Using Stories to Prevent Anxiety Disorders in a School Context: Dominique’s Handy Tricks Program

1. Introduction

Several studies have highlighted the significant consequences of anxiety disorders in children (Donovan & Spence 2000; Rapee et al., 2009; Merikangas et al., 2009). These children experience greater difficulties in their social relationships, often suffer from loneliness and are often victims of aggression or rejection from their peers (Last, 1993; March, 1995; Vasey & Dadds, 2001; Morris & March, 2004). Children who suffer from an anxiety disorder can experience fatigue, difficulty concentrating, irritability, and school refusal (Dadds & Barrett, 2001). They are also more susceptible to psychosomatic illnesses and more likely to use health care services (Morris & March, 2004). Along with their distress and their vulnerability to stress, they are more at risk of developing early drug addiction problems or attempting suicide (Morris & March, 2004). Finally, there is a high probability that during adolescence or adulthood they will develop anxiety disorders that will compromise their personal and social lives (Costello et al., 2003; Hirshfield et al., 2008).

The positive results obtained by teaching cognitive-behavioral techniques for anxiety management to young children (Kendall, 1994; Kendall et al., 1997; Barret et al., 2001; Compton et al., 2004; Cartwright-Hatton et al., 2004; Hirshfeld-Becker et al., 2010) militates for the feasibility to develop attitudes and behaviors that could be protective factors for anxiety disorders. Some emotion regulation skills seem to play a key role in the capacity of children to manage their anxiety. These skills include knowledge about physiological reactions to anxiety and stress, the capacity to identify the source of emotion dysregulation and to verbalize their emotions, the ability to restructure dysfunctional thoughts in order to generate emotions that stimulate productive action, the use of problem-solving strategies or of personal support networks, and the capacity to gradually expose oneself to threatening situations (e.g. Miller et al., 2010; Stallard, 2010).

When it comes to developing prevention program, the question arises regarding the relevance of providing prevention interventions to all children or only to children who are at risk (Lowry-Webster et al., 2001). We believe that some cognitive and behavioral characteristics of children who are more vulnerable to anxiety and that are common amongst all anxiety disorders should form the basis and pedagogical strategies of prevention programs. Underlying cognitive characteristics that transcend all anxiety disorders rest on the association between fear and situations that are: perceived as threatening, and / or unexpected, and / or uncontrollable and / or where the child has a poor sense of perceived self-efficacy to cope with the situation. In addition, there is a common transdiagnostic behavioral characteristic that must also be targeted in the prevention of anxiety disorders: avoidance of threatening stimuli (also referred to as safety seeking behaviors). These cognitive and behavioral characteristics are often expressed by children through excessive worries, anxiety sensitivity, avoidance, panic attacks or communicating to adults their feeling that they can’t face a problem or a situation (Ollendick & March, 2004).

Learning anxiety management skills could also be of benefit for the majority of children, not only those at risk for a disorder (Hiersfeld-Becker et al., 2002; Lowry-Webster et al., 2001; Stallard, 2010). Anxiety is a normal emotional reaction and most children could benefit from better emotion regulation skills. In addition, many children consider their normal fears as disruptive of their daily activities (Muris et al., 2000). Over the course of their development, all children are faced with various anxiety-producing situations that test their capacity for adaptation (Dacey & Fiore, 2000). These episodes could be related to difficult living conditions (e.g., poverty), a developmental crisis or specific unanticipated events (Becker & Chorpita, 2008). In essence, a universal primary prevention program could be relevant for all children and foster their capacity to adapt to daily problems (Lazarus & Folkman, 1984; Hardy et al., 1993).

