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Preventative Strategies

Article · January 1994

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 24
Preventative Strategies

Susan H. Spence

INTRODUCTION

The prevention of fears and anxiety disorders in childhood has received very little attention.
This omission is perhaps not surprising, given that the whole area of prevention of
psychological problems has been relatively neglected. Various legislative influences,
however, have emphasized the need for preventative interventions. For example, in the
United States, the Joint Commission on Mental Health and Mental Illness created by the
Mental Health Study Act in the 1950s was asked to review and make recommendations
about practices designed to reduce the number of new cases and the duration of mental
illness (Hightower & Braden, 1991). Prevention was also specified as a direct service to be
provided under the 1963 Mental Retardation Facilities and Community Mental Health
Centers Construction Act (PL 88-164).
Despite an awareness of the need for and value of preventative interventions, preven-
tion occupies an extremely small proportion of the professional time of mental health
workers. Peterson, Hartmann, and Gelfand (1980) reviewed studies that reported the degree
to which mental health workers are involved in preventive interventions. It was noted that
prevention was rarely mentioned as an area in which time was spent, and only around 5% of
work time was spent in areas such as education or consultation, which were the areas most
closely related to prevention. Even then, much of this time was focused on early interven-
tion, rather than prevention prior to the onset of problems. Behavior therapists were just
as neglectful of prevention as were other mental health workers (Wade, Baker, & Hartmann,
1979).

SUSAN H. SPENCE • Department of Psychology, University of Queensland. St. Lucia, Queensland 4072.
Australia.

453

T. H. Ollendick et al. (eds.), International Handbook of Phobic and Anxiety Disorders in Children and Adolescents
© Springer Science+Business Media New York 1994
454 The lack of effort given to preventative efforts is disappointing when one considers the
Susan H. Spence potential value of preventative programs. Psychological disorders in children affect a
significant proportion of the child population, and mental health resources struggle to meet
the demand for therapy (Price, Cowen, Lorion, & Ramos-McKay, 1988). Even worse,
evidence suggests that the majority of children in need of psychological intervention are not
referred for treatment (Esser, Schmidt, & Woerner, 1990). The large numbers of children
who progress through childhood without intervention or who continue to show psychologi-
cal problems despite therapy are problematic. It is of concern not only that so many children
experience the distress of psychological problems during childhood, but also that many will
continue to show such problems during adulthood. There is now considerable evidence to
suggest that the onset of many adult psychological problems can be traced back to
childhood, and this is particularly true for anxiety disorders (Mattison, 1992; Ost, 1987).
For example, a high proportion of socially phobic adults recall an onset during early adoles-
cence (Turner & Beidel, 1989). Similarly, evidence from prospective studies of children
suggests that a high proportion of children do not "grow out of" anxiety disorders. Unless
successfully treated, anxiety disorders in childhood frequently persist or develop into some
other form of anxiety disorder. For example, Cantwell and Baker (1989) completed a 4-year
follow-up of children 2-11 years old. These authors found that a high proportion of the
children with a DSM-III diagnosis of an anxiety disorder either maintained their diagnosis
or could be classified as fitting the criteria for another disorder. As an illustration, 25% of
the overanxious children remained overanxious 4 years later, 25% had no diagnosis at
follow-up, and the remainder met the criteria for some other problem, which mainly related
to another anxiety or affective disorder. Mattison (1992), in reviewing studies that have
investigated the persistence of childhood anxiety disorders, concluded that although more
definitive follow-up studies are needed for specific child anxiety disorders, a variety of
evidence suggests that children with anxiety disorders are at risk for ongoing morbidity.
Thus, there is a strong case for the development of programs that aim to reduce the
prevalence of psychological problems in childhood, and anxiety disorders in particular. If
we could prevent the onset of such disorders, the benefits in terms of cost savings to the
mental health system and reductions in the degree of personal suffering experienced by
individuals and their families would be enormous.
A great deal has been written about models of prevention. Traditionally, three levels of
prevention have been described (Caplan, 1964). Primary prevention, the first level, aims to
reduce the prevalence of disorders by reducing the incidence of new cases through
intervention before disorders occur. Secondary prevention aims to reduce the prevalence of
disorders through early identification of problems or mild disorders, with intervention
before the disorder becomes severe. Tertiary prevention aims to reduce the prevalence of
disorders by reducing their duration. This third level involves treatment of existing dis-
orders and prevention of relapse (Hightower & Braden, 1991; Weinstein, 1990).
This chapter will focus on primary prevention. Various approaches may be taken to
primary prevention. Interventions may be designed that are applied to all individuals within
a community with the aim of reducing the probability that a disorder will develop. Whole
classes or schools may be involved in a prevention program, or whole communities may be
targeted through media communications or community programs. Alternatively, preventa-
tive efforts may be targeted at specific groups who are considered to be "at risk" for the
development of particular problems. For example, children who have experienced some
traumatic event, or whose parents experience some form of psychological disorder, may be
considered to be more likely to develop certain psychological problems in comparison to
the general population. Preventative interventions may therefore be targeted toward these
specific groups, on the basis of the assumption that it is more cost-effective to focus on high- 455
risk groups rather than on the population as a whole, who have a lower probability of Preventative
developing psychological difficulties. A further type of primary prevention approach is Strategies
targeted to children who are required to undergo some form of aversive experience, such as
certain medical or dental procedures. The aim in this case is to reduce negative psychologi-
cal reactions during the procedure and to future occurrences of the event.

PREVENTION AS IT APPLIES TO CHILDREN'S FEARS

It is important to make a distinction between the prevention of maladaptive anxiety

disorders and fear vs. adaptive fearful behavior in children. Undoubtedly, the prevention of
pathological anxiety disorders is an important goal for mental health professions. The
prevention of fears, however, requires a little more discussion. It must be acknowledged that
fear does serve an important function in the survival of the human species, and a certain
degree of fear and avoidance behavior may be adaptive in some situations. Thus, the aim of
prevention is to reduce the prevalence of pathological fear, rather than to eliminate adaptive
fear. For example, a certain degree of fear of road traffic, poisonous spiders and snakes (if
you live in Australia!), and fast-flowing water currents is valuable in reducing the chance
of a fatal accident for children. It is only if the fear produces consequences that interfere
with daily living or produces distress in the absence of dangerous stimuli that the fear
becomes problematic. As part of their development, children need to acquire control over
their fears by learning to:
1. Discriminate dangerous from non dangerous situations or stimuli and thus learn
when it is adaptive and appropriate to be afraid and avoid them (e.g., a fast-flowing
river vs. a swimming pool with a swimming teacher present).
2. Develop appropriate avoidance procedures that deal successfully with threatening
stimuli without interfering in daily living (e.g., learning to avoid being hit by a car
by learning to cross the street at a pedestrian crossing; pathological avoidance
would be staying at home and avoiding school because of fear of crossing the road).
3. Acquire practical skills for maximizing the chance of a positive outcome and
reducing the chance of a negative outcome from potentially dangerous situations
(e.g., learning to swim).
4. Cope with relatively aversive situations that may be necessary or inevitable (e.g.,
dental or medical procedures, or school exams).
These goals should be taken into account in the establishment of preventative
programs.

