Clin Child Fam Psychol Rev (2014) 17:8596
DOI 10.1007/s10567-013-0152-0
Little Children with Big Worries: Addressing the Needs of Young,
Anxious Children and the Problem of Parent Engagement
Nicholas D. Mian
Published online: 15 August 2013
Springer Science+Business Media New York 2013
Abstract Anxiety disorders in preschool-age children
represent an important clinical problem due to high preva-
lence, substantial impairment, persistence, and associated
risk for later emotional problems. Early intervention may
mitigate these problems by capitalizing on a strategic
developmental period. Elevated neuroplasticity, availability
of screening tools, and the potential to modify parenting
practices position anxiety as a good candidate for early
intervention and preventive efforts. While some novel
interventions show promise, the broad success of such pro-
grams will largely depend on parent engagement. Since
parents are less likely to identify and seek help for anxiety
problems compared to other childhood behavior problems,
especially in a preventive manner, methods for understand-
ing parents decisions to participate and enhancing levels of
engagement are central to the success of early childhood
anxiety prevention and intervention. Understanding these
processes is particularly important for families characterized
by sociodemographic adversity, which have been under-
represented in anxiety treatment research. This review
summarizes the developmental phenomenology of early
emerging anxiety symptoms, the rationale for early inter-
vention, and the current state of research on interventions for
young, anxious children. The roles of parent engagement and
help-seeking processes are emphasized, especially among
economically disadvantaged and ethnic minority commu-
nities who are acutely at risk. Evidence-based strategies to
enhance parent engagement to facilitate the development
and dissemination of efficacious programs are offered.
N. D. Mian (&)
Center for Anxiety and Related Disorders, Boston University,
648 Beacon Street, 6th Floor, Boston, MA 02215, USA
e-mail: nickmian@gmail.com
Keywords Anxiety
Preschool
Early childhood

Parent engagement
Prevention
Early intervention
Childhood anxiety disorders represent a major mental
health problem, with lifetime prevalence estimates ranging
from 14 to 25 % for community samples of children and
adolescents (Costello et al. 2004). Estimates for preschool-
age children are approximately 9 % (Egger and Angold
2006b), but younger children are less likely to receive
treatment (Egger and Angold 2006a). Anxiety symptoms
and disorders are often chronic and relatively stable across
development if left untreated (Karevold et al. 2009; Mian
et al. 2011), and child anxiety predicts anxiety disorders as
well as other emotional disorders and negative sequelae,
such as substance abuse, in adolescence (Bittner et al.
2007; Cole et al. 1998; Kendall et al. 2004).
While progress has been made in developing empirically
supported treatments and prevention programs for young
children, this research has tended to under represent eco-
nomically disadvantaged and ethnic minority families
despite higher risk for emotional problems in such popu-
lations (Aisenberg 2001; Allen et al. 2008; Copeland
2005). One of the greatest challenges to developing inter-
ventions to target these high-risk children is low rates of
parent engagement in early intervention programs (Prinz
et al. 2001). There is reason to believe that this challenge is
particularly salient for anxiety-focused interventions, as
parents are less likely to identify and seek help for anxiety
problems, compared with more disruptive behavior prob-
lems (Pavuluri et al. 1996). However, very little research
has investigated parent engagement in anxiety-focused
intervention research.
This review summarizes relevant developmental factors
and the current state of research on interventions for
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preschool-age children with elevated anxiety symptoms.
The focus of the review is on children aged 26 years, but
some interventions reviewed include children as old as
9 years. In addition, this review emphasizes the importance
of studying processes related to parent engagement in early
intervention, especially among economically disadvan-
taged and ethnic minority communities. The purpose of this
review is to synthesize research on the phenomenology of
anxiety in young children, intervention approaches, and
parent engagement to facilitate the development of inter-
vention research for young, anxious children, with the hope
that interventions can be designed to meet the needs of
diverse and underserved populations.
Anxiety in Young Children
Rationale for Assessing Anxiety and Intervening
in Early Childhood
Prevalence rates of anxiety disorders among preschool
children are as high as 9.4 % (Egger and Angold 2006b).
Common, normative fears in young children are often
transient and include fears of separation, the dark, and
animals, but if they lead to significant impairment and/or
distress or do not decline with age, they may be associated
with severe irritability, mood swings, and worry (Egger and
Angold 2006a). Anxiety in preschool children interferes
with development, family relationships, and learning. There
is also substantial evidence suggesting that young, anxious
children are likely to struggle with emotional problems later
in childhood and into adulthood if left untreated (Biederman
et al. 2007; Bosquet and Egeland 2006; Cole et al. 1998;
Karevold et al. 2009). Hence, in addition to alleviating
current distress, intervening in early childhood provides a
developmentally strategic opportunity to improve long-
term emotional functioning. Theoretically, improving par-
entchild transactional processes by teaching parenting
skills has the potential to influence emotion regulation and
coping throughout childhood (Bayer et al. 2011; Hirshfeld-
Becker and Biederman 2002). Intervening with young
children shifts the primary agent of change from the child to
the parent, thereby making successful parent engagement a
crucial ingredient in early intervention.