2. Using realistic stories to teach coping strategies

Stories and metaphors are already used in treatment programs for anxiety disorders to help adults understand their reactions in order to develop new attitudes and behaviors (Otto, 2000). Using books to teach cognitive-behavioral techniques has also been proven useful with depressed adolescents (Ackerson et al., 1998; Scogin et al., 1990) and with individuals suffering from panic disorders (Gould et al., 1993; Wright et al., 2000). Some books may be self-treatment manuals or simply provide support for the intervention of the therapist. Dominique’s Handy Tricks used the latter approach, in which stories about problems in school or at home provide support for a workshop leader to teach relevant anxiety management techniques.

Building a universal and primary prevention program around the use of realistic stories is based on the assumptions that it could: (a) provide meaningful illustrations of key concepts and adaptive behavior, (b) facilitate exchanges with and between participants, (c) normalize emotional reactions to stressors, (d) put into words what the children experiences daily, and (e) offer the opportunity for anxious children to share apprehensions or worries without having to disclose details of events that occurred to them.

The events faced by Dominique and his friends highlight stressors encountered among school-age children, such as having academic problems, being judged by others, being separated from their parents or being ridiculed. Various useful cognitive and behavioral strategies can also be illustrated, such as facing fears, coping with bullying, or confide in adults. The stories also provide non-threatening means of discussing subjects that, if dealt with directly, could embarrass children suffering from an anxiety disorder, induce emotions or reveal confidences that could become detrimental to them (Milich et al., 1992).

In summary, the prevalence of anxiety disorders in children and the fact that all children can benefit from anxiety management techniques lead to the development of a universal prevention program that do not target dysfunctional anxiety up front. The originality of the program rests on the use of storybooks depicting situations that are known stressors for many children, normalize their concerns and set the stage to provide information and exercises to learn the typical cognitive-behavioral techniques used to cope with everyday life stressors as well as anxiety disorders.

3. Description of the program

The program Dominique’s Handy Tricks (original French title: Les Trucs de Dominique) includes 10 illustrated storybooks (on average 50 pages per book) about a little boy named Dominique. In addition to the 10 storybooks, the program uses a children workbook containing the exercises for each of the 10 sessions, a parent’s workbook providing information on the program and a workshop leader's guidebook.

3.1. Dominique's stories

Dominique's stories are about situations that are meaningful for elementary school-age children (9 to 12 years old). They were written because they address significant school-age children concerns and worries. Each one explains daily stressors related to the main problem in the book. For example, the book targeting academic problems lead to arguments with parents, worrying about an imminent report card, criticism from the teacher, being made fun of by others, etc. Each of the stories describes typical interactions around the problem, with the adult and child characters adopting attitudes and behaviors that are sometimes appropriate, sometimes not. In the story scenarios, the various characters also express a variety of emotions and ways of thinking as they deal with problems. As part of the program, the aim of these stories is to support the teaching of anxiety prevention and emotion regulation skills by illustrating key concepts or behaviors.

In order to ensure the educational quality of the stories, they were developed by combining deductive and inductive methods. Triangulation of qualitative and quantitative data was performed along the qualitative research methodology proposed by Mayer and Ouellet, 1991). For example, the story describing the daily life of a little girl living with an alcoholic mother (used in Session 9) was produced according to the following steps. First, a literature review provided answers to questions such as: What specific everyday problems do children living with alcoholic parents encounter? What are the attitudes and behaviors of peers and adults associated with this family situation? What behaviors are most often associated with resilience? Second, data was collected from about twenty children and their alcoholic parents in order to ensure that the theoretical content was relevant. A draft version of the scenario was then submitted to the same individuals (children and adults), acting as an advisory committee. Focus groups were used to gather primary information on the realism of the narrative, its pertinence, the quality of the information and the accessibility of the language used. Finally, the revised story was submitted to a sample of senior elementary school students. These students filled out a questionnaire of about ten questions aimed at determining the pertinence and educational qualities of the narrative. These questions dealt with how appealing the stories were, their linguistic clarity and the nature of the messages. Once this final verification was complete, the story was illustrated and published. In summary, the qualities of each of the stories (realism, pertinence, accessibility of the language) were subject to field testing prior to their use in the program.