A MULTILEVEL MODEL FOR THE PREVENTION OF CHILDREN'S

MALADAPTIVE FEARS AND ANXIETY DISORDERS

Programs that aim to prevent the development of mental health problems typically
make use of approaches that manipulate those factors that are normally involved in the
development or maintenance of the problems in question. Thus, in designing a preventative
intervention for children's maladaptive fears or anxiety disorders, it is important to have a
thorough understanding of the etiology of these conditions and an awareness of the variables
that determine their persistence. Etiological and maintaining variables may relate to
456 features of the environment or the individual's characteristics. The environmental influences
Susan H. Spence may, in turn, be broken down into general influences (such as cultural or physical
environment factors) and into more direct, specific influences that form each person's
learning experiences.
Table I summarizes some of the many factors that are thought to influence the
development and maintenance of maladaptive fears and anxiety disorders in childhood.
This table illustrates the way in which an awareness of these factors provides an indication
of the methods that may be incorporated into preventive programs. In the same way that
etiological and maintaining factors may stem from the environment and the individual,
preventative interventions may also be targeted toward environmental change or toward
altering "person" characteristics.

General Sociocultural and Physical Environment Influences

It is clear that the prevalence of many psychological problems in childhood is
associated with a variety of sociocultural variables, such as socioeconomic status, housing
conditions, family size, and marital discord. In the case of childhood anxiety disorders,
however, the relationship with such variables is unclear, and we do not have clear evidence
to permit conclusions to be drawn (Gittelman, 1986). There is therefore a need for studies
that clarify the relationship between the development of childhood anxiety disorders and
sociocultural factors. Once such evidence is forthcoming, governments and social change
agencies will have an indication of the type of social policy and legislative changes that
could assist in reducing the prevalence of anxiety disorders among children.

Table 1. A Multilevel Model for the Prevention of Maladaptive Fears and Anxiety Disorders in
Childhood
Source of influence Etiological or maintaining factor Preventative approaches

General sociocultural! Sociocultural factors (yet to be Sociopolitical activities directed to

physical determined) sociocultural change
environment Community education programs
Physical environmental factors (e.g., Environmental change (e.g., reducing
presence of snakes/dogs) aversive events)
Specific environmental Modeling of fearful responses
influences/learning Modeling of nonfear/coping skills Modeling of nonfear/coping skills
experiences Operant conditioning of fear behaviors Operant conditioning of nonfear and
Classical conditioning behaviors
Preexposure (latent inhibition) Preexposure (latent inhibition)
Instructions and education re feared Instructions and education re feared
event and coping skills event and coping skills
Parental attitudes re feared event Changing parental attitudes
Cognitive restructuring with children
Exposure to negative life events (e.g., Coping skills training
bereavements, family separation,
trauma)
Child characteristics Genetic Influences Identification of high-risk children
Temperament factors (e.g., via early temperament factors
Conditionability or parent anxiety disorder)
Coping skills repertoire Coping skills training
Cognitive style Cognitive restructuring
 At first sight, social policy and legislative change may appear to be rather an idealistic 457
goal for mental health practitioners. The creation of an optimal sociocultural environment in Preventative
which to promote the development of mental health should, however, remain a long-term Strategies
goal for mental health professions, governments, and social change agencies alike. One
example of a way in which legislative changes could facilitate the prevention of distress and
anxiety problems in children was proposed by Hess and Camara (1979). These authors
suggested that the legal system at that time exacerbated the adjustment problems of many
children following their parents' divorce. The way in which custody, access, and property
settlements were negotiated tended to impair relationships between parents and increase the
risk of child maladjustment. Thus, Hess and Camara stressed the need for changes in public
policy in order to facilitate the maintenance of positive family relationships following
divorce.
Prevention programs may also focus on reducing the presence of those factors that
generate increased risk for psychological disorder in children. For example, in addition to
reducing the negative impact of divorce, it may also be feasible to develop programs that
enhance marital satisfaction and thereby reduce divorce rates. Obviously, social change of
this type is not the only answer to prevention. Many cases of psychological disorders
emerge from what appear to be ideal sociocultural backgrounds, in which none of the
traditional sociocultural risk factors such as poverty, marital discord, or large family size is
evident. Thus, prevention programs must also look to other environmental and individual
factors.
Physical environment factors include the presence of events and stimuli that are likely
to increase the probability of traumatic or aversive experiences. Although many physical
environment factors, such as storms or earthquakes, cannot be modified, there are some
stimuli that are associated with the development of children's fears that could be influenced.
One possible example could be stricter regulations for the control of dogs in order to reduce
the number of children who experience negative experiences and subsequently develop
phobias of dogs. Similarly, reduction in the number of children who have aversive dental
experiences has been suggested as a means of preventing the incidence of dental fears
(Weinstein, 1990). Increased use of anesthetics and attempts to make the physical environ-
ment more appealing to children have been proposed as methods of reducing the aversive
nature of dental visits.

Specific Environmental Influences and Learning Experiences

It is clear that a variety of learning processes may be involved in the development of
pathological fears in children, and an understanding of these processes is useful in guiding
the content of preventative approaches. Primary prevention programs have typically
attempted to create learning experiences that serve to minimize the development of new
fears. Secondary prevention approaches, on the other hand, have aimed to create learning
experiences that reduce the severity of existing fears before they worsen. The following
section reviews some of the major aspects of children's learning history that may influence
the development and maintenance of maladaptive fears.

Classic Conditioning and Latent Inhibition

We know that many pathological fears develop following an aversive experience with
the feared stimulus, indicating a classic conditioning explanation in many instances. For
458 example, Dollinger, O'Donnell, and Staley (1984) reported a high level of fears of storms
in a group of children who were survivors of a severe lightning strike. A generalization
Susan H. Spence
gradient of fears relating to storms, noise, the dark, death, and dying was found, with fears
being strongest for the stimuli most related to storms, with least fear being found to
unrelated events such as social or school situations. This effect was not found among
nontraumatized matched control children. Milgrom, Vignehsa, and Weinstein (1992) also
found an association between the development of maladaptive fear and a previous aversive
experience. Adolescents who exhibited dental fear were much more likely to have experi-
enced a painful dental procedure compared to those who were not fearful.
Evidence suggests that the degree of classic conditioning to an aversive stimulus may
be influenced by a process of latent inhibition. Classic conditioning is less likely to occur
if the CS is presented alone on several occasions without the UCS. Weinstein (1990)
suggests that latent inhibition accounts for the findings that anxiety related to dental visits is
less likely to develop if children experience nontraumatic dental visits prior to any painful
procedure. Thus, preexposure to nonaversive experience of a potentially fearful situation
may be used in programs to prevent the development of fears.

