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Clinical Child and Family Psychology Review (2021) 24:164–181 https://doi.org/10.1007/s10567-020-00338-w

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Adventurous Play as a Mechanism for Reducing Risk for Childhood Anxiety: A Conceptual Model

Helen F. Dodd1  · Kathryn J. Lester2

Accepted: 17 December 2020 / Published online: 19 January 2021 © The Author(s) 2021

Abstract In this conceptual article, we draw upon the literature regarding cognitive and behavioural factors that underpin childhood anxiety to outline how a range of these risk markers might be targeted through adventurous play. When children play in an adventurous way, climbing trees, riding their bikes fast downhill and jumping from rocks, they experience feelings of fear and excitement, thrill and adrenaline. We propose that the positive, thrilling and playful emotions associated with this type of child-led play facilitate exposure to fear-provoking situations and, in doing so, provide opportunities for children to learn about physiological arousal, uncertainty and coping. We hypothesise that these learning opportunities will, over time, reduce children’s risk for elevated anxiety by increasing children’s expectations and ability to cope with anxiety, decreasing intolerance of uncertainty and preventing catastrophic misinterpretations of physiological arousal. If our conceptual model is correct, then ensuring that children have the physical and psychological space required to play in an adventurous way may help to decrease their risk for elevated or clinical anxiety.

Keywords Play · Risky play · Child anxiety · Fear · Adventurous play · Risk

It is well established that trajectories to anxiety disorders begin early in life (Caspi et al. 1988). Half of all anxiety disorders begin before the age of 11 and elevated anxiety symptoms early in life predict subsequent anxiety disorders (Hudson and Dodd 2012; Kessler et  al. 2005). Develop- mental models of anxiety psychopathology (e.g. Manassis and Bradley 1994; Vasey and Dadds 2001) have stimulated extensive research directed at understanding and delineat- ing pathways of risk and resilience for anxiety. Childhood anxiety is associated with a range of cognitive and behav- ioural factors including child temperament, specifically behavioural inhibition (Chronis-Tuscano et al. 2009; Hud- son and Dodd 2012; Lahat et al. 2011), avoidance (Craske 2003), over-involved parenting (Hudson et al. 2011; McLeod et al. 2007), intolerance of uncertainty (Osmanağaoğlu et al. 2018), a bias to interpret ambiguity in a negative way and

a tendency to anticipate that they will not be able to cope in ambiguous situations (Dodd et al. 2015; Field and Lester 2010; Stuijfzand et al. 2018). To decrease children’s risk for developing high levels of anxiety or an anxiety disorder, prevention and early intervention programmes have been designed to target these factors (e.g. Chronis-Tuscano et al. 2015; Kennedy et al. 2009). In this conceptual paper, we outline a model (see Fig. 1) which hypothesises that adven- turous play during early and middle childhood (ages 3 to 11 years) can target these same cognitive and behavioural factors and, as a result, decrease children’s risk for anxiety.

Adventurous play is defined as child-led play where chil- dren experience subjective feelings of excitement, thrill and fear; often this occurs in the context of age-appropriate risk- taking. We argue that this type of play provides opportu- nities for children to learn about uncertainty, fear, arousal and coping and describes the mechanisms through which we hypothesise that adventurous play might affect chil- dren’s risk for elevated and clinical anxiety. We focus on early to middle childhood because this is a crucial period for the initial development of anxiety-related problems in children, and the age group for whom prevention and early intervention for anxiety are typically designed. Furthermore, much of the research into risk factors and correlates of child

* Helen F. Dodd [email protected]

1 School of Psychology and Clinical Language Sciences, University of Reading, Whiteknights, Reading RG6 6AL, UK

2 School of Psychology, University of Sussex, Falmer, Brighton BN1 9QH, UK

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anxiety focuses on this age range, providing an evidence base for our model. Our overarching hypothesis is that, if children are given ample opportunity, across childhood, to explore age-appropriate, healthy risk-taking through child- led adventurous play, they may learn skills that help them successfully navigate subsequent anxiety and fear-provoking situations; the focus is not on treatment for clinical child anxiety disorders.