3.2. Children workbook

The general approach for teaching the cognitive-behavioral techniques in this workbook follows a sequence where participants help Dominique or his friends to identify anxiety-producing situations and adopt appropriate strategies to deal with them. Each session highlights one or two specific cognitive or behavioral strategies to reduce or cope with anxiety. These effective coping solutions are called Dominique’s handy tricks and homework are given to apply and master these skills at home in stressful situations called “personal challenges”.

Many of the exercises in the children's workbook were designed along the same lines as those used in treatment programs for anxiety disorders for children (e.g., Friends and Coping Cat, Kendall, 1992). However, our original approach gives a different angle to these exercises. As universal coping strategies, they are applied in the workshops in reference to a precise section or illustrations in the books. This learning approach is fun and stimulating for children, does not require children to experience an anxiety disorder in order to apply the strategies, as well as favoring instructive interactions between the group and the workshop leader. The core skills addressed in the entire program are (see Table 1): (a) understanding the relationship between stressors, thoughts, emotions/anxiety and actions; (b) detecting early signs of anxiety; (c) cognitive-restructuring; (d) exposure, (e) problem solving and (f) using the social network. Different techniques are used to teach the strategies to children, such as illustrations of key concepts, schematic representation with icons to differentiate stressors, thoughts, emotions and actions, asking children to write in bubbles what a character is thinking or to draw information, etc. The manual and all key concepts are illustrated (see Figure 1).

Figure 1.

Excerpts from sections of the children workbook illustrating: (a) key concepts in the program (stressors, thoughts, emotions and actions), (b) the role of appraisal and (c) the introduction of cognitive restructuring to counter dysfunctional thoughts.

Table 1.

Summary of the program’s weekly skills, aims and stressors.

3.3. Parent’s workbook

This document presents the program and explains different aspects of anxiety, its mechanisms and its consequences. Parents also find information on daily stressors children often meet, children’s potential reactions and general recommendations to help their child cope with anxiety-producing situations. The parents also have access to the story books and to supportive recommendations related to the topic addressed in the story. In addition, they are encouraged to follow their child’s progress. Some activities requiring the cooperation of the parents are also explained.

3.4. Workshop leader's guidebook

Designed specifically for the workshop leaders, it contains basic notions on the nature of anxiety and the symptoms associated with anxiety management problems. It summarizes the cognitive-behavioral theoretical principles that form the basis of the program and includes explicit details on the aims and activities of each workshop. The general transdiagnostic model for the development of an anxiety disorder proposed that temperamental / genetic risk factors, combined with environmental / familial factors can lead to a greater susceptibility to stressors due to dysfunctional cognitive and behavioral characteristics (see section 1 above). Among susceptible children, various life events could lead to the development of different anxiety disorders, depending on what is associated with threat and avoidance.

3.5. Description of the workshops

Information related to the conduct of the workshops is summarized in Table 1 above. The ten workshops in the program last about seventy-five minutes each. The workshop usually begins with a review of what was learned the week before and the homework exercises done during the week. The reading of the story then follows, lasting about twenty minutes. The learning activities deal first with the identification of everyday stressors related to the workshop themes (e.g., receiving a report card, in the case of academic stress), followed by exercises designed to develop the skills targeted for each session (see Table 1). At this stage, it is important to recall that for the purposes of normalization in the program (as in the text above) the term stress is used rather than anxiety.

3.5.1. Workshop 1 - Dominique’s handy trick: Know your stressors

Supporting story: Dominique still wets his bed at the age of seven. This problem is a great source of stress for him. The same is true for the annoyances that go along with his enuresis: being scolded by his parents, being made fun of by others, not being able to go to summer camp, washing his sheets. Dominique reacts to his stressors in various ways. He thinks he is different from other children and goes through a whole range of emotions, from anger to sadness or shame, which causes him to shut himself off in his room.