Influence of Parent Behavior and Modeling

Evidence suggests that parent behavior plays an important role in the development of
children's fears. For example, McFarlane (1987) reported that the best predictor of
posttraumatic phenomena in children following a bush fire disaster was the mother's
response to the events. This effect was even stronger than the degree of exposure to the
disaster in determining the child's behavior. The children of mothers who were the most
anxious and overprotective following the fire tended to exhibit the most posttraumatic
symptoms. Parents also have a strong influence on the degree of anxiety and distress shown
by children during medical procedures. Children are more likely to exhibit greater distress
during medical procedures if accompanied by an anxious mother (Jacobsen, Manne, Gar-
finkle, & Schorr, 1990; Bush, Melamed, Sheras, & Greenbaum, 1986).
The response of parents to fearful situations has also been implicated in the develop-
ment of anxiety disorders in children. For example, Heard, Dadds, and Rapee (1992)
demonstrated that the parents of children referred for treatment of anxiety disorders tended
to influence their children's judgments about the degree of threat involved in performing
specific tasks (in a negative direction) in comparison to the parents of control children.
Several mechanisms may be proposed to account for the way that parents influence the
development of children's fears. The modeling of fearful behavior is one possibility.
Similarly, parents may influence their child's perceptions of the degree of threat posed by
situations and thus reduce the child's degree of self efficacy relating to ability to cope with
the situation. This type of parental behavior may also serve to inhibit the child's develop-
ment and use of coping strategies, such as relaxation or positive self-talk. Parents may also
encourage avoidance behavior, thereby reducing the likelihood of exposure to feared
situations in the absence of negative outcomes. Thus, the child may fail to learn that the
feared negative consequences will not occur.
An alternative possibility is that in some instances, parents may unwittingly reinforce
fearful behavior through provision of attention and social reinforcement. If this process is
combined with a failure to reinforce nonfearful and coping behavior, then it would not be
surprising if fearful behavior was strengthened and maintained.
Learning through the observation of others is known to be important in determining
the fear responses of children. The role of modeling in demonstrating fearful behavior and 459
in the use or nonuse of coping strategies was mentioned above, in relation to parental Preventative
influences. Parents are not the only source of modeling experiences for children, however, Strategies
and siblings, teachers, peers, and television may provide alternative forms of influence.
Given the importance of observational learning in the development and maintenance
of maladaptive fears, it is perhaps not surprising to find that modeling may also be an
effective means of reducing fearful behavior. The work of Bandura and colleagues has been
influential in demonstrating the forms of modeling that are most effective in modifying
children's reactions to fearful stimuli (Bandura, 1971). These studies showed that anxiety
reduction is greater if the characteristics of the model are similar to those of the observer.
Furthermore, anxiety reduction is enhanced if the model engages in coping behaviors in the
presence of the feared stimulus, rather than mastery responses, and if a positive outcome
results from the interaction. The results of these studies have had an enormous influence
on the development of programs to prevent or reduce fear and anxiety.
The model outlined in Table I emphasizes the role of modeling in prevention programs
and also indicates the value of interventions that aim to change the parental factors that
influence the development and maintenance of children's maladaptive fears. For example,
training parents in skills to facilitate the reinforcement of nonfearful behavior and to reduce
the reinforcement of maladaptive responding would be beneficial.

Characteristics Relating to the Child

We all differ remarkably in terms of our individual characteristics, and this difference
extends from physical features to psychophysiological, temperamental, intellectual, cogni-
tive style, and coping skill characteristics. These features serve to mediate the impact of
environmental events and life experiences. The degree to which these characteristics are
genetic vs. acquired will not be the focus of this discussion, but an interactionist view will
be accepted in which the importance of genetic influences is not ignored.
The question arises why some children develop fears and anxiety disorders following
certain learning experiences (e.g., an aversive exposure) and others do not. A variety of
explanations may be proposed, although evidence is lacking. Innate temperamental and
conditionability factors may playa role in this phenomenon, and it is clear that children
show individual differences in behavioral and physiological reactivity to novel and fearful
situations, and these differences may be relevant in explaining differential fear acquisition.
Kagan and his research team have conducted several studies on what they describe as
inhibited and uninhibited children. Kagan, Snidman, Julia-Sellers, and Johnson (1991)
described the inhibited temperament as being reflected in behaviors such as initial timidity,
shyness, and emotional restraint when exposed to unfamiliar people, places, or contexts.
Uninhibited children, on the other hand, approach the same events with minimal uncer-
tainty and affective spontaneity. Kagan and his colleagues have also demonstrated in a
series of studies that these two groups of children can be distinguished physiologically.
Indeed, Kagan et al. (1991) reported that children who are classed as behaviorally inhibited
tend to show a specific pattern of heart rate changes and pupillary dilations to stressor tasks,
in addition to higher urinary levels of the derivatives of norepinephrine, higher levels of
morning salivary cortisol, and greater increases in muscle tension levels compared to
uninhibited children. These physiological patterns were proposed to reflect a difference in
the threshold of excitability in the limbic system in inhibited children. Inhibited status for
children who fall at the extreme end of this dimension also tends to be relatively stable over
460 time (Kagan, Reznick, & Gibbons, 1989). Kagan and Snidman (1991) suggested that
Susan H. Spence although shy, timid, and fearful behavior can be the product of specific environmental
learning experience, a small proportion of children begin life with a predisposition to
develop such a profile, given specific environmental conditions. If Kagan and colleagues
are correct, then these extremely "inhibited" children may well turn out to be a high-risk
group for the development of anxiety disorders in later childhood. It is to be hoped that
ongoing longitudinal studies will indicate whether this is indeed the case.
Variations in cognitive style may also be relevant to the development of fears and
anxiety disorders in childhood, although evidence appears to be lacking. Certainly, in the
area of depression in childhood, studies suggest that children who manifest a style of
thinking that leads to negative appraisal of events are more likely to report symptoms of
depression (Ward, Friedlander, & Silverman, 1987; Weiss, Weiss, Wasserman, & Rintoul,
1987). It is likely that bias toward interpretation of events as fearful and uncontrollable, or a
tendency to anticipate aversive outcomes, may also predispose children toward develop-
ment of anxiety disorders. Certainly, this suggestion warrants investigation.
Children also differ markedly in their ability to use a range of coping skills that
influence the degree of fear, anxiety, and distress experienced in response to unpleasant
experiences. Much of this evidence comes from the literature on coping with aversive
medical procedures. Methods such as seeking out information, positive self-talk, diver-
sion of attention, relaxation, and thought-stopping have been demonstrated to be associated
with lower levels of anxiety and distress (Brown, O'Keefe, Sanders, & Baker, 1986;
Peterson, Harbeck, Chaney, Farmer, & Thomas, 1990). Interestingly, there appear to be
developmental differences in the way children try to cope with feared situations. Band and
Weisz (1988) proposed a primary-secondary model of coping in children. Primary
approaches to coping aim to change the aversive stimulus directly (e.g., attempting to
remove the feared event through verbal protest or running away). Secondary coping
strategies, on the other hand, accept the occurrence of the aversive situation and focus on
methods of producing the least degree of aversiveness and distress. Band and Weisz
suggested that children gradually learn that primary coping attempts are generally not
successful in preventing the feared situation. Thus, with increasing age, children begin to
use secondary coping methods that aim to produce the least degree of distress to the
aversive situation. This model fits with evidence that with increasing age, children show
increased use of strategies such as positive self-talk or relaxation (Brown et aI., 1986).
The importance of coping strategies in enabling children to deal with aversive and
fearful situations has clear implications for the way in which prevention programs should be
designed. The ultimate aim of primary prevention of childhood fears and anxiety disorders
should be to teach children strategies that may facilitate their handling of a wide range of
fearful and aversive situations. This approach provides children with the skills that may be
generalized to novel situations, rather than being limited to specific fearful events. These
skills could include relaxation, use of positive self-talk strategies, rational interpretation of
events and prediction of outcomes, and problem-solving abilities. It would obviously be
much more cost-effective to approach preventative interventions in this way, rather than to
target specific situations one at a time, such as the dark, swimming lessons, routine dental
visits, or test-taking. Nevertheless, it is acknowledged that some situations may be
sufficiently aversive or difficult to handle that they require additional training in the use of
coping skills. For example, specific preventative efforts may be warranted to help children
deal with painful medical or dental procedures. Some situations may also occur very
infrequently and require specific coping skills. For example, children transferring from
elementary grades up to secondary school may find that the transition requires many new 461
skills. These skills may relate to the use of public transport, social skills for making friends, Preventative
and independent study skills, all of which may influence the success of the school transfer. Strategies
Specific skills training may therefore be important, in addition to the acquisition of more
general anxiety- and fear-management skills.