Before describing the relevant literature and conceptual model, there are two caveats. The first is that the overall effect size of adventurous play on children’s risk for anxi- ety is likely to be small. Anxiety is underpinned by a broad range of risk factors and complex causal pathways, where multiple risk factors interact with one another to affect risk for anxiety. We propose that adventurous play may be one way of decreasing children’s long-term risk by providing important opportunities to learn about coping, uncertainty and physiological arousal, not that it provides a broad solu- tion to child anxiety. Children will also learn via a wide range of other experiences such as modelling (Askew and Field 2008) and information transfer (Muris and Field 2010). In the context of the Vasey and Dadds (2001) developmental psychopathological model of child anxiety, we view adven- turous play as a protective influence which interacts with other protective influences and predisposing factors to con- tribute to a child’s cumulative risk.

A second caveat is that we focus on child anxiety and specific cognitive and behavioural factors for which there is a plausible link with adventurous play. In our model, we have considered anxiety as a broad concept, but it is possible that adventurous play may be more beneficial in prevent- ing specific subtypes of anxiety than others. For example, adventurous play may have less relevance for social anxiety than for generalised anxiety or phobias. It is also possible that this type of play is beneficial for other emotional and

behavioural problems such as externalising problems. This is beyond the scope of the present paper but may be of interest in future research.

Adventurous Play

Play is prolific in childhood. Children play at home, at the park, with friends, at school, even when they’re eating. There are few constructs as intimately entwined with childhood and as ubiquitous as play. Despite this, play as a broad topic is relatively neglected in psychological research relative to other aspects of child development. When scientific research does focus on play in children, it is dominated by work on pretend play (Lillard et al. 2013; Pellegrini et al. 2007). In contrast, psychological study of locomotor (or physical) play in children is rare, to such an extent that it has been claimed that ‘psychologists have ignored one of the most common forms of play’ (Pellegrini 2009, p. 137). This is surprising given that playgrounds are a staple of western neighbour- hoods and it is estimated that children spend around 20% of their time engaged in locomotor play, which includes climb- ing, swinging, chasing, balancing, jumping and other playful physical activity (McGrew 1972; Smith and Connolly 1980).

In contrast to human children, locomotor play has been extensively studied in animals (e.g. Bekoff and Byers 1981; Fagen 1981; Povinelli and Cant 1995). Almost all mammals have been observed to spend some of their time engaged in locomotor play (Pellis and Pellis 2009). An important component of animal locomotor play appears to be to expe- rience thrill through exposure to moderately fear-provoking situations. For example, primates leap and swing in trees and chase one another, playing in such a way that they appear to intentionally switch between being in and out of control,

Fig. 1 A novel psychological model capturing how environ- mental and social factors affect children’s adventurous play and how, in turn, adventurous play might affect anxiety risk and anxiety symptoms via cog- nitive-behavioural factors proposed to underpin anxiety. This occurs within the context of the individual child. This is not intended to be exhaustive and we recognise that other environmental and social factors such as attachment, poverty and stress affect children’s play and that other factors might mediate any adventurous play-anxiety relationship

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thus exposing themselves to moderate levels of fear and arousal (Spinka et al. 2001).

It has been proposed that, in juvenile animals, this type of play provides exposure to moderately fear-provoking stimuli and facilitates learning about how to cope emotionally with the unexpected (e.g. Pellis and Pellis 2009; Spinka et al. 2001). Specifically, Spinka et al. (2001) hypothesise that a major function of play is to provide a context where animals ‘lose full control over their locomotion, position or sensory/ spatial input and need to regain these faculties quickly’. It is argued that when playing in this way animals learn not only ‘increased versatility of movements’ but also how to ‘avoid emotional overreaction during unexpected stressful situa- tions…These may include locomotor shocks…and psycho- logical shocks such as suddenly being faced with frightening or dangerous stimuli, unexpectedly meeting a stranger or experiencing a sudden reversal in dominance’ (p. 143). Simi- larly, Pellis and Pellis (2009) present evidence that indicates that play experience in rats may ‘fine-tune’ coping skills needed for managing emotional responses to social and non- social situations. To date, these ideas have not been explored empirically in humans, but it seems plausible that adventur- ous play serves a similar purpose in human children.