In session approach: After being given general information on stress and discussing frequent sources of fear and stress in 8-to-12-year old according to them, the participants attempt to identify the stressors related to Dominique's enuresis. They learn to differentiate his stressors (e.g., the criticisms of his parents) from his reactions to the stress, his thoughts (e.g., I'm a baby!), his emotions (e.g., anger) and his actions (e.g., shutting himself off in his room).

At home approach: The children must each make a list of three "personal" stressors (called personal challenges) that will be used to practice Dominique’s handy tricks. Another exercise asks the children to question their parents about their fears when they were young.

3.5.2. Workshop 2 - Dominique’s handy trick: Recognize your signs of stress

Supporting story: School is a great source of stress for Dominique’s friend François. His stressors are exams, boredom and recess, as well as arguments with his parents about his poor marks. Specific signs indicate his stress. He is physically tense during exams and obsessed with all kinds of distracting or negative thoughts during classes. His great sadness sometimes turns to despair, making him cry. Fortunately, following a request from his teacher, he presents in class an activity that he finds rewarding. Thanks to this positive experience he thinks, then feels and acts differently; he finds himself more intelligent and recognizes some of his own capacities.

In session approach: The activities during the workshop teach children to distinguish the different signs of anxiety and stress in the character. For example, they note his thoughts, his emotions, his physical reactions and his actions during his exams or following his academic failures.

At home approach: The children identify their own signs of anxiety in accordance with the list of personal challenges produced in the first session.

3.5.3. Workshop 3 - Dominique’s handy trick: Find “obstacle thoughts”

Supporting story: For Dominique, Mélanie and their friends, social pressure is an important stressor. They all react to the pressures of competition by making negative judgments about their appearance or their intellectual and athletic capacities. For example, Mélanie is convinced she is fat. Dominique would like to be better at sports and Minh-Thi is unhappy whenever she is not at the top of her class. The judgments of others are such an important source of stress for these grade five students that they forget their own strengths. By chance, a competition organized by the school principal gives Mélanie an opportunity prove her skills against those of other students in her class.

In session approach: The exercises help the children look for and identify obstacle thoughts (dysfunctional beliefs, as opposed to helping thoughts) behind the feelings and behaviors of the characters. By identifying those thoughts (e.g. self-depreciation of the different characters in the story), the children learn how their own thoughts influence both their feelings and their actions.

At home approach: The children review their lists of personal challenges and identify a obstacle thought associated with each of their challenges. In order to firmly establish the idea of a link between thoughts, feelings and actions, they practice their skills in another exercise: finding the logical link between what they thought, felt and did during various situations occurring during the week.

3.5.4. Workshop 4 - Dominique’s handy trick: Find “reassuring thoughts”

Supporting story: The separation of Dominique’s and his sister Mélanie’s parents is accompanied by arguments and frustrations. The reactions of the two children to this major change in their lives are intense and they are afflicted with negative thoughts. Dominique worries in anticipation of the idea of having to move, to leave his friends or to change school. Mélanie feels responsible for the arguments between her parents. Her emotions overwhelm her so much that she is sick to her stomach. Both children are haunted by the fear of losing their parents, of being separated from them or of being abandoned. Over time, the stress experience by the two children diminishes. Mélanie and Dominique finally find a balance and discover a new ways of living happily with their mother and their father.

In session approach: The children work on differentiating in the characters the parts of their internal dialogue that is a source of anxiety from the ones that reassures them. They have to differentiate thoughts that contribute to worrying Dominique (I won't see Mom anymore!) and those that can reassure him (Mom loves us too much to abandon us). The children learn here to test the anxiety-producing thoughts of the characters (obstacle thoughts) and suggest to the characters reassuring (coping) thoughts. Reassuring thoughts are clearly presented as real and grounded thoughts, as opposed to positive thoughts or magical thinking.

At home approach: The take home exercises require the children to identify and note obstacle thoughts and reassuring thoughts related to their personal challenges.