FROM THEORY TO PRACTICE

The model for the prevention of maladaptive fears and anxiety disorders outlined
above emphasizes the need for preventative efforts at three levels producing changes in
(1) the general sociocultural/physical environment, (2) specific environmental influences/
learning experiences, and (3) characteristics relating to the child. Given that most clinicians
are not in a position to produce a marked impact on the general sociocultural/physical
environment or genetic influences, we will focus here on preventative approaches that may
be used to reduce the probability that fears will develop and increase the child's ability to
cope with unpleasant or stressful events.
The literature suggests that various methods may be beneficial in teaching coping
skills and reducing the development of fears. These methods include:
1. Modeling of coping skills and successful handling of the feared situation.
2. Provision of information about feared situations, in order that children obtain a
sense of control over the feared event
3. Direct instruction in the use of coping strategies, including positive self-
instructions, relaxation, and attention-diversion methods.
4. Use of latent inhibition to reduce the probability of classic conditioning of feared
stimuli by prior exposure of es (situational cues) in the absence of ues (aversive
situation).
5. Exposure to fearful situations in the absence of feared consequences.
6. Training of parents to model appropriate coping behavior, to reinforce their child's
use of coping skills, and to reduce their own overprotective and anxious behaviors.

EXAMPLES OF PREVENTION PROGRAMS

AND THEIR EFFECTIVENESS

Several authors have written about the need for programs to prevent childhood
maladaptive fears and anxiety disorders and have even outlined the types of approaches that
could be used (e.g., King, Hamilton, & Murphy, 1983; Martinez, 1987; Robinson, Rotter,
Fey, & Robinson, 1991). Robinson et al. (1991) discussed various levels of intervention that
could be used in the prevention of childhood fears. They stressed the need to teach coping
skills to facilitate the child's ability to cope effectively with threatening situations that are an
inevitable and essential part of normal development. Their approach emphasized the
development of concepts of control, security, and self-worth and the acquisition of coping
skills to deal with developmentally appropriate fear situations. As an illustration, these
authors outlined a classroom-based intervention for the prevention of fears of the dark,
which included components such as studying creatures of the night, talking about night
shift workers, reading stories about the dark, and studying the stars and the night sky. This
462 program also stressed the need for parent education concerning the developmental process
Susan H. Spence of normative childhood fears and parenting techniques for dealing with fearful behavior.
The use of parent newsletters and workshops was proposed.
Unfortunately, suggestions for programs to prevent childhood fears and anxiety
disorders have rarely been put into practice. There is a marked absence of empirical data to
permit evaluation of the effectiveness of preventative programs for children's maladaptive
fears or anxiety disorders. What are needed are large-scale studies that assess the long-term
impact of preventative interventions, in comparison to no intervention and placebo ap-
proaches. Reliable and valid outcome measures of maladaptive fears and anxiety problems
should be included, which should involve information from a variety of sources (e.g.,
parent, child, and teacher) across a range of settings (e.g., home and school). Furthermore,
follow-ups should be of adequate duration (e.g., 5-10 years) to permit evaluation of the
long-term impact of any preventative intervention. Ideally, such programs should aim to
teach the type of generalizable coping skills outlined above, in order to reduce maladaptive
fear and anxiety across a wide range of situations.
To date, well-controlled experimental studies of this type are yet to be conducted. We
can gain some insights into the effectiveness of preventative interventions, however, by
considering those studies that have examined the prevention of fears relating to specific
situations or prevention approaches with "high-risk" samples.