There is also reason to believe that early intervention
may be more effective due to heightened neuroplasticity in
young children, increasing the potential for changes in
neural pathways related to attentional processes and
approach-avoidance behaviors thought to be biological
precursors to anxiety (Bar-Haim et al. 2007; Derryberry
and Reed 1994). Research with rodents has demonstrated
that early life stress increases fear relapse following
extinction, the relationship between fear response and
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Clin Child Fam Psychol Rev (2014) 17:8596
context, and long-term memory of fear context, which are
adult-like reactions to fear stimuli (Callaghan and
Richardson 2011). Hence, early life stress may be associ-
ated with accelerated development of limbic structures and
pathways associated with fear acquisition and attentional
biases. This research highlights the potential role of neu-
roplasticity of structures related to anxiety and fear in
young children. From a theoretical perspective, if early life
stress can lead to changes in brain development, it is rea-
sonable to suspect that targeted interventions might have
the potential to buffer such effects or alter brain develop-
ment in a protective fashion at this stage.
Developmental Issues
Interesting advances have been made in the phenomenol-
ogy of early childhood anxiety. Multiple research groups
have used factor analysis to identify patterns of symptom
differentiation according to diagnostic profiles in pre-
schoolers. These have tended to reflect social phobia (or
shyness), general anxiety, separation anxiety, obsessive
compulsive symptoms, and fears (Eley et al. 2003; Spence
et al. 2001). A similar model, supporting separation anxi-
ety, social phobia, generalized anxiety, and obsessive
compulsive symptoms, has also been supported in 2- to
3-year-olds (Mian et al. 2012). Of note, obsessivecom-
pulsive symptoms have been shown to further differentiate
in young children, representing just right and repetitive
behavior symptoms in children as young as 1 year of age
(Evans et al. 1997). Still, most early childhood research
applies an undifferentiated construct that represents anxiety
symptoms as reflective of a single, diffuse, construct (e.g.,
Marakovitz et al. 2011). If symptoms do reflect syndromes
corresponding to psychiatric diagnoses, then applying an
undifferentiated approach may mask differences in etiol-
ogy, risk, trajectories, and treatments for young children.
For example, Kendall et al. (1997) found that school-age
children diagnosed with avoidant disorder improved less
than children with overanxious and separation disorders.
Weems (2008) offers a theoretical model that differen-
tiates between primary and secondary features of anxious
emotion. Primary features represent the underlying dys-
regulation of the emotional response system that likely
accounts for general risk for anxiety disorder, including
physiological, cognitive, and behavioral symptoms. Sec-
ondary features represent symptoms that are disorder-spe-
cific, such as fear of embarrassment in social anxiety
disorder. The same underlying primary feature may man-
ifest as different disorders at different developmental
periods, affecting whether any individual child remains on
a particular trajectory. Although differentiated symptoms
are present in children as young as 2 years (Mian et al.
2012), primary features may still represent the main source
Clin Child Fam Psychol Rev (2014) 17:8596
of distress for young children. As such, research that
investigates whether treatments, such as exposures, have an
effect on primary versus secondary features of anxious
emotion could shed light on mechanisms for treatment.
A related developmental consideration is differentiating
between temperamental variations and symptoms, which
are difficult to disaggregate (Rapee and Coplan 2010).
About 15 % of children present with behavioral inhibition,
a temperamental construct characterized by low levels of
approach behavior and higher autonomic reactivity in novel
situations (Kagan 1984) and thought to be a risk factor for
later anxiety disorders (Biederman et al. 2001). However,
some researchers now question whether this presentation is
better thought of as an early sign of anxious symptomology
(e.g., Egger and Angold 2006a). Inhibited children can
present very similarly to those who are clinically anxious;
differentiation is most likely due to the degree of distress or
impairment. In one study, 90 % of children identified as
having behavioral inhibition were found to meet criteria for
anxiety disorder (Kennedy et al. 2009), suggesting signifi-
cant overlap. These two constructs can be differentiated
conceptually, particularly in that a substantial number of
individuals have fearful temperaments without a history of
anxiety disorder and that interventions tend to have stronger
effects on symptoms than temperamental characteristics
(Rapee and Coplan 2010). However, challenges remain in
differentiating the two through measurement. One method
may be by assessing functional impairment, which should
be more associated with disorders.
Implications for Family Involvement in Treatment
Research on the impact of parental behaviors on childrens
anxiety symptoms and the high likelihood that parents will
also be anxious suggest that including parents in treatment
will help to reduce parenting behaviorssuch as modeling
anxious behaviors or reinforcing avoidancethat have
been implicated in anxiety disorders (Ginsburg and Sch-
lossberg 2002). Hence, early, family intervention could
help to foster healthier, active coping from a young age.
With school-age children, family-based cognitive-behav-
ioral therapy (CBT), which provides parents with infor-
mation on contingency management, personal anxiety
management, and how to respond to the child, has been
shown to be as effective or more effective than standard
CBT (for a review, see Ginsburg and Schlossberg 2002).