Human children’s play mirrors this type of play seen in animals; children also deliberately expose themselves to moderate levels of fear, for example, through play at heights or high speed (Sandseter 2009). Naturally, there are indi- vidual differences between children in what constitutes a risk and in desire for risk (see Morringiello and Ladenby-Lessard 2007 for a review) but a desire for some degree of thrilling play experience appears to be common across all children (Sandseter and Kennair 2011). This individual difference in desire for risk-taking aligns with the construct of sensation seeking and is likely to be an important child factor influenc- ing children’s engagement in adventurous play.

Following theoretical ideas about the purpose of this adventurous or risky play in animals, it has been proposed that this type of play may serve a similar purpose in children (e.g. Gray 2011, 2013; Sandseter and Kennair 2011). For example, Gray (2013) argues that when children are free to play, they ‘deliberately put themselves into fear-inducing, vulnerable positions in their play…testing their own fear as well as their physical prowess’ (p. 172–173). This leads to thrilling feelings that come from simultaneous fear and joy. He argues that, through this type of play, children learn how to solve their own problems, control their impulses and modulate their emotions. Sandseter and Kennair (2011) pro- vide a detailed theoretical account of how risky play, which is synonymous with adventurous play, may serve to expose children to stimuli that they previously feared. Sandseter and Kennair propose that through risky play, children naturally perform exposures, which function to reduce developmen- tally normal fears. Specifically, they argue that the positive,

thrilling emotion associated with this type of play facilitates and motivates exposure to feared stimuli. This process of exposure mirrors the mechanisms that underpin successful exposure therapy for clinically diagnosed phobias (Hoffman 2008; Whiteside et al. 2020).

On the basis of Sandseter’s (2007) six categories of risky play (great heights, high speed, dangerous tools, play near dangerous elements, rough-and-tumble, play where chil- dren can disappear/get-lost), Sandseter and Kennair (2011) propose that specific categories of risky play have specific anti-phobic functions. For example, the category ‘Play with great heights’ is proposed to provide a desensitising experi- ence and skill development that results in reduced fear of heights. Consistent with this hypothesis, and in the opposite direction to what would be predicted by conditioning theory, a prospective study showed that children who injured them- selves falling from heights during middle childhood were subsequently less likely to report a fear of heights at age 18 (Poulton et al. 1998). Similarly, play where children can ‘disappear’ or get ‘lost’ is hypothesised to support expo- sure to separation. Again, broadly consistent with this idea, children who experienced more planned separation experi- ences from a caregiver between age 3 and 5 years (albeit not specific to play situations) had fewer separation anxiety symptoms later in childhood (Poulton et al. 2001). In very young children, play involving vicarious risk, where children observe others taking risks, is hypothesised to have the same arousing effect as ‘real’ risky play experiences and may act as a precursor to risky play, and with a potentially similar desensitising experience to feared stimuli (Apter 1992).

In this paper, we propose a conceptual model (see Fig. 1) that builds on Sandseter and Kennair’s (2011) ideas. Whereas Sandseter and Kennair focus solely on phobias and exposure, in this article we draw on the anxiety literature and propose that adventurous play provides a range of learning experiences that can target cognitive and behavioural mecha- nisms associated with anxiety in children. As a consequence, we hypothesise that this type of play may help to prevent elevated anxiety more broadly defined.