Prevention of Dental Fears

Fear of attending the dentist and subsequent avoidance of dental treatment represents a
significant public health problem. Estimates of the prevalence of dental fears vary according
to the criteria used to define the problem, but Milgrom et al. (1992) reviewed evidence to
suggest that between 10% and 20% of children and adolescents are classified as having high
dental fear. Dental fears do not tend to decline with age, and it is important to note that a
high proportion of adult dental phobics report an onset in childhood and adolescence, with a
mean age of onset of 12 years (Ost, 1987; Milgrom et al., 1992). Prevention of dental fears in
childhood is important for several reasons. First, it would reduce the degree of subjective
distress to the patient. Second, prevention of dental fears and their associated disruptive
behavior would reduce the work stress experienced by dentists in having to deal with
anxious patients. Finally, prevention of dental fears would limit the dental health problems
that result from avoidance of dental visits.
Weinstein (1990) reviewed the literature relating to prevention of dental fears in
children. Methods such as providing the child with as much control over the procedure as
possible, nontraumatic preexposure prior to invasive treatment, and videotaped modeling
of another child coping with the same procedure have all been reported to be beneficial in
reducing child anxiety to subsequent dental visits. The effectiveness of modeling video-
tapes has been most widely researched, with several studies demonstrating that viewing
another child coping with the dental procedure reduces fear and disruptive behavior in
young children (Melamed, Hawes, Heiby, & Glick, 1975; Melamed, Weinstein, Hawes, &
Katin-Borland, 1975). Modeling has not always been found to be effective, however, with
negative results being reported by Sawtell, Simon, & Simeonsson (1974). Interestingly, the
provision of information about the procedures, either verbally or through film, has not been
found to reduce fear and disruptive behavior; thus, the provision of information alone is
unlikely to explain the positive results of modeling studies (Green, Meilman, Routh, &
McIver, 1977; Melamed, Yurcheson, Fleece, Hutcherson, & Hawes, 1978).
Prevention of Fear and Anxiety Relating to Medical Procedures 463
Preventative
Many children are required to undergo medical procedures that are novel, stressful, Strategies
and sometimes painful or unpleasant. The aversive nature of some medical procedures
makes it likely that children will be fearful of undergoing such experiences and may develop
fear reactions in anticipation of future occurrences. It must be pointed out, however, that
medical procedures do not have to be painful in order for the event to be perceived as
stressful and anxiety-provoking to a child. A variety of events related to hospitalization and
illness are stressful to children, and fears relating to separation from parents, illness, and
unfamiliar surroundings may also be involved (Traughber & Cataldo, 1983).
There are several obvious reasons that fear of medical procedures is problematic. First
and foremost is the subjective distress experienced by the child before and during the
experience. Second, the fearful behaviors may include avoidance responses, such as temper
tantrums, running away, and protestations. These behaviors in turn produce considerable
distress to the parents, nurses, and medical personnel and may also result in noncompliance
with meclical regimens. Some medical procedures, such as a tonsillectomy, occur only
once, and the goal is to reduce the degree of anxiety experienced by the child before and
during the procedure and to facilitate a psychological state that promotes rapid recovery
during the postexperience phase. Other stressful medical procedures may occur repeatedly.
Such procedures include injection treatments (insulin for diabetes or growth hormone),
changing of burn dressings, and bone marrow aspirations in pediatric oncology, to mention
just a few. The goal with repetitive experiences is to reduce the child's subjective distress
and to facilitate the child's cooperation with the procedure. For occasional and repetitive
interventions, the aims are to enhance the child's coping skills for dealing with the
procedure and to prevent the occurrence of anxiety and fear responses.
Early attempts to reduce anxiety and distress during medical procedures focused
primarily on providing children with information about the forthcoming event. This
approach was based on the rationale that unpredictable stressors produce higher levels of
anxiety than anticipated events. Thus, informing children about what to expect during a
medical procedure was proposed to reduce the level of anxiety experienced. Preparatory
information, if used in isolation, appears, however, to be oflimited value in preventing child
anxiety (Melamed, Seigel, & Ridley-Johnson, 1988). Similarly, the use of modeling
demonstrations, usually involving films or puppets, has been reported to produce some
benefits in reducing children's anxiety toward medical procedures (e.g., Melamed &
Seigel, 1975). Evidence suggests, however, that modeling alone is not sufficient to enable
many children to reduce their fear of unpleasant stimuli, and additional measures may be
required to teach the skills necessary to cope with the situation (Peterson & Shigetomi,
1981). Peterson and Shigetomi showed that a combination of training in coping skills plus
modeling was superior to modeling or instructions alone in reducing child distress at
tonsillectomy. The coping skills taught included cue-controlled relaxation, distracting
mental imagery, and use of comforting self-talk.
Programs that teach coping skills have now been developed for use with children
undergoing a wide variety of medical procedures. For example, Jay, Elliott, Katz, and
Siegel (1987) reported the effectiveness of a cognitive-behavioral intervention to reduce
anxiety during bone marrow aspirations. This study demonstrated that children receiving
modeling plus training in coping strategies showed significantly lower behavioral distress,
lower pain ratings, and lower pulse rates than when they received Valium or an attention-
control procedure. The cognitive-behavioral procedure involved exposure to a modeling
464 videotape that demonstrated the procedures plus positive coping behaviors such as breath-
Susan H. Spence
ing exercises, imagery, and positive self-statements. The imagery methods included
emotive imagery using hero images, such as Superman or Wonder Woman, and attention-
distraction methods, such as pleasant mental scenes. These approaches were combined with
a positive incentive scheme that presented the child with a small trophy for successful
coping and behavior rehearsal involving role-played conduct of the bone marrow aspiration
procedure with a doll, using actual equipment with the older children.
Although group design studies suggest that coping skills training can be beneficial in
reducing anxiety and distress relating to medical procedures, it is clear that children differ
in their responses to particular coping skills, and different coping skills may be required for
different types of medical procedures. Furthermore, different skills may be required at
different stages of a medical procedure, such as prior to, during, and after the event. The
task of current researchers in the area is to attempt to match optimal coping strategies with
the child's individual characteristics and the medical situation being faced at a given time.
As mentioned above, parent behavior also influences the level of anxiety experienced
by children during medical treatments. Preventative interventions should therefore aim to
bring about changes in parent behavior in addition to enhancement of child coping skills.
For example, a component of any preventative intervention should also aim to reduce parent
anxiety and increase parent coping skills. Parents should also be encouraged to model
coping behaviors and to reinforce their child's nonanxious behavior.

Prevention of Test Anxiety

It seems that coping skills training can be effective in the prevention of anxiety and fear
relating to stressful and aversive medical and dental procedures. This suggests that similar
approaches are likely to be valuable in preventing the development of fear and anxiety in
relation to other forms of aversive situations that children have to deal with in the course of
their lives, such as transition to new schools or taking examinations. Test anxiety is one of
the most common fears among 9- to 12-year-olds and frequently persists through adoles-
cence (Morris and Kratochwill, 1991). The negative consequences of test anxiety include
not only the distress experienced by the young person, but also impairment of test
performance. In extreme instances, the child may also resort to a variety of avoidance
behaviors, including absence from school and failure to attend exams (Tryon, 1980). Given
the high incidence of test anxiety and the negative consequences produced, there is a strong
case for preventative programs in this area.
Research into methods of reducing test anxiety has focused primarily on children who
are already highly anxious about examinations. Nevertheless, techniques found to be
effective in the treatment of existing test anxiety may provide an indication as to methods
that are likely to be effective in preventing the onset of test anxiety in children. In a re-
view of treatments for test anxiety, 'fryon (1980) concluded that a variety of methods have
been found to be effective in reducing subjective, affective feelings of anxiety concerning
tests. These methods included relaxation training, systematic desensitization, flooding,
training in study skills, positive self-talk training, cognitive restructuring, and modeling.
Of particular importance was the finding that most of the studies that actually produced an
improvement in test performance were those that attempted to reduce the "worry"
component of test anxiety. Those methods that focused purely on the affective component
of test anxiety were less effective in improving academic performance. Tryon suggests that
it is important to reduce both the affective feelings of anxiety and the level of worrying
thoughts in the treatment of test anxiety. If worry remains high, then the interfering 465
thoughts continue to disrupt the cognitive processes required for academic tasks. Preventative
Van der Ploeg-Stapert and Van der Ploeg (1986) outline a complex cognitive- Strategies
behavioral program that was found to be effective in reducing test anxiety with test-anxious
11- to 20-year-olds. The program was conducted on a group basis with approximately 12
students per group over 8 sessions. The intervention included muscle relaxation exercises,
study skills training, self-monitoring with concentration techniques, and rational emotive
training to reduce worry. The 3-month follow-up data suggested that the program was
effective in reducing affective test anxiety and worry and improved grades for around half
the students in comparison to a waiting-list control sample. It may be feasible to adapt
programs of this type for implementation on a class basis as a means of prevention of test
anxiety.