Parent involvement is thought to facilitate the transfer of
knowledge and skills from therapist to parent and from
parent to child (see Ginsburg and Schlossberg 2002). This
model suggests that if these processes are successful, par-
enting changes can continue to lead to positive effects long
after formal treatment ends (e.g., Rapee 2013). With
younger children, including parents in therapy has been
87
strongly recommended (Hirshfeld-Becker and Biederman
2002; Pincus et al. 2005; Suveg et al. 2006). Preschool-age
children often spend far more time with their parents,
suggesting that parents have a stronger influence on their
childrens behavior. Also, separating from parents, sleep-
ing alone or away from home, and approaching novel sit-
uations or people are among the most commonly reported
anxiety symptoms for young children (Spence et al. 2001),
suggesting that symptoms often relate directly to parents.
Lastly, parents of young children are more likely to
exclusively make decisions regarding treatment attendance,
highlighting the importance of parent engagement. Virtu-
ally, all interventions described below emphasize parental
involvement.
Early Intervention Models for Preschool-Age Children
The term prevention is used broadly in this review to refer
to interventions that target children who are not yet expe-
riencing an anxiety disorder (Mrazek and Haggerty 1994).
Prevention and treatment are thought to be part of the same
continuum of providing care, and the distinction can be
misleading, as treatment in early childhood is inherently
preventive if the effects reduce symptoms in the future.
However, the distinction is applied here because more
severe symptomology is predictive of seeking clinical
services (Pavuluri et al. 1996). Hence, it is likely that
engagement patterns may differ for prevention and treat-
ment approaches.
Prevention Approaches
There is a growing interest in the cost-effectiveness of
providing mental health services in a preventive fashion
(Mrazek and Haggerty 1994). Anxiety has been presented
as a good candidate for selective (targeted) prevention due
to its prevalence, developmental stability, known risk fac-
tors, and availability of screening tools (Bayer et al. 2011;
Hirshfeld-Becker and Biederman 2002; Rapee 2002). The
risk factors that have received the most support are
behavioral inhibition and parental anxiety disorder
(Hirshfeld-Becker and Biederman 2002; Rapee 2002), but
early manifestations of anxiety symptoms (Mian et al.
2011) and attention bias to threat (Bar-Haim et al. 2007)
may also represent good candidates. More research is
needed on the sensitivity and specificity of using risk fac-
tors to identify at-risk children and identifying the optimal
developmental period for prevention. While some
researchers have targeted pre-adolescence (Ginsburg
2009), earlier intervention may be preferable to decrease
anxiety symptoms throughout childhood (Rapee et al.
2005).
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The most highly developed and tested prevention pro-
grams for young children have been conducted in Australia
by Rapee et al. (2005), who designed a selective prevention
intervention (Cool Little Kids) for young children at risk
for anxiety by virtue of being behaviorally inhibited (Rapee
2002). The 146 children (aged 36 to 62 months) who met
criteria were randomly assigned to either a monitoring
group or a 6-session parent education group that focused on
CBT strategies, including psychoeducation, use of fear
hierarchies, the relationship between overprotection and
anxiety, and cognitive restructuring for parents own wor-
ries (children did not directly receive services). At
12-month follow-up, the intervention led to a decrease in
the development of an anxiety disorder, but did not affect
temperamental inhibition. Interestingly, girls in the inter-
vention group were assessed to have fewer internalizing
problems 11 years later, at age 15, compared to the control
group (this effect was not found for boys), suggesting that
even a brief, parenting-focused program can have long-
lasting preventive effects (Rapee 2013).
The same research group later targeted children at even
higher risk by including children who were inhibited and
had a parent with an anxiety disorder (Kennedy et al.
2009). The intervention was also enhanced by adding two
additional parent sessions. Seventy-one children (mean of
47 months old) were randomly assigned to a parent edu-
cation group or a 6 months waitlist. At post-intervention,
there were significant treatment effects for both maternal-
reported and observational measures of inhibition, and
more children in the intervention group were free of anx-
iety disorders compared to those in the control group (46.7
vs. 6.7 %, respectively). The results of this study are
impressive because changes were observed in diagnostic
status, symptom severity, and level of inhibition, a tem-
peramental construct that is thought to be relatively stable
over time. A translational randomized controlled trial
(RCT) is now under way, which will test the intervention
without previous limitations, such as research university
location, self-selection of participants, and laboratory
assessment methods (Bayer et al. 2011). As described, this
trial will include participants from low, medium, and high
socioeconomic levels.
Another prevention approach was conducted in Canada
by Lafreniere and Capuano (1997). This study included
children (mean age of 4.5 years) identified by an elevated
anxious-withdrawn score on a parent-report measure. designed to treat specific phobias, and it is unclear whether
Half the children were randomly assigned to a series of 19
individual parent meetings (mostly home visits). This
intervention was aimed at addressing general social-emo-
tional development by improving developmental under-
standing, parent competence, parent stress, and social
support. Although there were positive results in this study,
changes on the anxious-withdrawn subscale indicated only
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Clin Child Fam Psychol Rev (2014) 17:8596
marginal, non-significant improvements, suggesting that
this intervention was not powerful or targeted enough to
change anxious/withdrawn behaviors.
Other examples of prevention-based approaches have
focused on universal prevention, which strives to provide
an intervention for all children in a particular population.
