention, social-emotional competence, resilience, universal prevention, risk factors,
protective factors

Australian and New Zealand Standard Research Classifications (ANZSRC)
170106 100%

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Preventing anxiety and promoting social and emotional strength
Table of Contents

Declaration by author __________________________________________________________i
Statement of Contributions to Jointly Authored Works Contained in the Thesis__________i
Acknowledgements ___________________________________________________________iii
Abstract_____________________________________________________________________iv
Table of Contents_____________________________________________________________vi
List of Figures________________________________________________________________ix
List of Tables ________________________________________________________________ x
List of Abbreviations and Symbols ______________________________________________xi
CHAPTER ONE: EARLY CHILDHOOD ANXIETY __________________________________ 1
Fears and Anxiety during the Preschool Years_____________________________________ 2
Epidemiology_______________________________________________________________ 3
Prevalence of Anxiety Disorders_________________________________________________ 5
Clinical Studies _____________________________________________________________ 5
Community Studies___________________________________________________________ 6
Anxiety Disorders in Preschoolers_______________________________________________ 9
The use of “clinically significant cut-points” ______________________________________ 9
Evidence for subtypes of anxiety disorders _______________________________________ 10
The DSM-IV_______________________________________________________________ 11
Assessment of Anxiety in Early Childhood_______________________________________ 18
Summary__________________________________________________________________ 24
CHAPTER TWO: RISK FACTORS FOR CHILDHOOD ANXIETY DISORDERS__________ 26
Risk Factors for Childhood Anxiety_____________________________________________ 26
Behavioural Inhibition_______________________________________________________ 26
Anxiety, Behavioural Inhibition and Resilience____________________________________ 31
Parental Psychopathology____________________________________________________ 34
Parenting stress____________________________________________________________ 37
Parenting Practices and Behaviours____________________________________________ 42
Parental Modelling _________________________________________________________ 42
Reinforcement of anxious behaviours ___________________________________________ 44
Protective Factors for Childhood Anxiety________________________________________ 45
Child Protective Factors _____________________________________________________ 46
Family Protective Factors____________________________________________________ 48
Community Protective Factors ________________________________________________ 49
Summary__________________________________________________________________ 50
CHAPTER THREE: TREATMENT OF ANXIETY DISORDERS _______________________ 52
Individual Cognitive Behaviour Therapy_________________________________________ 53
Group Cognitive Behaviour Therapy____________________________________________ 53
Parental and Family Involvement in Anxiety Treatment_____________________________ 55
Fathers’ involvement in the treatment of childhood anxiety__________________________ 57
Summary__________________________________________________________________ 59
CHAPTER FOUR: TREATMENT OF CHILDHOOD ANXIETY DISORDER: THE FRIENDS
PROGRAMS __________________________________________________________________ 61
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Preventing anxiety and promoting social and emotional strength
Overview of the Treatment Model______________________________________________ 61
Overview of the Clinical Problem ______________________________________________ 61
Conceptual model underlying treatment _________________________________________ 62
Main Themes of the Treatment Program_________________________________________ 63
Characteristics of the Treatment Program_______________________________________ 63
Participants and Program Format _____________________________________________ 63
Content of Treatment________________________________________________________ 64
Family Skills_______________________________________________________________ 70
Skills Emphasised in Treatment________________________________________________ 71
Facilitator Manuals and Workbooks____________________________________________ 75
Evidence on the Effects of Treatment ___________________________________________ 75
How treatment is evaluated___________________________________________________ 75
Status of the Evidence _______________________________________________________ 76
Overall evaluation of the treatment_____________________________________________ 86
Recommendations regarding implementation in practice___________________________ 87
Family Involvement _________________________________________________________ 87
Program Delivery and Process ________________________________________________ 88
Booster Sessions and Follow-up _______________________________________________ 89
Program Training __________________________________________________________ 89
Directions for Future Research ________________________________________________ 89
Conclusions_________________________________________________________________ 90
CHAPTER FIVE: PREVENTION OF CHILDHOOD ANXIETY DISORDERS ____________ 92
Levels of Prevention_________________________________________________________ 93
Indicated Interventions for Anxiety Disorders_____________________________________ 95
Selective Interventions_______________________________________________________ 98
Universal Interventions _____________________________________________________ 100
Summary_________________________________________________________________ 104
CHAPTER SIX: SUMMARY OF PREVIOUS STUDIES AND METHOD _______________ 105
Summary of Works that Influenced the Current PhD Study _______________________ 105
Objectives and Hypotheses ___________________________________________________ 108
General Method for Studies One and Two ______________________________________ 109
Summary_________________________________________________________________ 112
CHAPTER SEVEN: STUDY ONE _______________________________________________ 114
Behavioural Inhibition and Anxiety____________________________________________ 115
Parental Psychopathology___________________________________________________ 116
Parenting Stress___________________________________________________________ 116
Method ___________________________________________________________________ 118
Results____________________________________________________________________ 120
Discussion _________________________________________________________________ 127
Clinical Implications _______________________________________________________ 129
Limitations_______________________________________________________________ 131
Summary_________________________________________________________________ 132
CHAPTER EIGHT: STUDY 2. __________________________________________________ 133
Method ___________________________________________________________________ 136
Results____________________________________________________________________ 141
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Preventing anxiety and promoting social and emotional strength
Discussion _________________________________________________________________ 151
Clinical Implications _______________________________________________________ 154
Limitations_______________________________________________________________ 156
Summary_________________________________________________________________ 157
CHAPTER NINE: GENERAL DISCUSSION ______________________________________ 158
Summary of Findings in Study One and Study Two ______________________________ 158
Clinical Implications ________________________________________________________ 163
Areas Needing Improvement _________________________________________________ 165
Future Directions___________________________________________________________ 167
Summary_________________________________________________________________ 170
REFERENCES________________________________________________________________ 172
APPENDIX __________________________________________________________________ 206

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