Facilitating the Transition to a New School

Children are required to deal with many changes throughout their lives, but the
transition to a new school is suggested to be one of the most stressful (Soussignan, Koch, &
Montagner, 1988). Changes to a new school occur at different ages in different countries,
but transitions typically occur from preschool to infanUprimary/elementary at around age
5, with a further transfer occurring to secondary school at around the age of 11-12 years. In
response to such transitions, children are generally required to adapt to different physical,
social, and academic environments. They are faced with new buildings to negotiate their
way around, a new peer group, new teachers, and a new set of rules and regulations. The
styles of teaching and studying are also likely to be different. Not surprisingly, many
children find the changes very difficult to accommodate, and a variety of behavior problems
have been linked with school transitions. These problems include peer-relationship diffi-
culties, school refusal, and somatic complaints, with academic failure, increased substance
abuse, delinquency, and school dropout in older children (Hightower and Braden, 1991).
Fortunately, the stressful nature of school transitions is now being recognized, and
programs have been developed to prevent or reduce the distress produced. For example,
FeIner and Adan (1988) describe the School Transition Environment Project (STEP). In
particular, the program targeted schools with complex organizational structures, which
received children from a large number of feeder schools and which had limited support
services. The STEP program consists of three components. The first organizes the physical
plan of the school into units with homerooms, in order to facilitate familiarity with the
school environment. Children allocated to the program attend core academic subjects
together in these homerooms. This process is suggested to make the school transition less
overwhelming and stressful to incoming students.
The second aspect of STEP includes a "homeroom" staff member who has the
responsibility for taking the daily attendance list, following up absences, and counseling
pupils regarding academic or school-adjustment problems. The final component involves a
coordinated liaison between teaching and school counseling staff. The overall aims of the
program are to increase personal relationships between pupils and staff and to create
subenvironments within the overall large school environment.
Evaluations of the STEP approach have demonstrated that children who participated in
the program showed greater improvements in academic performance and self-esteem,
better school attendance, and lower school dropout rates compared to control children who
did not take part (FeIner & Adan, 1988). Furthermore, the benefits have been replicated in a
466 variety of different school settings with children from various social backgrounds. Overall,
Susan H. Spence
the approach appears to be a valuable method of reducing the problems associated with
school transition and to provide a model that could be routinely adopted by school
authorities. Although not designed specifically to prevent fears or anxiety disorders in
children, this program illustrates an approach to the reduction of the severity of a stressor
experience in order to prevent the development of a range of behavioral difficulties. It is
particularly interesting in that the approach is essentially one of environmental and
organizational structural change.

Working with "At-Risk" Children

The previous section focused on prevention of anxiety, fear, or distress in children who
are required to deal with various aversive or stressful events. Some aversive events,
however, occur unexpectedly and are of sufficient magnitude that they constitute a trau-
matic experience to the child. Such trauma may occur on a group basis, as is often the case
with environmental disasters (e.g., earthquakes, war, storms, or fires), or on an individual
basis, such as occurs with death of a parent, a car accident, or parental separation or
divorce.

Prevention of Fears and Anxiety Disorders following a Traumatic Experience

There is now considerable evidence that children who experience traumatic events are
at risk of developing fears and anxiety problems (see Chapter 12). For example, following
trauma, children may show increased levels of fears relating to stimuli associated with the
traumatic event, avoidance behaviors, somatic complaints, depression, sleep disturbance,
and intrusive experiences (Dollinger, 1986; Dollinger et aI., 1984; Terr, 1981; Yule &
Williams, 1990). Although such problems abate relatively quickly in most children, a
significant proportion of children show persistent anxiety symptoms for many months after
the trauma (Terr, 1981). There is therefore a strong case for rapid intervention following
trauma in order to prevent or at least minimize the development of persistent psychological
problems.
Although much has been written about the need for interventions to prevent long-term
psychological difficulties following trauma in children, we still have very little empirical
evidence to permit us to determine the most effective approaches to prevention. This is
particularly true for large-scale natural disasters, which tend to be unpredictable and limit
the possibility of neat experimental designs. We are therefore reliant on subjective opinions
regarding which intervention approaches should be used following trauma. Sugar (1989)
emphasized the need for initial interventions with the parents of children who experience a
traumatic event, given the evidence that parent reaction plays a highly significant role in
determining child response (e.g., McFarlane, 1987). In large-scale disasters that affect
whole communities, Sugar (1989) also stressed the need for community counseling and
crisis-oriented group approaches in order to provide mutual support, decrease isolation, and
provide a larger perspective for the individual. Sugar pointed out, however, that the
cornerstone of therapy should be individual counseling with children, which takes into
account their developmental level and specific details of the traumatic situation experi-
enced. The approach taken to intervention should therefore be tailored to the needs of each
child.
A variety of approaches have been used in what is commonly termed the "debriefing"
of trauma victims. Yule (1990) suggests that this procedure should commence somewhere 467
between 7 and 14 days following the event, with most survivors being too numb to benefit Preventative
from counseling prior to this time. Nevertheless, Yule admits that there is a lack of data to Strategies
validate this proposal, and we really do not know what type of intervention should best be
used or at what time after the occurrence of a traumatic event it should be instituted.
A variety of debriefing methods have been suggested to be beneficial in preventing
long-tenn adjustment problems in child trauma victims. These methods include encourag-
ing children to describe their reactions and reassuring them that such reactions are
understood and a nonnal response to an abnonnal experience. Alternatively, children may
be trained in relaxation skills and exposed to stimuli and memories relating to the trauma
event. In this instance, Yule (1990) draws on the Rachman (1980) model of emotional
processing, which emphasizes the need for vivid and prolonged exposure to disaster-related
cues in order to facilitate emotional processing. This approach contrasts with the avoidance
of disaster-related stimuli and situations, which is frequently encouraged by the parents of a
child who has experienced a traumatic event.
Debriefing methods such as these are proposed to be beneficial in facilitating
children's adaptation following trauma and in preventing the development of long-tenn
psychopathology. There is now a need for studies that evaluate the effectiveness of various
approaches in achieving these goals. Such studies may be feasible using children who have
experienced the type of trauma that occurs relatively frequently within society, such as the
survivors of car accidents involving a fatality.