Pahl and Barrett (2010) designed a school-based program
for preschool-age children (aged 4 to 6 years), also in
Australia, called the Fun FRIENDS program. This CBT-
based program was delivered directly to children in a
preschool classroom over nine one-hour sessions. It
includes developmental modifications of CBT strategies,
including relaxation, active coping, thought monitoring,
and self-talk. In addition, parents were offered three
information sessions on psychoeducation about anxiety and
session content. The RCT conducted with this intervention
demonstrated feasibility of providing an intervention in this
format, but did not achieve significant effects for symptoms
across intervention groups. Notably, effects of this inter-
vention were undermined by high levels of attrition and
low levels of parent participation (discussed in more detail
below). Dadds and Roth (2008) also conducted a universal
prevention study in Australia that was designed to prevent
the development of anxiety disorders, but with limited
success. This study included 734 parents of children aged 3
to 6 years. Parents participated in a six-session CBT-based
training program, which specifically targeted the develop-
ment of positive encouragement, positive self-talk, and
strength-based coping. Although anxiety symptoms
decreased, these effects were small and only evident in
teacher reports; they were also no longer present at
7-month follow-up, suggesting this universal intervention
may have been too general to address anxiety symptoms.
Treatments for Anxiety with Young Children
It has been documented for decades that specific phobias (or
fears) can be treated in preschool-age children with operant
approaches (for a review, see Ollendick and King 1998),
suggesting that such interventions (i.e., exposures and
modeling) are effective with young children. However, most
of these studies preceded the advent of current methodo-
logical recommendations for empirically supported treat-
ments, including maximizing the representativeness of
clinical samples (Weisz et al. 2005). These treatments were
addressing the underlying features of anxious emotion (e.g.,
cognitive distortions, stimulus generalization, attention
biases), found in more complex anxiety disorders, requires a
treatment that goes beyond behavioral techniques, such as
cognitive restructuring does with older children. Specific
phobias have also been shown to be easier to treat, with
school-age children benefitting from single-session exposure
Clin Child Fam Psychol Rev (2014) 17:8596
treatments (Ollendick et al. 2009). Differences between
fearan autonomic response to present threatand anxi-
etya multi-faceted, future-oriented response of apprehen-
sion (Barlow et al. 1996)suggest that treatments that
address both will be most useful.
Recent advances have been made in developing treat-
ments for young children diagnosed with an anxiety disorder.
Targeting children with clinically severe symptomology
avoids the major challenge of engaging parents who may not
be highly motivated, a significant problem for preventive
approaches. Hirshfeld-Becker et al. (2010, 2008) conducted
a RCT for CBT targeting 4- to 7-year-old children with
anxiety disorders. This group employed developmental
adaptations to develop Being Brave: A Program for Coping
with Anxiety for Young Children and Their Parents. This
program includes 20 sessions reflecting four modules: parent
anxiety management (sessions 13), coaching the child in
anxiety management (46), child anxiety management
(719), and relapse prevention (20). The first six sessions
involve parents only, allowing parents to learn the content
before assisting the child. Content includes psychoeduca-
tion, parental modeling, cognitive restructuring (for parents),
dangers of overprotection, exposure exercises, relaxation
exercises, and maintenance strategies. Developmental
adaptations include relaxation techniques designed for
younger children, self-instructive strategies (rather than
cognitive restructuring), inclusion of games in exposure
exercises, and immediate positive reinforcement. After
treatment, 59 % of children receiving the intervention were
free of anxiety diagnosis, compared to 18 % of controls.
Gains were largely maintained at 1-year follow-up. Inter-
estingly, children who were rated as behaviorally inhibited
were less likely to benefit. As with many treatment studies,
this sample represented low levels of sociodemographic risk
(despite high levels of psychiatric risk): 80 % of children
identified as European American, 88 % were from intact
families, and the sample was largely middle class and well-
educated. While this study provides good evidence that CBT
can be effectively adapted for young children, it is unclear
whether similar protocols would be effective with more
disadvantaged or diverse samples.
Cartwright-Hatton et al. (2011) also developed a CBT-
focused intervention, Timid to Tiger, for young children
(aged 2.79 years; mean = 6.6 years) with anxiety disor-
ders. Most children (64 of 74) were self-referred. Parents
were invited to 10 group sessions (children did not attend)
that focused on maintaining a warm, predictable home
environment and teaching parents how to manage child
anxiety by applying CBT strategies. Even with this brief
intervention, results were similar to the CBT study above;
57 % of children were free of their primary anxiety diag-
nosis, compared to 15 % of controls. Gains were also
demonstrated for anxiety symptom levels. Again, this
89
sample appeared to represent mostly White, middle, and
upper-middle class families.
Two research groups are adapting parentchild interac-
tion therapy (PCIT), an empirically supported treatment for
preschool-age children with behavior problems, for use
with young, anxious children (Comer et al. 2012; Pincus
et al. 2008; Puliafico et al. 2012). Unlike the treatments
described above, PCIT is not a downward extension of an
intervention designed for older children, but was originally
designed for preschool-age children and their parents.