3.5.5. Workshop 5 - Dominique’s handy trick: Take the problem in hand

Supporting story: Being persecuted by Simon is a great source of stress for Francis. He is so terrorized when Simon is around that he is unable to concentrate in class. He takes detours to get to school for fear of running into him on the street, convinced he can solve the situation by systematically avoiding his tormentor. What happens is just the opposite: avoidance is a trap, not a solution. In fact, his stress increases every day and he is so obsessed with his fear of Simon that he has nightmares about him. He would like to confront his fear and defend himself, but he does not believe he can solve the problem. He confines himself in the role of victim and his life becomes intolerable. The bullying stopped at last when an incident forces him to disclose the bullying to his parents.

In session approach: The children look for Francis’s thoughts that contribute to his avoidance and suggest him new ones to convince him he can solve his problem. They look for alternative behavior to face his fear.

At home approach: As an application exercise, the children report avoidance behaviors in a stress situation experienced during the week by identifying obstacle and reassuring thoughts related to that event.

3.5.6. Workshop 6 - Dominique’s handy trick: Use small steps plan

Supporting story: Dominique feels uneasy with persons with disabilities. He reacts with panic and run away when he encounters Benoît, a new student in the class who has cerebral palsy. He is so uncomfortable with Benoît that he is completely disconcerted when he sees him. His presence alone causes him so much stress that all he wants to do is run away. A series of circumstances, however, helps Dominique realize that his concerns are unjustified. Even though he first has difficulty being around the new school mate, progressive and various contacts make Dominique more and more at ease with Benoît. The more he does things with Benoît, the more Dominique becomes able to tame his fears and, finally, he finds he has made a new friend.

In session approach: The activities show to the children how to find the thoughts and progressive exposure steps that help Dominique conquer his fear.

At home approach: With the workshop leader, the children make their own gradual exposure plan called “small steps plan”. They divide exposure to a personal challenge into very small stages, planning reassuring thoughts and little rewards to provide encouragement at each small step. They have to carry out their plans one step at a time over a period of two weeks.

3.5.7. Workshop 7 - Dominique’s handy trick: Confide in someone

Supporting story: The behavior of Mr. Dubois is a great source of stress and worry for Dominique. He is overwhelmed by contradictory feelings toward Mr Dubois that prevent protecting himself from this abusive neighbour. Dominique feels affection for the man, who has given him privileges. But at the same time, he worries more and more about his physical advances. Gradually, Mr. Dubois' actions become such a source of despair for Dominique that he can no longer sleep and he shuts himself off from his parents and his friends. He has difficulty deciding whom he can share his worries with. Fortunately, he decides to share his secret with his parents.

In session approach: The children have to identify the various thoughts that explain Dominique's contradictory feelings and the ones that prevent him from acting (e.g., I promised to keep it a secret). The identification of obstacle thoughts is followed by looking for reassuring thoughts to encourage Dominique to take action to solve the problem. By helping Dominique evaluate the pros and cons of talking about his concerns, the children are initiated to the basics of problem solving. Finally, the participants propose small steps to Dominique in order to get out of his difficulties.

At home approach: The take home exercise requires participants to identify persons that they could confide in or ask for information in case of problems. They should also complete the last stages of their small steps plan initiated in the previous workshop.

3.5.8. Workshop 8 - Dominique’s handy trick: Apply new solutions

Supporting story: Mélissa has no friends at school. To make herself more interesting to students in her class, she tells lies. Far from helping her to make friends, this behavior only makes things worse for her. Moreover, one day she finds herself trapped in a huge lie. She feels foolish and is looking for a solution to avoid facing the ridicule of her peers. She is even considering telling a bigger lie to get herself out of trouble. Fortunately her neighbor Marjorie helps her find a new and more productive solution.

In session approach: The children have to identify the obstacle thoughts that come to Mélissa's mind (e.g., I'm stupid). They suggest to her reassuring thoughts so that she can stop ruminating on feelings of guilt, and stop thinking of herself as foolish and stupid. Helping Mélissa make up for her mistake is an opportunity to learn applying a problem-solving technique that is accessible to children (define the problem, evaluate then choose among alternative solutions, assess the results, etc.).