Injury Prevention in the Context of Adventurous Play

Discussion of risk-taking in play often  raises questions about injuries. In many countries, unintentional injuries are a leading cause of death in children (Peden et al. 2008) and there is understandable concern about protecting chil- dren from unnecessary risks. In the UK between 1980 and 2010, 31% of child deaths among 1–4-year-olds and 20% of child deaths among 5–14-year-olds were from unintentional injuries (Royal College of Paediatrics and Child Health 2013). Data on hospital attendance and admissions show

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that approximately 2 million UK children under the age of 15 attend Accident and Emergency, and 108,000 children require hospital admission each year due to unintentional injury (Child Accident Prevention Trust 2013); the estimated cost of treating children’s accidents amounts to more than £275 million a year (Royal Society for the Prevention of Accidents 2020).

While these are sobering statistics, the category of unin- tentional injury is broad and includes road traffic injuries as well as poising and fire-related injuries. The majority of children’s accidents happen in the home (Shanon et al. 1992). For young children, falls are the leading cause of injury-related hospital admissions (CDC 2019), with these most commonly happening from furniture and more seri- ous accidents involving falls from windows, balconies and stairs (Consumer Safety Unit 2002). In contrast, research indicates that when children are playing, they display strat- egies for preventing serious injury (Christensen and Mik- kelsen 2008) and recognise that major injuries communicate carelessness and clumsiness (Green 1997). Medically treated injuries during children’s play are very rare; for children aged 6–12 years, there are between 0.15 and 0.17 injuries per 1000 hours of physically active leisure time. This contrasts with 0.2–0.61 injuries per 1000 hours of organised sport. Thus, while we recognise that child injuries can be serious and associated with long-term costs, for children growing up in western society, the risk of being injured during play is very low (Nauta et al. 2015). In this context, a risk benefit approach is required which takes into account the benefits of challenging play experiences as well as the risks, ensur- ing children are not exposed to unnecessary danger but that they are given space to play in a way that is adventurous, stimulating and creative (Ball et al. 2012; Gill 2018).

A caveat here is that certain groups of children are over- represented in injury statistics, and some children are con- tinually exposed to riskier, more dangerous environments than others (Giles et al. 2019). For example, children living in poverty and marginalised communities are more likely to be affected by unintentional injuries; compared to children whose parents are employed in higher professional occupa- tions, children of parents who are long-term unemployed or who have never worked are 13 times more likely to die from an unintentional injury (Towner et al. 2005). Similarly, children living in impoverished and marginalised communi- ties are more likely to experience unintentional injury both in and outside of the home (Balan and Lingam 2012). They also often have fewer opportunities for play due to unequal access to safe parks and playgrounds and age-appropriate extracurricular activities (Barnes 2012; Milteer et al. 2012). While we hypothesise that there will be benefits of age- appropriate, healthy risk-taking through child-led adventur- ous play, as Giles et al. (2019) highlight, this is unlikely to be relevant for children who are exposed to chronic levels

of risk. We therefore acknowledge that our hypothesis may be most relevant for children who are growing up in relative safety.

Cognitive–Behavioural Factors Hypothesised to be Affected by Adventurous Play

Research on childhood anxiety disorders has established a range of cognitive–behavioural factors that underpin dys- functional anxiety and/or are implicated in the aetiology of anxiety. Anxiety is multifaceted and causal pathways are complex. We propose that adventurous play could target some of the specific cognitive–behavioural factors associ- ated with child anxiety, as shown in Fig. 1, and in doing so, it could decrease children’s risk for anxiety in the long term. Each of these factors will now be discussed in turn.