Pincus et al. (2008) tailored PCIT for children with sepa-
ration anxiety disorder (SAD) based on the importance of
parents unique involvement in the maintenance of SAD. A
new phase was added to the PCIT protocol: the bravery-
directed interaction (BDI). Parents receive psychoeduca-
tion about anxiety and relevant maintaining factors (i.e.,
avoiding feared situations) and are coached to guide the
child through exposure exercises and reinforce bravery.
Coaching parents to conduct the exposures without the
therapist visible may increase portability beyond the ther-
apy office. The first RCT for this treatment (with nine
sessions) is being conducted with children ages 4 to 8 years
with a principle diagnosis of SAD (Pincus et al. 2008).
Preliminary findings are encouragingclinician-reported
measures of symptom severity decreased from 5.54 to 2.80
on a scale of 08. Parents reported the intervention
increased their confidence. Another research group has
developed the CALM Program, which is an adaptation of
PCIT for a range of anxiety disorders (Comer et al. 2012;
Puliafico et al. 2012). In addition to the core PCIT skills,
this program employs CBT principles, such as teaching
parents to selectively attend to children to reinforce brave
behavior during in vivo exposures. Unlike standard PCIT
and the modification by Pincus et al. (2008), the CALM
program does not address child discipline, as in the parent
directed interaction phase. A small, pilot trial with 12
sessions has provided encouraging results, with 86 % no
longer meeting criteria for anxiety disorder. Since PCIT
has been used with younger children (Schuhmann et al.
1998), these treatments may be useful for children younger
than 4 as well.
These examples of CBT and PCIT mark important pro-
gress in developing treatments for young, anxious children.
Both approaches have produced encouraging preliminary
results and reflect rigorous methodology. These approaches
are theoretically and empirically derived and represent
adaptations of existing empirically supported approaches.
However, only one of the studies above (Cartwright-Hatton
et al. 2011) included children younger than age 4, and they
all include children of school age. Including separate
analyses for younger children or testing age as a moderator
(as in Hirshfeld-Becker et al. 2010) can help demonstrate if
the intervention works equally well across ages. Studies
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with children under age 4 have generally taken the form of
parent trainings (Cartwright-Hatton et al. 2011; Rapee et al.
2005), reflecting the difficulty of implementing individual
treatments in this age group as well as evidence that
changing parenting alone can lead to improvements.
However, treatments that include both child and parent
components have been implemented for behavior problems
(Webster-Stratton and Reid 2003). While the studies cited
above provide encouraging progress, they are limited by
low clinical representativeness of samples and settings, like
much efficacy research (Weisz et al. 2005).
Finally, there is a dearth of research from different
theoretical orientations in the child anxiety literature. Play
therapy, which reflects a psychodynamic framework, uses
play to encourage emotional expression, learning, and
integration of feelings (Benham and Slotnick 2006). While
widely practiced with young children, empirical outcome
data are conspicuously lacking, especially for specific
problems. Bratton et al. (2005) analyzed results from 94
studies that included a broad range of diagnostic problems
and approaches. Only 43 had been published, of which
only seven included an outcome measure for anxiety or
fear. The effect size for these studies was 0.69, one of the
lowest investigated. Despite difficulties related to measur-
ing, standardizing, and quantifying this treatment, its
developmental appropriateness for young children suggests
it may inform interventions for preschool-age children.
The Challenge of Parent Engagement
The Importance of Parent Engagement
The greatest challenges to dissemination and establishing
effectiveness of early childhood anxiety interventions for
high-risk children will likely be related to parents interest,
willingness, or ability to engage in these programs. In the
general population, the vast majority of children in need of
mental health services do not receive them (Horwitz et al.
2003; Pavuluri et al. 1996), and rates of unmet need are
highest among children younger than age 6, uninsured
children, and children of color (Kataoka et al. 2002). Low
rates of professional service utilizationas low as 3 %
have been found for 4-year-olds with clinical diagnoses
(Lavigne et al. 2009). Low rates are also seen in prevention
program participation (Prinz et al. 2001). This problem is
particularly important for anxiety intervention, as parents
are generally less likely to recognize there is a problem and
seek help for internalizing symptoms compared to prob-
lematic externalizing or hyperactive behaviors (Chavira
et al. 2004; Pavuluri et al. 1996; Wu et al. 1999). Parents
may perceive behavior problems as having more severe
consequences such as school expulsion, social isolation, or
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Clin Child Fam Psychol Rev (2014) 17:8596
academic failure. In addition, parents may be more likely
to see anxiety as something that will get better by itself, a
barrier to help seeking that was endorsed by 79 % of
parents in one study (Pavuluri et al. 1996).
One theoretical model for parents help-seeking behav-
iors for young childrendrawn from the health beliefs and
pediatric mental health service literaturesidentifies
behaviors necessary for receiving help: recognizing that a
problem exists, deciding to seek help, identifying an action
plan, and taking action (Godoy and Carter 2013). Many
factors, such as feedback from family members and pro-
fessionals or parents own anxiety, can affect parental
motivation at each step and move a parent toward or away
from taking action. One of the most important influences
on this process is the parents appraisal of the childs
problem, which encompasses explanatory models, per-
ceived severity, and worry about the problem. When sta-
tistically modeled among low-income parents, parental
appraisals have predicted parents considering seeking help,
which then predicted service receipt (Godoy et al. 2013).