At home approach: The children apply the problem-solving to a personal challenge.

3.5.9. Workshop 9 - Dominique’s handy trick: Recharge your batteries

Supporting story: The story describes problems in the life of Cathou, a girl whose mother is alcoholic and depressed. Cathou finds an outlet for her problems in her passion for gymnastics. Life at home is a source of daily stress for her. She has to take care of herself while supporting her mother. She feels responsible for her mother's problems and is eating her heart out with worries about her. Also, she does not want anyone else to know what is happening with her mother. In order to face the daily problems resulting from her family life, she energizes herself by practicing her favorite activity.

In session approach: After identifying the daily stressors in the life of the main character, the participants suggest to her various actions to charge her batteries, that is, energize herself. The first exercises apply what was learned in the previous workshops: choose for Cathou thoughts that generate energy and help her adopt behaviors that reduce her stress (e.g., seek out information).

At home approach: The children have to find and practice activities that provide them energy, or relaxation, and identify their own personal support networks.

3.5.10. Workshop 10 - Dominique’s handy trick: Remember what you’ve learned

Supporting story: The story recounts the daily problems of Sébastien who suffers from attention-deficit hyperactivity disorder. Sébastien's difficulties are a great source of stress for him. Because of his problems, he is regularly scolded by his teacher and his parents. In the class, he even has to work behind a screen to stop disrupting everyone. He is rejected by his schoolmates. Sébastien's agitation and impulsive behaviors also cause stress for everyone around him. But Sébastien does not understand the reactions of others towards him, whether it comes from father, his sister, his teacher or other students. Sébastien has to learn ways to better manage his situation.

In session approach: This workshop is an opportunity to sum up everything learned in the previous sessions. The participants review the techniques they have learned so far. They have to identify Sébastien's stressors and find his signs of stress. They apply the notions they have learned to explain the reactions of other characters towards him. They have to imagine the thoughts of his teacher or his sister to explain their aggressiveness towards him and suggest to Sébastien solutions to reduce his worries and carry out his tasks (e.g., make a small steps plan).

At home approach: Each child receives a proof of participation in the form of a diploma. The stress management techniques taught in the program are listed on the diploma so that it can be used as a memory aid and a rewarding attestation.

4. Qualitative impressions from the implementation of the program

Dominique handy tricks program has been implemented with 46 children with the hope of improving their feelings of self-efficacy to cope with stressors, reducing anxiety sensitivity and anxiety symptoms and fostering the development of problem-solving skills. After approval from the University of Quebec in Outaouais’ Ethics in Research Committee, the program was delivered in the schools according to the manual described in this chapter. For ethical concerns about not providing effective treatment to children that could be screened as potentially severe enough to warrant a treatment, it was decided to exclude and refer to treatment those who would obtain a clinically significant score on the Child Behavior Checklist (global score > 75), on the Screen for Child Anxiety Related Emotional Disorders (global score > 60) or on one of the clinical outcome measure. An initial sample of 59 children were recruited, 55 started the program and 9 did not completed the post-program assessment. Participants were aged between 9 to 12 years old and randomly assigned to a waiting list (and received the program later) or to receive the program. Quantitative analyses of outcome results are being conducted on the Coping Scale for Children and Youth, the Perceived Self-efficacy Towards Problem-solving Scale, the Childhood Anxiety Sensitivity Index, the Multidimensional Anxiety Scale for Children, and the Fear Survey Schedule for Children-Revised and will be the focus of a future article.

To complement the description of the program detailed in this chapter, this section will report on qualitative data gathered during a focus group conducted with the seven workshop leaders, during contact with the parents, and through comments from children after their involvement in the implementation and evaluation of the program. These qualitative observations provided important information that is very difficult to obtain in quantitative trials. It also highlights specific challenges experienced during the application of a universal prevention program dedicated to the teaching of cognitive-behavioral techniques for anxiety and stress management.

