Clinical Child and Family Psychology Review (2021) 24:164–181

https://doi.org/10.1007/s10567-020-00338-w

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 a tendency to anticipate that they will not be able to cope
begin early in life (Caspi et al. 1988). Half of all anxiety in ambiguous situations (Dodd et al. 2015; Field and Lester
disorders begin before the age of 11 and elevated anxiety 2010; Stuijfzand et al. 2018). To decrease children’s risk
symptoms early in life predict subsequent anxiety disorders for developing high levels of anxiety or an anxiety disorder,
(Hudson and Dodd 2012; Kessler et al. 2005). Develop- prevention and early intervention programmes have been
mental models of anxiety psychopathology (e.g. Manassis designed to target these factors (e.g. Chronis-Tuscano et al.
and Bradley 1994; Vasey and Dadds 2001) have stimulated 2015; Kennedy et al. 2009). In this conceptual paper, we
extensive research directed at understanding and delineat- outline a model (see Fig. 1) which hypothesises that adven-
ing pathways of risk and resilience for anxiety. Childhood turous play during early and middle childhood (ages 3 to
anxiety is associated with a range of cognitive and behav- 11 years) can target these same cognitive and behavioural
ioural factors including child temperament, specifically factors and, as a result, decrease children’s risk for anxiety.
behavioural inhibition (Chronis-Tuscano et al. 2009; Hud- Adventurous play is defined as child-led play where chil-
son and Dodd 2012; Lahat et al. 2011), avoidance (Craske dren experience subjective feelings of excitement, thrill and
2003), over-involved parenting (Hudson et al. 2011; McLeod fear; often this occurs in the context of age-appropriate risk-
et al. 2007), intolerance of uncertainty (Osmanağaoğlu et al. taking. We argue that this type of play provides opportu-
2018), a bias to interpret ambiguity in a negative way and 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-
* Helen F. Dodd
h.f.dodd@reading.ac.uk dren’s risk for elevated and clinical anxiety. We focus on
early to middle childhood because this is a crucial period
1
School of Psychology and Clinical Language Sciences, for the initial development of anxiety-related problems in
University of Reading, Whiteknights, Reading RG6 6AL, children, and the age group for whom prevention and early
UK
intervention for anxiety are typically designed. Furthermore,
2
School of Psychology, University of Sussex, Falmer, much of the research into risk factors and correlates of child
Brighton BN1 9QH, UK

13
Vol:.(1234567890)
Clinical Child and Family Psychology Review (2021) 24:164–181 165

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

anxiety focuses on this age range, providing an evidence behavioural problems such as externalising problems. This is
base for our model. Our overarching hypothesis is that, if beyond the scope of the present paper but may be of interest
children are given ample opportunity, across childhood, to in future research.
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 Adventurous Play
anxiety disorders.
Before describing the relevant literature and conceptual Play is prolific in childhood. Children play at home, at the
model, there are two caveats. The first is that the overall park, with friends, at school, even when they’re eating. There
effect size of adventurous play on children’s risk for anxi- are few constructs as intimately entwined with childhood
ety is likely to be small. Anxiety is underpinned by a broad and as ubiquitous as play. Despite this, play as a broad topic
range of risk factors and complex causal pathways, where is relatively neglected in psychological research relative to
multiple risk factors interact with one another to affect risk other aspects of child development. When scientific research
for anxiety. We propose that adventurous play may be one does focus on play in children, it is dominated by work on
way of decreasing children’s long-term risk by providing pretend play (Lillard et al. 2013; Pellegrini et al. 2007). In
important opportunities to learn about coping, uncertainty contrast, psychological study of locomotor (or physical) play
and physiological arousal, not that it provides a broad solu- in children is rare, to such an extent that it has been claimed
tion to child anxiety. Children will also learn via a wide that ‘psychologists have ignored one of the most common
range of other experiences such as modelling (Askew and forms of play’ (Pellegrini 2009, p. 137). This is surprising
Field 2008) and information transfer (Muris and Field 2010). given that playgrounds are a staple of western neighbour-
In the context of the Vasey and Dadds (2001) developmental hoods and it is estimated that children spend around 20% of
psychopathological model of child anxiety, we view adven- their time engaged in locomotor play, which includes climb-
turous play as a protective influence which interacts with ing, swinging, chasing, balancing, jumping and other playful
other protective influences and predisposing factors to con- physical activity (McGrew 1972; Smith and Connolly 1980).
tribute to a child’s cumulative risk. In contrast to human children, locomotor play has been
A second caveat is that we focus on child anxiety and extensively studied in animals (e.g. Bekoff and Byers 1981;
specific cognitive and behavioural factors for which there Fagen 1981; Povinelli and Cant 1995). Almost all mammals
is a plausible link with adventurous play. In our model, we have been observed to spend some of their time engaged
have considered anxiety as a broad concept, but it is possible in locomotor play (Pellis and Pellis 2009). An important
that adventurous play may be more beneficial in prevent- component of animal locomotor play appears to be to expe-
ing specific subtypes of anxiety than others. For example, rience thrill through exposure to moderately fear-provoking
adventurous play may have less relevance for social anxiety situations. For example, primates leap and swing in trees and
than for generalised anxiety or phobias. It is also possible chase one another, playing in such a way that they appear
that this type of play is beneficial for other emotional and to intentionally switch between being in and out of control,