According to this model, parents would be expected to be
less motivated to participate in the prevention programs
because they target children who are not yet experiencing
clinical problems (Mrazek and Haggerty 1994). Unlike
preventive medicine, such as vaccines and regular check-
ups, the benefits of prevention programs for mental health
concerns are virtually unknown. Hence, understanding
parents decisions related to participation and identifying
ways to change parent appraisals or attitudes are
paramount.
In Rapee et al. (2005) prevention study described above,
1,647 of 5,609 (29.4 %) screening packets were returned.
In addition, 73 children were self-referred by parents. Of
the 1,720 children, 285 scored above a behavioral inhibi-
tion cut score and were invited to attend a laboratory
assessment and 180 (63 %) attended. Of the 180, 148 met
laboratory-based assessment for behavioral inhibition, and
146 (aged 36 to 62 months) agreed to participate. It is not
clear how many of the 73 self-referred children are repre-
sented in the 146 participants. This study illustrates some
challenges with conducting this type of prevention pro-
gram. First, this sample included predominantly Anglo-
Saxon or European participants (approximately 85 % of
the final sample), potentially limiting generalizability of
both results and engagement to other ethnic groups (it
would be interesting to compare this proportion to the
areas population to assess for different engagement pat-
terns across groups). Second, only 146 of 5,682 potential
participants met criteria and agreed to participate. Since an
85th percentile cut score was used for the initial screening,
it could be expected that approximately 852 children would
have met initial criteria for participating if all packets were
returned. Of that estimated number, 146 (17 %) actually
Clin Child Fam Psychol Rev (2014) 17:8596
attended, and this likely includes self-referred children.
Although participating parents benefited substantially,
programs like this must reach more parents to achieve
large-scale societal impact. Further, since 90 % of partic-
ipants had an anxiety disorder at the study onset (see
Kennedy et al. 2009), it is likely that parents with children
with relatively severe anxiety self-selected to participate.
The translational RCT that is currently under way (Bayer
et al. 2011) will likely be crucial in assessing feasibility for
large-scale dissemination. Challenges related to engaging
families were found across many studies in this review;
Dadds and Roth (2008) invited a potential 1,646 parents;
734 consented to participate, but only 107 parents (30 % of
the intent-to-treat group) actually attended sessions.
Retention has also been a problem. In the Fun FRIENDS
study (Pahl and Barrett 2010), a high level of initial
engagement was successfully achieved by offering the
program through a public preschool, but 41 % of partici-
pants failed to complete the post-treatment assessments.
Another important consideration is the relationship
between parent engagement and effectiveness. Pahl and
Barrett (2010) reported low levels of parent participation at
information sessions, which was thought to reduce overall
intervention effects. Also, those with higher levels of pre-
treatment anxiety symptoms were more likely to complete
the program, suggesting that parents for whom the program
was most relevant were more engaged with it. Similarly,
Dadds and Roth (2008) found that more highly stressed
parents tended to remain in the intervention. Such results
highlight the importance of tracking engagement as it can
relate to statistical power, effects, and generalizability.
These results are consistent with the finding that parents of
low socioeconomic status benefit less from parent training
programs, except when problems are severe (Leijten et al.
2013). As suggested by the authors, this moderation effect
is most likely due to lower levels of parent engagement
among this population. This effect is especially problem-
atic for prevention programs and may also be more prob-
lematic for interventions targeting anxiety if such
symptoms are perceived as less severe.
Rationale for Focusing on Families with High
Sociodemographic Adversity
Achieving long-term societal benefit by helping young,
anxious children necessitates being able to reach the chil-
dren who are most in need. Research suggests that children
from families characterized by sociodemographic risk
including poverty, minority ethnicity, immigration, stress-
ful life events, single-parent households, and low parent
education are at higher risk for mental health problems
(Allen et al. 2008; Briggs-Gowan et al. 2001; Costello
1989; Duncan et al. 1994; McLeod and Shanahan 1993).
91
Paradoxically, these high-risk samples are under-repre-
sented in treatment studies, including those described in
this review. Huey and Polo (2008) identified only three
controlled studies addressing anxiety among minority
(school-age) youth. These are increasingly important
problems, as ethnic minority individuals are estimated to
represent half of the US population by 2050, with half
being Hispanic (Day 1996). Moreover, families character-
ized by low socioeconomic status benefit less from parent
training programs (Leijten et al. 2013).
Focusing on families characterized by sociodemographic
adversity may be particularly important for anxiety inter-
ventions due to the relationship between uncontrollability in
the environment and anxiety (Chorpita and Barlow 1998).