The program was provided for free and on a voluntary basis. Yet, the research agenda required children and parents to take part in long assessment sessions, which raised worries about the feasibility of a primary prevention program. Our concerns regarding recruitment proved to be unfounded. The program was accepted enthusiastically by those working in the schools, as it was by parents. Both groups expressed on several occasions their enthusiasm to see a program targeting stress experienced by children. In addition, the application of the program took place without any substantial attrition problem (only 4 dropped-out during the program). Very few children missed even one session. Answers from children and the focus group with workshop leaders confirmed that the stories told in each session were an important motivating element for the attendance and participation of the children in the workshops, even for the more delicate topics such as alcoholism and sexual abuse.

Comments from participants confirmed children's interest in the exercises as they appear in the children's workbook. Based on discussions in the focus group, such a program should be applied with some flexibility to adapt the use of these exercises to the characteristics of the participants. In their original form, most of the workshop exercises were designed to be done in discussions or in paper-and-pencil activities. This approach appeared to be particularly well suited to girls but the focus group revealed it may be less suitable for boys, who were more receptive to a presentation of content in the form of interactive activities. These observations supported our impression about the usefulness in the workshop leader's guidebook of options to adapt some activities in order to make them more active. After the outcome trial, the guidebook was revised to include several additional suggestions on how to adapt some exercises according to the dynamics of the groups. Distinguishing the thoughts, emotions, physical sensations and actions of a character can, for example, be done either by drawing individually in the workbook or in the form of a group identification game. In the same way, finding reassuring thoughts to convince Francis, victim of bullying, (session 5) to do something to solve his problem could be done in two ways: either by individually writing him a postcard explaining him reasons to act (as suggested in the workbook) or in the form of a group role-play game where participants have to convince Francis to do something and the participant playing the role of Francis expressing which argument he considers most convincing.

Comments from the participants highlighted that planning and carrying out take home activities represented a challenge for the children. Since these exercises are essential for the generalization of recently acquired skills learned learn in session to practical issues occurring in their own lives, compliance with homework deserves to be mentioned. Doing the weekly exercises requires a high level of motivation. However, since the program was not intended for, nor delivered to, a clinical population, the children motivation vanished rapidly once they had left the session. They were not highly motivated to initiate exercises to master their new coping behaviors. This may have contributed to the fact that some of them invested little time in the homework or sometimes failed to complete the exercises in the workbook.

It is reasonable to believe that take home activities could also be perceived as a burden given their already occupied academic agenda and their school homework. Although behavioral changes require involvement and practice, in primary prevention programs it may be more difficult to enroll children to invest in practicing behavior changes if the motivation is extrinsic and rather hypothetical compared to children who want to stop suffering from an anxiety disorder. Even though participants confirmed weekly that the exercises in their workbooks had been completed, it is difficult to ensure that the exercises have not been done hastily or at the last minute. Innovative approaches could be developed to increate adherence to homework, such as on-line contact with the workshop leader during the week (to notify him or her that the exercise has been done) or the use of a buddy system (two children supporting each other in doing the application exercises) as is the case in other programs such as Coping Cat (Kendall, 1992).

The qualitative data also documented a significant and positive impact when parents agreed to get involved and followed weekly the development of the child’s exercises in the workbook. Interestingly, we observed that such parental involvement was not without its disadvantages. Many children did not want their parents to look at their exercise workbooks because they felt the contents were personal. This calls into question the relevance and depth of parental involvement in primary prevention program for internalizing disorders. One might posit that parental involvement could just as well create resistance as it could provide positive support to the children's learning.