13

166 Clinical Child and Family Psychology Review (2021) 24:164–181

thus exposing themselves to moderate levels of fear and thrilling emotion associated with this type of play facilitates
arousal (Spinka et al. 2001). and motivates exposure to feared stimuli. This process of
It has been proposed that, in juvenile animals, this type of exposure mirrors the mechanisms that underpin successful
play provides exposure to moderately fear-provoking stimuli exposure therapy for clinically diagnosed phobias (Hoffman
and facilitates learning about how to cope emotionally with 2008; Whiteside et al. 2020).
the unexpected (e.g. Pellis and Pellis 2009; Spinka et al. On the basis of Sandseter’s (2007) six categories of risky
2001). Specifically, Spinka et al. (2001) hypothesise that a play (great heights, high speed, dangerous tools, play near
major function of play is to provide a context where animals dangerous elements, rough-and-tumble, play where chil-
‘lose full control over their locomotion, position or sensory/ dren can disappear/get-lost), Sandseter and Kennair (2011)
spatial input and need to regain these faculties quickly’. It is propose that specific categories of risky play have specific
argued that when playing in this way animals learn not only anti-phobic functions. For example, the category ‘Play with
‘increased versatility of movements’ but also how to ‘avoid great heights’ is proposed to provide a desensitising experi-
emotional overreaction during unexpected stressful situa- ence and skill development that results in reduced fear of
tions…These may include locomotor shocks…and psycho- heights. Consistent with this hypothesis, and in the opposite
logical shocks such as suddenly being faced with frightening direction to what would be predicted by conditioning theory,
or dangerous stimuli, unexpectedly meeting a stranger or a prospective study showed that children who injured them-
experiencing a sudden reversal in dominance’ (p. 143). Simi- selves falling from heights during middle childhood were
larly, Pellis and Pellis (2009) present evidence that indicates subsequently less likely to report a fear of heights at age
that play experience in rats may ‘fine-tune’ coping skills 18 (Poulton et al. 1998). Similarly, play where children can
needed for managing emotional responses to social and non- ‘disappear’ or get ‘lost’ is hypothesised to support expo-
social situations. To date, these ideas have not been explored sure to separation. Again, broadly consistent with this idea,
empirically in humans, but it seems plausible that adventur- children who experienced more planned separation experi-
ous play serves a similar purpose in human children. ences from a caregiver between age 3 and 5 years (albeit
Human children’s play mirrors this type of play seen in not specific to play situations) had fewer separation anxiety
animals; children also deliberately expose themselves to symptoms later in childhood (Poulton et al. 2001). In very
moderate levels of fear, for example, through play at heights young children, play involving vicarious risk, where children
or high speed (Sandseter 2009). Naturally, there are indi- observe others taking risks, is hypothesised to have the same
vidual differences between children in what constitutes a risk arousing effect as ‘real’ risky play experiences and may act
and in desire for risk (see Morringiello and Ladenby-Lessard as a precursor to risky play, and with a potentially similar
2007 for a review) but a desire for some degree of thrilling desensitising experience to feared stimuli (Apter 1992).
play experience appears to be common across all children In this paper, we propose a conceptual model (see
(Sandseter and Kennair 2011). This individual difference in Fig. 1) that builds on Sandseter and Kennair’s (2011) ideas.
desire for risk-taking aligns with the construct of sensation Whereas Sandseter and Kennair focus solely on phobias and
seeking and is likely to be an important child factor influenc- exposure, in this article we draw on the anxiety literature and
ing children’s engagement in adventurous play. propose that adventurous play provides a range of learning
Following theoretical ideas about the purpose of this experiences that can target cognitive and behavioural mecha-
adventurous or risky play in animals, it has been proposed nisms associated with anxiety in children. As a consequence,
that this type of play may serve a similar purpose in children we hypothesise that this type of play may help to prevent
(e.g. Gray 2011, 2013; Sandseter and Kennair 2011). For elevated anxiety more broadly defined.
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 Injury Prevention in the Context
as well as their physical prowess’ (p. 172–173). This leads of Adventurous Play
to thrilling feelings that come from simultaneous fear and
joy. He argues that, through this type of play, children learn Discussion of risk-taking in play often  raises questions
how to solve their own problems, control their impulses and about injuries. In many countries, unintentional injuries
modulate their emotions. Sandseter and Kennair (2011) pro- are a leading cause of death in children (Peden et al. 2008)
vide a detailed theoretical account of how risky play, which and there is understandable concern about protecting chil-
is synonymous with adventurous play, may serve to expose dren from unnecessary risks. In the UK between 1980 and
children to stimuli that they previously feared. Sandseter and 2010, 31% of child deaths among 1–4-year-olds and 20% of
Kennair propose that through risky play, children naturally child deaths among 5–14-year-olds were from unintentional
perform exposures, which function to reduce developmen- injuries (Royal College of Paediatrics and Child Health
tally normal fears. Specifically, they argue that the positive, 2013). Data on hospital attendance and admissions show