Young children living in poor, urban communities are more
likely to be exposed to potentially traumatic experiences,
ranging from parental conflict to domestic and community
violence (for reviews, see Briggs-Gowan and Mian in press;
Margolin and Gordis 2000; Osofsky 1999). In a study by
Aisenberg (2001), 26 % of young, poor, Latino children had
experienced violence toward themselves and 45 % had
witnessed violence in their lifetime. Not surprisingly,
exposure to trauma, violence, or family conflict is associ-
ated with elevated anxiety symptoms in young children
(Marakovitz et al. 2011; Margolin and Gordis 2000;
McDonald et al. 2007), suggesting exposure may be a
mechanism through which sociodemographic adversity can
lead to anxiety. This could be due to associated increases in
feelings of insecurity or uncontrollability (Chorpita and
Barlow 1998), affecting the development of brain structures
associated with fear responses (Callaghan and Richardson
2011). Research investigating the relationship between
potentially traumatic experiences and anxiety is needed.
Patterns of Service Use and Factors Associated
with Parent Engagement
There is a dearth of research on treatments for ethnic
minority and high-risk children, which is partly explained by
service use patterns that differ from White, European fami-
lies and reflect disparities in access to care and variations in
attitudes regarding the cause, meaning, and treatment for
psychological problems (Alegria et al. 2004; Cauce et al.
2002; Copeland 2005; Garland et al. 2005; Harari et al.
2008). Consistent with this concept, single mothers and
ethnic minority children are more likely to drop out of CBT
for child anxiety (Kendall and Sugarman 1997). Similar
sociodemographic trends can be seen in rates of accessing
community child mental health services (Garland et al. 2005;
Pavuluri et al. 1996). However, once parents engage initially,
higher symptom levels and lower stress have been associated
with retention in prevention programs (Dadds and Roth
2008; Pahl and Barrett 2010).
123
92
No known studies have specifically investigated factors
related to engagement in programs targeting early childhood
anxiety; hence, research cited below relates to engagement in
programs targeting externalizing problems. While it may be
more challenging to engage parents in interventions for
anxiety, it is unclear whether these programs will require
different engagement practices. Some barriers to treatment
relate directly to the situational difficulties that characterize
many families living in disadvantaged communities,
including poverty, healthcare, transportation, and scheduling
(Linfoot et al. 1999). Time demands and scheduling issues
are often the most import barriers cited by parents (Gross
et al. 2001; Spoth and Redmond 2000). Spoth and Redmond
(2000) found that more highly educated parents of school-
age children were more interested in participating and
reported higher perceived benefits. Another barrier they cited
was not wanting to be a research subject, suggesting parents
may experience mistrust of research institutions.
Heinrichs et al. (2005) investigated parent recruitment
rates and barriers to attendance in a two-phase study that
involved completing assessments (phase 1) and then
attending a 4-week parenting program. Targeted children
aged 36 years were recruited through preschools in Ger-
many. Parents from low SES neighborhoods were recruited
at a rate of 23 %, with these families being four times less
likely to participate than parents from high SES neighbor-
hoods. Regarding participation in the parenting program,
77 % of parents who completed assessments in phase 1
participated in the program. Again, parents from lower SES
neighborhoods, as well as single parents, were less likely to
participate. Another research group that investigated parent
engagement in early childhood prevention trials (in the
United States) for low-income parents achieved rates of
35 % for project enrollment, as defined by parents agreeing
to participate (Garvey et al. 2006). However, 33 % of parents
who enrolled never attended sessions and 8 % attended only
one. Hence, only 23 % (196/858) of targeted families
attended, despite strong and impressive results for those who
did. Thus, parent engagement rates in programs targeting
early childhood behavior problems are often lower than 30 %
within high-risk communities. It is reasonable to expect that
rates for programs targeting anxiety would be even lower.
Enhancing Parent EngagementWhat Can Be Done?
McKay et al. (2004, 1996a) have developed the most widely
implemented strategies to enhance initial parent engagement
for child mental health services. The parent engagement inter-
vention strives to: (a) clarify the need for mental health services,
(b) maximize the caregivers investment and efficacy related to
help seeking, (c) identify attitudes about seeking services
including negative attitudes based on previous experiences, and
(d) develop strategies to overcome concrete obstacles to seeking
123
Clin Child Fam Psychol Rev (2014) 17:8596
services, such as lack of childcare or transportation. Training
providers in specific strategies aimed at improving parent
engagement improved rates of attending first appointments by
30 % in low-income, urban samples (McKay et al. 1996a).
Szapocznik et al. (1988) also investigated an engagement
strategy, but among families with adolescent drug users. This
protocol used a family-based, strategic structural-systems
engagement method that employed family therapy techniques
(joining and restructuring) according to different types of
patient resistance. The therapist strived to join the family in a
way that did not threaten family structure (e.g., aligning with a
particular parent based on which was ambivalent or disengaged
in seeking treatment). Hence, the engagement strategy used
varied according to the type of family resistance (for a detailed
description, see Szapocznik et al. 1988). This technique suc-
cessfully engaged 93 % of families compared to 42 % in the
control condition (Szapocznik et al. 1988). However, it is
important to note that these studies aimed at engaging parents of
school-age children in community clinics, to which they had
already been referred. Early intervention and prevention pro-
grams may require more powerful methods of engaging parents,
since parents will be introduced earlier in the help-seeking
process (Godoy and Carter 2013). However, both protocols
could theoretically be adapted for early intervention. Rather
than clarifying the need for clinical services in McKays pro-
tocol, the potential benefit of preventive services could be
emphasized. Szapoczniks protocol identifies family barriers to
engagement before the first session, which could be very useful
for engaging parents of young children.