The Importance of Exposure Rather than Avoidance

Avoidance is critical to theories of anxiety and is hypoth- esised to play a role in both the development of anxiety and the maintenance of anxiety over time (Craske 2003; Hudson and Rapee 2004; Manassis and Bradley 1994). Behavioural avoidance, characterised by moving away from a threat, serves an adaptive function when threat level is high, reduc- ing the potential for harm. However, when an individual perceives a stimulus or situation to be more dangerous than it objectively is, avoidant responses prevent exposure to the feared situation and the learning opportunities that then follow. When a feared situation is experienced, rather than avoided, this offers an opportunity for threat and coping appraisals to be challenged and adjusted. Exposure supports fear extinction (Craske 2003) and the gathering of informa- tion which can challenge misappraisals and disconfirm pre- dictions of fear and negative outcomes (Rudaz et al. 2017).

Support for the importance of exposure to feared situa- tions and stimuli comes from research with children who are Behaviourally Inhibited (BI). Children who are BI respond to novel and unfamiliar situations with avoidance and wariness (Kagan et al. 1984). Due to the tendency to respond with avoidance, children who are BI have reduced opportunity for exposure to feared stimuli and the learning opportunities that this brings. Hudson and Rapee (2004) pro- pose that this tendency, combined with parental support of avoidance, shapes vulnerability toward anxiety disorders. In support of this, BI children are at a significantly increased risk for anxiety disorders later in life (e.g. Chronis-Tuscano et al. 2009; Hudson and Dodd 2012) and this risk is exacer- bated when their mothers support avoidance (Hudson et al. 2019). Early intervention programmes for BI children that lead to decreased long-term mental health problems focus on

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exposure exercises (decreasing avoidance) and parental sup- port for exposure (Rapee et al. 2005). Similarly, in evidence- based treatments for child anxiety, avoidance behaviour is addressed via exposure exercises during which the child faces situations that evoke anxiety and fear (e.g. Kendall 1994). These exposure exercises are a central component of effective treatment (Bouchard et al. 2004; Kendall et al. 2005; Whiteside et al. 2020). Thus, exposure is a critical process for reducing risk for anxiety which needs to be tar- geted in effective treatment.

Coping

Coping has been defined in a number of ways. Here we adopt the definition of Compas and colleagues that coping involves ‘efforts to regulate emotion, cognition, behaviour, physiol- ogy, and the environment in response to stressful events or circumstances’ (Compas et al. 2001, p. 89). Aligning with Eisenberg’s definition, coping is viewed as a subset of self- regulation (e.g. Eisenberg et al. 1997). Cognitive–behav- ioural theories for the treatment of child anxiety have coping at their core (Kendall 1994); Kendall describes that an effec- tive treatment programme is one that leads a child to acquire a ‘coping template’ (Kendall 2011). This is defined as a cog- nitive structure for future events that incorporates adaptive skills and cognitions associated with adaptive functioning.

In support of the idea that maladaptive coping underpins childhood anxiety, clinically anxious children employ more maladaptive and less adaptive coping strategies in response to negative life events than non-anxious children (Legerstee et al. 2010). Specifically, studies in non-clinical commu- nity samples have shown that fearfulness is associated with greater use of maladaptive coping strategies characterised by rumination, self-blame and catastrophising and less use of adaptive coping strategies characterised by positive reap- praisal (Garnefski et al. 2007). Clinically anxious children have also been found to ruminate more about the feelings associated with negative life events, and to focus more on catastrophic thoughts that emphasise the negative aspects of their experiences; they engage in less positive reappraisal of negative life events and are less able to refocus to plan what steps to take, and how to handle negative life events (Legerstee et al. 2010). Further, when faced with ambigu- ous scenarios, children higher in anxiety anticipate that they will experience more negative emotion than those with lower anxiety, indicative of reduced expectations of coping (Creswell and O’Connor 2011; Dodd et al. 2015; Waters et al. 2008). Evidence that coping plays at least a mainte- nance role, and possibly a causal role in anxiety comes from research demonstrating that improvements in coping medi- ate outcomes in psychological therapy, with children who show greater improvements in coping efficacy (the belief that they are able to actively cope with, rather than avoid

anxiety-provoking situations) more likely to show improve- ments in anxiety across treatment (Kendall et al. 2016; Lau et al. 2010; Ollendick et al. 2017).