13
Clinical Child and Family Psychology Review (2021) 24:164–181 167

that approximately 2 million UK children under the age of of risk. We therefore acknowledge that our hypothesis may
15 attend Accident and Emergency, and 108,000 children be most relevant for children who are growing up in relative
require hospital admission each year due to unintentional safety.
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 Cognitive–Behavioural Factors
Accidents 2020). Hypothesised to be Affected by Adventurous
While these are sobering statistics, the category of unin- Play
tentional injury is broad and includes road traffic injuries
as well as poising and fire-related injuries. The majority Research on childhood anxiety disorders has established a
of children’s accidents happen in the home (Shanon et al. range of cognitive–behavioural factors that underpin dys-
1992). For young children, falls are the leading cause of functional anxiety and/or are implicated in the aetiology of
injury-related hospital admissions (CDC 2019), with these anxiety. Anxiety is multifaceted and causal pathways are
most commonly happening from furniture and more seri- complex. We propose that adventurous play could target
ous accidents involving falls from windows, balconies and some of the specific cognitive–behavioural factors associ-
stairs (Consumer Safety Unit 2002). In contrast, research ated with child anxiety, as shown in Fig. 1, and in doing so,
indicates that when children are playing, they display strat- it could decrease children’s risk for anxiety in the long term.
egies for preventing serious injury (Christensen and Mik- Each of these factors will now be discussed in turn.
kelsen 2008) and recognise that major injuries communicate
carelessness and clumsiness (Green 1997). Medically treated The Importance of Exposure Rather than Avoidance
injuries during children’s play are very rare; for children
aged 6–12 years, there are between 0.15 and 0.17 injuries per Avoidance is critical to theories of anxiety and is hypoth-
1000 hours of physically active leisure time. This contrasts esised to play a role in both the development of anxiety and
with 0.2–0.61 injuries per 1000 hours of organised sport. the maintenance of anxiety over time (Craske 2003; Hudson
Thus, while we recognise that child injuries can be serious and Rapee 2004; Manassis and Bradley 1994). Behavioural
and associated with long-term costs, for children growing avoidance, characterised by moving away from a threat,
up in western society, the risk of being injured during play serves an adaptive function when threat level is high, reduc-
is very low (Nauta et al. 2015). In this context, a risk benefit ing the potential for harm. However, when an individual
approach is required which takes into account the benefits perceives a stimulus or situation to be more dangerous than
of challenging play experiences as well as the risks, ensur- it objectively is, avoidant responses prevent exposure to the
ing children are not exposed to unnecessary danger but that feared situation and the learning opportunities that then
they are given space to play in a way that is adventurous, follow. When a feared situation is experienced, rather than
stimulating and creative (Ball et al. 2012; Gill 2018). avoided, this offers an opportunity for threat and coping
A caveat here is that certain groups of children are over- appraisals to be challenged and adjusted. Exposure supports
represented in injury statistics, and some children are con- fear extinction (Craske 2003) and the gathering of informa-
tinually exposed to riskier, more dangerous environments tion which can challenge misappraisals and disconfirm pre-
than others (Giles et al. 2019). For example, children living dictions of fear and negative outcomes (Rudaz et al. 2017).
in poverty and marginalised communities are more likely to Support for the importance of exposure to feared situa-
be affected by unintentional injuries; compared to children tions and stimuli comes from research with children who
whose parents are employed in higher professional occupa- are Behaviourally Inhibited (BI). Children who are BI
tions, children of parents who are long-term unemployed respond to novel and unfamiliar situations with avoidance
or who have never worked are 13 times more likely to die and wariness (Kagan et al. 1984). Due to the tendency to
from an unintentional injury (Towner et al. 2005). Similarly, respond with avoidance, children who are BI have reduced
children living in impoverished and marginalised communi- opportunity for exposure to feared stimuli and the learning
ties are more likely to experience unintentional injury both opportunities that this brings. Hudson and Rapee (2004) pro-
in and outside of the home (Balan and Lingam 2012). They pose that this tendency, combined with parental support of
also often have fewer opportunities for play due to unequal avoidance, shapes vulnerability toward anxiety disorders. In
access to safe parks and playgrounds and age-appropriate support of this, BI children are at a significantly increased
extracurricular activities (Barnes 2012; Milteer et al. 2012). risk for anxiety disorders later in life (e.g. Chronis-Tuscano
While we hypothesise that there will be benefits of age- et al. 2009; Hudson and Dodd 2012) and this risk is exacer-
appropriate, healthy risk-taking through child-led adventur- bated when their mothers support avoidance (Hudson et al.
ous play, as Giles et al. (2019) highlight, this is unlikely to 2019). Early intervention programmes for BI children that
be relevant for children who are exposed to chronic levels lead to decreased long-term mental health problems focus on

