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
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).
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
3.5.1. Workshop 1 - Dominique’s handy trick: Know your stressors
3.5.2. Workshop 2 - Dominique’s handy trick: Recognize your signs of stress
3.5.3. Workshop 3 - Dominique’s handy trick: Find “obstacle thoughts”
3.5.4. Workshop 4 - Dominique’s handy trick: Find “reassuring thoughts”
3.5.5. Workshop 5 - Dominique’s handy trick: Take the problem in hand
3.5.6. Workshop 6 - Dominique’s handy trick: Use small steps plan
3.5.7. Workshop 7 - Dominique’s handy trick: Confide in someone
3.5.8. Workshop 8 - Dominique’s handy trick: Apply new solutions
3.5.9. Workshop 9 - Dominique’s handy trick: Recharge your batteries
3.5.10. Workshop 10 - Dominique’s handy trick: Remember what you’ve learned
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
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
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.
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.
This study was funded by a joint research grant from the