Participation of at least one of the parents in the three information sessions provided during the program was very low. Family members of less than 15% of the participants attended these information meetings, which were held in the evening to accommodate them. The workshop leaders have, however, reported positive comments from the parents who did attend. Parents reported that the stories facilitated communication with their children and suggested positive attitudes to adopt. The stories also allowed discussing openly about potential anxiety reactions parents had observed in their children following stressful events such as divorce or learning difficulties. Discussions with parents were an opportunity to provide information and alleviate their own worries about children’s problems. In spite of these positive observations, the low attendance to the meetings raises the question of the feasibility to involve at least one parent from each family in a primary prevention program. When their child is not suffering from an anxiety disorder, parents may prioritize other family needs instead of attending to meeting in a prevention program. The impact of including or not the parents in the program on children’s learning remains however unclear and questionable (Hudson et al., 2008).

The fact that workshops sessions were held in schools facilitated that professionals and teachers put pressure for the inclusion of children with externalized disorders in a universal primary prevention program for anxiety disorders. This reaction was predictable insofar as resources for children in difficulty are scarce. The qualitative data collected confirmed the importance of caution with respect to the inclusion in the groups of children with behavioral disorders, most notably hyperactivity. Many exercises in the program require self-observation by the children and a capacity to identify their feelings or recognize their own reactions to events. Some children who openly claimed to be suffering from attention deficit and hyperactivity disorder appeared to have, in addition to their behavioral problems, difficulties with introspection, which may have complicated their learning and hindered the functioning of the group. In one workshop group, where three children claimed suffering from attention deficit with hyperactivity disorder, the participants became very disruptive in several sessions, requiring the workshop leader to work harder to manage the group. Although our observations about attention deficit and hyperactivity are based on a small number of cases and were not systematically gathered, they converge with the results of studies showing that learning cognitive techniques is a significant challenge for these children (Abikoff, 1991). This possibility illustrates the importance of careful selection of the children and of the make-up of the groups of children. A universal primary prevention program for anxiety disorders is not a complement for the treatment of ADHD. It is not a free treatment for anxiety disorders either. School staff and sources of referral must understand that primary prevention is meant to be implemented before emotional and behavioral problems occur.

5. Conclusion

The qualitative information collected during and after the implementation of the program should guide further trials of the program. They have raised some shortcomings that will be taken into consideration when revising the program for a new trial. More schools have expressed a desire to implement the program and several pilot projects for new trials are considered. Results of the outcome trial are expected soon, yet some of the less tangible benefits of a universal program have been already observed, such as heightened awareness about anxiety and its consequences, early detection of children at high risk for the development of internalized disorders, and the promotion of psychological services to prevent and treat anxiety disorders. It is hoped that a better understanding of the nature of anxiety and its disorders could contribute to more supportive behaviors from classmates and adults.

The resources allocated for the prevention and treatment of externalized disorders, such as ADHD, are far greater than those allocated for the prevention of internalized disorders. Dominique’s handy tricks program can contribute to the promotion of knowledge about anxiety disorders, which are the most prevalent disorders in this age group (Merikangas et al., 2009). Adherence to universal prevention programs and sustained efforts to master new skills may be challenged by motivational issues in children and their parents. New methods that rely on computer technologies (Bouchard, 2011) may increase children’s interest toward the use of CBT treatment and prevention tools. In the meantime, it is hoped that by focusing on strategies to cope with various stressors instead of dysfunctional anxiety, Dominique’s handy tricks program will stir interests in children.

Acknowledgments

This study was funded by a joint research grant from the Ministère de la Santé et des Services Sociaux and the Régie Régionale de la Santé et des Services Sociaux de l’Outaouais – Programme de subvention en santé publique. The study was conducted in the Laboratoire de Cyberpsychologie de l’UQO (http://www.uqo.ca/cyberpsy) where the second author now holds the Canada Research Chair in Clinical Cyberpsychology. Corresponding address: Jean Gervais, Département de psychoéducation et de psychologie, Université du Québec en Outaouais, PO Box 1250, Station Hull, Gatineau, Qc, J8X 3X7. e-mail : [e-mail]. The authors wish to thank Claudie Loranger for her input in the preparation of this chapter.