13

168 Clinical Child and Family Psychology Review (2021) 24:164–181

exposure exercises (decreasing avoidance) and parental sup- anxiety-provoking situations) more likely to show improve-
port for exposure (Rapee et al. 2005). Similarly, in evidence- ments in anxiety across treatment (Kendall et al. 2016; Lau
based treatments for child anxiety, avoidance behaviour is et al. 2010; Ollendick et al. 2017).
addressed via exposure exercises during which the child
faces situations that evoke anxiety and fear (e.g. Kendall Intolerance of Uncertainty
1994). These exposure exercises are a central component
of effective treatment (Bouchard et al. 2004; Kendall et al. Recent theoretical and empirical work suggests that a fun-
2005; Whiteside et al. 2020). Thus, exposure is a critical damental fear of the unknown underpins anxiety (Carleton
process for reducing risk for anxiety which needs to be tar- 2016a). Individual differences in fear of the unknown are
geted in effective treatment. captured by the construct of Intolerance of Uncertainty
(IU). The most recent definition of IU is provided by Car-
Coping leton (2016b) as “an individual’s dispositional incapacity
to endure an aversive response triggered by the perceived
Coping has been defined in a number of ways. Here we adopt absence of salient, key or sufficient information and sus-
the definition of Compas and colleagues that coping involves tained by the associated perception of uncertainty” (p. 31).
‘efforts to regulate emotion, cognition, behaviour, physiol- Although early theory and evidence related to IU focused
ogy, and the environment in response to stressful events or on worry and generalised anxiety disorder specifically, more
circumstances’ (Compas et al. 2001, p. 89). Aligning with recent work has shown that IU may in fact be a transdiag-
Eisenberg’s definition, coping is viewed as a subset of self- nostic factor that has relevance across anxiety disorders. For
regulation (e.g. Eisenberg et al. 1997). Cognitive–behav- example, IU has been found to be significantly associated
ioural theories for the treatment of child anxiety have coping with social anxiety disorder (Boelen and Reijntjes 2009;
at their core (Kendall 1994); Kendall describes that an effec- Carleton et al. 2010), panic disorder (Carleton et al. 2014),
tive treatment programme is one that leads a child to acquire post-traumatic stress disorder (Bardeen et al. 2013; Fetzner
a ‘coping template’ (Kendall 2011). This is defined as a cog- et al. 2013; Oglesby et al. 2016) and separation anxiety
nitive structure for future events that incorporates adaptive (Boelen et al. 2014). Importantly, treatments for anxiety dis-
skills and cognitions associated with adaptive functioning. orders that specifically focus on exposure to uncertainty and
In support of the idea that maladaptive coping underpins cognitions around uncertainty, targeting IU, have been found
childhood anxiety, clinically anxious children employ more to be effective in reducing symptoms of anxiety in adults
maladaptive and less adaptive coping strategies in response (Hebert and Dugas 2019; van der Heiden et al. 2012) and
to negative life events than non-anxious children (Legerstee changes in IU have been found to predict treatment outcome
et al. 2010). Specifically, studies in non-clinical commu- (Bomyea et al. 2015; Boswell et al. 2013a, b). Although
nity samples have shown that fearfulness is associated with developmental research evaluating the role of IU as a causal
greater use of maladaptive coping strategies characterised risk factor for anxiety has yet to be conducted, a recent meta-
by rumination, self-blame and catastrophising and less use analysis of research into IU in child and adolescent anxiety
of adaptive coping strategies characterised by positive reap- and worry included 31 studies and showed a robust associa-
praisal (Garnefski et al. 2007). Clinically anxious children tion, supporting findings from the adult literature that IU is
have also been found to ruminate more about the feelings strongly related to anxiety and worry (Osmanagaoglu et al.
associated with negative life events, and to focus more on 2018).
catastrophic thoughts that emphasise the negative aspects
of their experiences; they engage in less positive reappraisal Interpretation of Physiological Arousal
of negative life events and are less able to refocus to plan
what steps to take, and how to handle negative life events Within a cognitive–behavioural framework, panic and ago-
(Legerstee et al. 2010). Further, when faced with ambigu- raphobia are thought to be underpinned by catastrophic mis-
ous scenarios, children higher in anxiety anticipate that interpretations of bodily sensations such as “When my heart
they will experience more negative emotion than those with beats rapidly, I believe I’m having a heart attack” (Clark
lower anxiety, indicative of reduced expectations of coping 1986). These misinterpretations lead to elevated fear and
(Creswell and O’Connor 2011; Dodd et al. 2015; Waters anxiety. Anxiety sensitivity (AS) refers to individual differ-
et al. 2008). Evidence that coping plays at least a mainte- ences in this type of dysfunctional belief, or the tendency to
nance role, and possibly a causal role in anxiety comes from fear arousal-related bodily sensations due to the belief that
research demonstrating that improvements in coping medi- they are harmful (McNally 2002). AS is sometimes referred
ate outcomes in psychological therapy, with children who to as ‘fear of fear’. When an individual is high in AS, they are
show greater improvements in coping efficacy (the belief more likely to experience high levels of anxiety because they
that they are able to actively cope with, rather than avoid fear their physiological reaction as well as the threatening