Working with Children following Parental Divorce

Divorce of the parents has been suggested to represent one of the most common and
severe life stressors that confront children and adolescents (Hightower & Braden, 1991;
Hodges, 1991). Many authors have emphasized the potential negative impact of divorce
on children and adolescents. For example, Hess and Camara (1979) suggested that the
emotional consequences for children are often severe, and include depression, anger,
anxiety, and withdrawal, particularly in the first 2 years following the divorce or separa-
tion. These authors concluded, however, that the adverse emotional consequences of
parental separation and divorce are mediated by the quality of the intrafamily relationships
involved. Thus, the negative effects were greatly mitigated when positive relationships
between the parents were maintained. Furthermore, the child's relationship with the
noncustodial parent was as important as that with the custodial parent. Hess and Camara
highlighted the need for public policy to focus on the development of systems that facilitate
the type of postdivorce family relationships that will enhance children's adjustment to the
situation. For example, the authors noted that many legislative and judicial practices shape
negative parental relationships through the procedures involved in custody, access, and
property settlements. Although recent family court practices go some way toward reducing
the potential animosity between divorcing parents and emphasize the need to maintain
positive relationships between children and both parents, Hess and Camara's comments
remain valid today. It is interesting to note that the need for public policy and judicial
changes in this area provides an example of the type of sociopolitical activities proposed in
Table l.
Changes in public policy relating to separation and divorce may go some way to
increasing the chance that separating and divorcing parents will be able to create the type of
positive family relationships that make it less likely that children will manifest severe
468 anxiety reactions (and other behavioral problems). Children are still likely, however, to
Susan H. Spence
experience the situation as extremely aversive and distressing. Attention has turned
recently to the development of programs designed to help children to cope with parental
divorce and to reduce the chance that long-term emotional or behavioral problems will
develop.
Before we describe such interventions, it is important to discuss the extent to which
children do experience long-term adjustment problems. As mentioned above, Hess and
Camara (1979) concluded that the consequences can be severe over the first 2 years, but that
the effects were less noticeable among children who had good relationships with both
parents and whose parents managed to continue a positive relationship. Forehand (1992) has
recently been highly critical of popular and alarmist literature that emphasizes the
relationship between parental divorce and maladjustment in children and adolescents.
Forehand presented evidence to suggest that, although children and adolescents to exhibit
more problems relating to anxiety-withdrawal and conduct disorder following parental
divorce, this effect is relatively small. Furthermore, being group results, the data mask the
fact that a large number of children continue to be well-adjusted following divorce and the
negative consequences may be limited to a minority of children. This point also emerges
from the meta-analysis conducted by Amata and Keith (1991). Thus, it is important that
preventative interventions relating to children of divorce bear in mind that not all children
are going to be seriously impaired by their family circumstances. One must question
whether, if a child is coping well with a difficult environmental situation, it may be
preferable to avoid any intervention that could disrupt this coping process. Ideally, we need
to identify the characteristics of those children who are most at risk of developing adverse
reactions to parental divorce and separation and target preventative programs in their
direction. The possible adverse consequences of preventative interventions for children
who would normally have coped well with a traumatic life event must be considered. Some
would say, however, that the possibility of adverse consequences is sufficiently small that
the advantages of large-scale preventative interventions for all children who fall into a
"high-risk" group outweigh the potential disadvantages.
Several programs have been developed for use with children whose parents have
recently divorced (e.g., Hodges, 1991; Pedro-Carroll & Cowen, 1985). Pedro-Carroll and
Cowen (1985) outlined the Children of Divorce Intervention Project (CO DIP), which was
developed for use on a small group basis within schools. The project aims to prevent or
ameliorate academic, behavioral, and emotional problems that children often experience
during or after their parents' divorce. More specifically, the aims include (1) developing a
supportive group environment, (2) facilitating the identification and expression of divorce-
related feelings, (3) promoting understanding of divorce-related concepts and rectifying
misconceptions, (4) teaching coping skills, including social problem-solving skills, and
(5) enhancing children's positive perceptions of themselves and their families. The program
involves 12-16 sessions, with methods including discussion, role-play, skills training, and
home-based tasks.
Evaluations of the program have demonstrated its effectiveness in producing reduc-
tions in anxiety, fewer behavioral problems, greater gains in school competencies, de-
creased feelings of self-blame, and better ability to solve divorce-related problems in
comparison to children of divorce who did not participate in the project. Follow-up
information suggests that the benefits are maintained for the majority of children at 2-year
follow-up, although only around half the children continued to show the gains they had
made over the comparison group at 3-year follow-up (Hightower & Braden, 1991).
 Although independent replications using this approach are required, the CODIP 469
appears to offer promise in the prevention of adverse psychological consequences in Preventative
children following parental divorce. Strategies

Working with the Siblings of Pediatric Cancer Patients

It is only relatively recently that attention has been paid to the siblings of terminally ill
children, with the focus previously being directed toward the hospitalized or sick child
rather than the siblings. Bendor (1990) described the types of fears and anxieties experi-
enced by siblings of pediatric cancer patients and emphasized the need for prevention
programs. Bendor outlined two multisession groups that she conducted, one for elementary-
school-age children and one for adolescents who had a brother or sister suffering from
cancer. A wide variety of concerns were identified among the children. These concerns
included feelings of resentment toward the sick sibling, jealousy about the amount of
parental attention directed toward the sick brother or sister, feelings of being neglected by
the parents, guilt, anger, loneliness, and lack of family recreational activity. The youngsters
also reported fears concerning contamination, getting sick, the sibling's death, and their
own death.
In addition to small-group preventative counseling, Bendor proposed a range of
additional activities that are likely to be beneficial in facilitating the adjustment of healthy
siblings of pediatric cancer patients. For example, she suggested that parents need to be
encouraged to redirect their attention to the needs of the healthy siblings, rather than to
focus purely on the sick child. In addition, parents need to be helped to discuss death with
their healthy children and to prepare them for events such as attending the funeral.
Postdeath follow-ups with families and liaison with siblings' schools were also recom-
mended. Although Bendor did not provide any data regarding the effectiveness of the
program, the approach makes intuitive sense and justifies studies to evaluate its efficacy.