Intolerance of Uncertainty

Recent theoretical and empirical work suggests that a fun- damental fear of the unknown underpins anxiety (Carleton 2016a). Individual differences in fear of the unknown are captured by the construct of Intolerance of Uncertainty (IU). The most recent definition of IU is provided by Car- leton (2016b) as “an individual’s dispositional incapacity to endure an aversive response triggered by the perceived absence of salient, key or sufficient information and sus- tained by the associated perception of uncertainty” (p. 31). Although early theory and evidence related to IU focused on worry and generalised anxiety disorder specifically, more recent work has shown that IU may in fact be a transdiag- nostic factor that has relevance across anxiety disorders. For example, IU has been found to be significantly associated with social anxiety disorder (Boelen and Reijntjes 2009; Carleton et al. 2010), panic disorder (Carleton et al. 2014), post-traumatic stress disorder (Bardeen et al. 2013; Fetzner et  al. 2013; Oglesby et  al. 2016) and separation anxiety (Boelen et al. 2014). Importantly, treatments for anxiety dis- orders that specifically focus on exposure to uncertainty and cognitions around uncertainty, targeting IU, have been found to be effective in reducing symptoms of anxiety in adults (Hebert and Dugas 2019; van der Heiden et al. 2012) and changes in IU have been found to predict treatment outcome (Bomyea et al. 2015; Boswell et al. 2013a, b). Although developmental research evaluating the role of IU as a causal risk factor for anxiety has yet to be conducted, a recent meta- analysis of research into IU in child and adolescent anxiety and worry included 31 studies and showed a robust associa- tion, supporting findings from the adult literature that IU is strongly related to anxiety and worry (Osmanagaoglu et al. 2018).

Interpretation of Physiological Arousal

Within a cognitive–behavioural framework, panic and ago- raphobia are thought to be underpinned by catastrophic mis- interpretations of bodily sensations such as “When my heart beats rapidly, I believe I’m having a heart attack” (Clark 1986). These misinterpretations lead to elevated fear and anxiety. Anxiety sensitivity (AS) refers to individual differ- ences in this type of dysfunctional belief, or the tendency to fear arousal-related bodily sensations due to the belief that they are harmful (McNally 2002). AS is sometimes referred to as ‘fear of fear’. When an individual is high in AS, they are more likely to experience high levels of anxiety because they fear their physiological reaction as well as the threatening

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stimulus or situation. AS can be measured via self-report questionnaires in adults and children (e.g. Silverman et al. 1991; Taylor et al. 2007) and is linked to risk for anxiety disorder. For example, AS predicts anxiety symptoms and panic attacks as well as anxiety diagnosis more broadly, over time (Calkins et al. 2009; Hovenkamp-hormelink et al. 2019; McLaughlin and Hatzenbuehler 2009; Schmidt et al. 2006) and a meta-analysis of studies in children and adolescents demonstrated that AS is associated with a range of anxiety disorders (Noel and Francis 2011). Given this, there is a focus on developing treatments that target anxiety sensitiv- ity. These demonstrate that, in adults, anxiety sensitivity can be changed and that this can have benefits for a range of anxiety-related mental health problems (Olthuis et al. 2014; Smits et al. 2008). Less research has been conducted with children and adolescents but initial evidence is consistent with these adult findings (Sherman et al. 2019). One of the ways that anxiety sensitivity is targeted in interventions is via Interoceptive Exposure (IE). IE involves exposure to the physical sensations that are associated with anxiety and fear (e.g. heart palpitations, sweating, muscle tension), with the view to increasing tolerance of these sensations and, in turn, reducing distress and fear related to these sensations (Craske and Barlow 2007). In IE, these physical sensations can be induced in a number of ways including via exercise, spinning and tensing the body (Boswell et al. 2013a, b).

Child Individual Difference Factors Hypothesised to Affect Adventurous Play

While not a central focus here, individual differences between chil

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