The Guiando a Ninos Activos (Guiding Active Children;
GANA) program, an adaptation of PCIT for Mexican
American families, is an example of a cultural adaptation
of an empirically supported treatment that includes a parent
engagement module (McCabe et al. 2005). The module is
based on McKays engagement strategies (McKay et al.
1996b), but include cultural variations, such as removing
terms such as therapy or mental health from protocols
to reduce stigma, increasing contact with family members
beyond the parentchild dyad and explicitly addressing
preconceptions of treatment. Despite these efforts, a RCT
with 37-year-old children did not demonstrate better
engagement rates compared to PCIT-as-usual (McCabe and
Yeh 2009), suggesting that more research may be needed to
enhance engagement for this group.
Many research studies on parent engagement in pre-
vention include school-age children, but it is likely that
such research can inform engagement procedures for
younger children. Spoth and Redmond reported in a series
of prevention studies with sixth graders that perceived
benefits about a program predicted reported inclination to
participate, and this predicted actual participation (Spoth
and Redmond 2000). Parents also emphasized meeting
location, program duration, evidence of efficacy, and the
Clin Child Fam Psychol Rev (2014) 17:8596
background of the program leader. Other research has
indicated that parents are more likely to attend sessions if
they perceive them to be aligned with their own prefer-
ences for type of clinical service (Bannon and McKay
2005). Gross et al. (2001) investigated the role of incen-
tives for participating parents of preschool-age parents. The
incentive most often endorsed was that the program be
offered on-site (at the childs day-care setting; 93 %),
followed by the personality of the recruiter (88 %), free
childcare (86 %), a copy of an assessment video (83 %),
and offering the program on weekday evenings (79 %).
Another engagement strategyaimed at reducing stigma
involves advertising the program in terms of the advanta-
ges of participating rather than the clinical need for ser-
vices, consistent with research indicating that parents
participate in programs to become better parents rather than
to reduce problematic behaviors (Gross et al. 2001).
Some research on specific recommendations for recruit-
ment among ethnic minority populations has emphasized
active, community-based recruitment, including: (1) using
participants native language, (2) recruitment in community
settings, and (3) recruitment through trusted community
leaders (Harachi et al. 1997). This study, which included
immigrant, non-English speaking parents of 67th graders,
used non-traditional methods, such as recruiting at church and
community events, using social networks, and going door-to-
door in nearby neighborhoods. Another strategy is linking the
research project with known and trusted community institu-
tions, leaders, or providers, referred to as community
endorsement, which is thought to mitigate the barrier of mis-
trust or not wanting to be a research subject (McCabe et al.
2005; Prinz et al. 2001). One example is including a letter from
the school principal (Prinz et al. 2001) or director of a childcare
program inviting parents to participate.
There is reason to believe that enhancing recruitment
strategies for programs addressing anxiety in young children
are particularly important due to the likelihood that partici-
pating parents will be anxious as well. As such, inviting
parents to groups may be anxiety provoking, especially if
parents are anxious about how their parenting strategies will
be perceived. Recruitment methods aimed at reducing anx-
iety in parents may make a substantial difference. Research
investigating pre-treatment modules to increase motiva-
tion and preparation (Westra and Dozois 2006) may be rel-
evant to parent engagement. However, it is also possible that,
paradoxically, more anxious parents will be more likely to
participate if they are anxious about their childs develop-
ment and seeking guidance. Another possibility is that active
recruitmentmore often used in prevention programs
might be more successful at reaching less anxious parents,
while programs that encourage parents to self-refer for
treatment tend to attract more anxious parents. Research
investigating associations between parent anxiety and
93
engagement is much needed, and multi-dimensional parent
anxiety measures that differentiate between subtypes (i.e.,
social anxiety) may prove particularly useful.
Conclusions
This review orients the present state of research at an
exciting moment in the development of interventions for
young children. Anxiety in preschool-age children is rec-
ognized as a serious issue, but interventions are relatively
nascent. Empirical bases for treatments for school-age child
anxiety, preschool externalizing behavior, and adapted
treatments for ethnic minority populations can inform the
development of interventions. It is advised that researchers
acknowledge and measure the role of parent engagement,
particularly as it relates to reaching anxious children from
diverse and high-risk backgrounds. While challenges rela-
ted to parent engagement are not unique to early childhood
anxiety, they may be particularly salient for this population.
Furthermore, these challenges represent a significant barrier
to developing treatment and prevention programs for
underserved populations and for wide-scale dissemination.
Demonstrating that prevention programs will reach parents
in need is important for the community partnerships and
funding agencies that make such research possible.
The development of effective interventions for young,
anxious children represents an opportunity to ameliorate
suffering for children and families as well as the potential to
improve the course of emotional functioning across the life
span. Extending such services to children in the most vul-
nerable communities and addressing barriers to treatment
represent important ethical and public health responsibili-
ties. As the field develops treatments and preventive
approaches for this population, it is hoped that program
development is informed by research related to engaging
parents from hard-to-reach families.
Acknowledgments I would like to thank Dr. Alice S. Carter for her
guidance and support of this project.
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