Other High.Risk Groups

There are many other factors associated with the development of anxiety and fear
problems in childhood that could be taken as indicators of "high risk." These factors
include being a child of a parent who experiences an anxiety disorder (Mattison, 1992) and
possession of early temperament characteristics that are predictive of later development of
anxiety problems. Space does not permit a detailed investigation of these areas, but a few
comments are warranted here. First, in relation to the children of parents with anxiety
disorders, it may be feasible to develop interventions targeted toward parents and children
in order to reduce the probability of development of anxiety problems in the child. Such
interventions could include training the parents to increase behaviors such as modeling of
use of coping skills and reinforcement of their child's use of coping skills and approach
rather than avoidance behaviors. '~t-risk" children could also be taught a range of coping
skills that could be applied across a wide range of stressful and aversive situations as they
arise. These skills could include relaxation, use of positive self-instruction, rational
interpretation of events and outcome expectancies, and problem-solving abilities.
Second, there is a strong case for the application of preventative approaches with
children who early on manifest physiological and behavioral characteristics that predict a
greater probability of developing anxiety or fear problems in later childhood. Although
research in this area is in its infancy, there is certainly some evidence to suggest that
470 children who exhibit what Kagan terms "inhibited" temperamental characteristics may be
Susan H. Spence
at risk for development oflater anxiety problems, particularly relating to social anxiety (see
the section entitled "Characteristics Relating to the Child" above). If Kagan is correct and
these children can be regarded as being at risk for the development of fears and anxiety
disorders, then there would be a strong case for early intervention. It may be possible, for
example, to teach children to modify physiological reactivity to novel and stressful
situations through relaxation training and cognitive self-instruction approaches. So far, this
area remains speculative but certainly warrants investigation.

METHODOWGICAL PROBLEMS IN THE IMPLEMENTATION

AND EVALUATION OF PREVENTATIVE PROGRAMS

It is clear from this chapter that there are many ways in which preventative programs
could be implemented in an attempt to reduce fears and anxiety problems in children. Much
of what has been written, however, refers to proposals or hypothetical models for ap-
proaches to prevention. Very few programs have actually been implemented for the
prevention of childhood fears or anxiety disorders, and even fewer have been evaluated
empirically. The few studies that have described experimental evaluations of outcome in
this area have been limited to a specific type of trigger situation, such as school transition or
parental divorce. We still await evaluation of a large-scale preventative program that is
designed to prevent childhood fears and anxiety disorders more generally.
There are several explanations that could be proposed to account for the lack of
involvement of mental health researchers and practitioners in the prevention of childhood
fears and anxiety problems. Indeed, many of these points could equally be made to explain
the lack of attention paid to prevention programs generally. First, the training of most
mental health professionals places minimal emphasis on prevention, and thus many
practitioners may not feel they have the skills or confidence to develop and implement
preventative programs. In fact, most mental health clinicians who have a good understand-
ing of the etiological and maintaining factors of a psychological disorder and are trained in
behavior-change methods would also have the skills to design and conduct a preventative
intervention.
Second, Hightower and Braden (1991) propose that many practitioners hold irrational
beliefs that reduce the probability that they will engage in preventative work. These include
the beliefs that they do not have time to engage in preventative efforts and that preventative
efforts do not work. These authors also emphasize the bias that many clinicians have toward
direct casework, rather than community-based interventions or work with nonclinical
groups before any diagnosable disorder is present. Obviously, attitudes such as these within
mental health professions would be a major barrier to progress in prevention programs.
Third, it is important to discuss the practical issues related to prevention programs
when it comes to empirical outcome studies. In order to evaluate the outcome of a
preventative program, studies typically need extremely large sample sizes if the base rate of
the disorder in the popUlation is relatively low. Only with such large samples is it then
possible to determine whether the prevalence of the presenting problem is lower in the group
receiving the preventative intervention compared to the no-intervention control group.
Studies of this type are therefore extremely expensive, and researchers are more likely to
work with populations and problems for which the base rate for the disorder or problem is
higher. Thus, programs are more likely to be implemented for "high-risk" groups and 471
frequently presenting problems (e.g., anxiety following parental divorce) than large-scale Preventative
studies with the general population and less commonly presenting problems (e.g., child Strategies
anxiety disorders). The wide range of possible etiological factors in childhood fears and
anxiety also produces practical problems for preventative programs. The ideal program
would need to tackle the numerous factors outlined in Table 1, and doing so would obviously
be very costly. There may be little point, however, in tackling only one etiological variable if
other adverse factors remain in place. For example, a school-based program to teach coping
skills to children for dealing with aversive and difficult situations would probably not be
particularly effective if a child remains in a home environment that actively models and
reinforces anxious and avoidance behaviors.
Although the points made in this section may explain why mental health researchers
and practitioners have paid relatively little attention to preventative interventions, it is
important that the relevant professions make attempts to redress this situation in the future.
The small amount of information available from research studies to date has produced some
optimistic results in the prevention of specific anxiety and fear problems in childhood, in
response to specific situations. We now have a great deal of information regarding the types
of methods that can be used to prevent fears and anxiety. These methods include the use of
modeling and teaching children a range of coping strategies for dealing with aversive and
stressful situations. We also know a great deal about the environmental and individual
factors that are related to the development of fears and anxiety problems in childhood, as
outlined in Table 1. Given this knowledge, we should therefore be in a position to design and
implement large-scale programs to prevent maladaptive fears and anxiety disorders in
childhood. These programs could be targeted toward high-risk groups or conducted on a
school-community basis with general population samples.
Although proposals of this type may appear grandiose, it is important to remember the
long-term benefits of prevention, in terms of long-term cost savings to the community and
reductions in personal suffering.

SUMMARY

There is a strong case for programs to prevent the development of maladaptive fears
and anxiety problems in childhood. Unfortunately, childhood anxiety disorders are rela-
tively prevalent and persistent. Although a costly process, prevention of such problems
would produce enormous cost savings to mental health services and would have the benefits
of improved quality of life and reduced suffering for many children.
This chapter outlined a multilevel model for the prevention of children's maladaptive
fears and anxiety problems. The model stressed the need for intervention at three levels,
namely: (1) the sociocultural/physical environment, (2) specific environmental influences!
learning experiences, and (3) the child's individual characteristics. Factors relating to the
etiology and maintenance of childhood maladaptive fears and anxiety at each of these levels
were outlined, followed by suggestions for appropriate intervention.
Although much has been written about hypothetical prevention programs designed to
prevent childhood anxiety disorders, large-scale, multifaceted programs of the type pro-
posed here are yet to be conducted. A review of the literature, however, reveals a large
number of studies that have evaluated the effectiveness of approaches for preventing fear
472 and anxiety in children facing aversive or stressful situations. These studies have demon-
Susan H. Spence
strated the value of modeling and training children in the use of coping strategies.
Environmental manipulations of the type outlined in the School Transition Environment
Project (STEP) also offer promise in the reduction of child anxiety problems. Methods used
in the prevention of specific fears provide some insight into the types of programs that could
be applied more generally to be prevention of childhood maladaptive fears and anxiety
disorders.
It is suggested, however, that mental health practitioners need to restructure their
beliefs about the role and importance of preventative interventions and their responsibility
to spend a significant proportion of their employment time on this area of work. There are a
great many benefits to be gained from prevention, if only we can shift our beliefs away from
the idea that we have to sit in our offices and wait for the client to present with the problem.

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