13
Clinical Child and Family Psychology Review (2021) 24:164–181 169

stimulus or situation. AS can be measured via self-report necessary to support healthy risk-taking during adventur-
questionnaires in adults and children (e.g. Silverman et al. ous play activities such as climbing trees, riding a bike at
1991; Taylor et al. 2007) and is linked to risk for anxiety speed and play fighting with peers. We might also expect
disorder. For example, AS predicts anxiety symptoms and the association between adventurous play and anxiety risk
panic attacks as well as anxiety diagnosis more broadly, over to be moderated by child age; it seems likely that there will
time (Calkins et al. 2009; Hovenkamp-hormelink et al. 2019; be stages of development, for example, when children are
McLaughlin and Hatzenbuehler 2009; Schmidt et al. 2006) pushing for more autonomy (Kuczynski et al. 2018), where
and a meta-analysis of studies in children and adolescents children might particularly benefit from the opportunity to
demonstrated that AS is associated with a range of anxiety play in an adventurous way.
disorders (Noel and Francis 2011). Given this, there is a Although we have focused here on early to middle child-
focus on developing treatments that target anxiety sensitiv- hood, adolescents may well also benefit from opportunities
ity. These demonstrate that, in adults, anxiety sensitivity can to engage in adventurous play. While adolescents are often
be changed and that this can have benefits for a range of perceived as not ‘playing’, they spend time engaged in self-
anxiety-related mental health problems (Olthuis et al. 2014; directed activity for enjoyment, without any clear purpose,
Smits et al. 2008). Less research has been conducted with which is in keeping with definitions of play. Given that risk-
children and adolescents but initial evidence is consistent taking increases during adolescence (Gardner and Stein-
with these adult findings (Sherman et al. 2019). One of the berg 2005), the current model, which focuses on supporting
ways that anxiety sensitivity is targeted in interventions is healthy risk-taking in children’s play, may not be a good fit.
via Interoceptive Exposure (IE). IE involves exposure to the Instead, for adolescents, it may be important to focus on pro-
physical sensations that are associated with anxiety and fear viding an environment that allows healthy risk-taking with a
(e.g. heart palpitations, sweating, muscle tension), with the view to decreasing unhealthy risk-taking and its associated
view to increasing tolerance of these sensations and, in turn, physical and mental health correlates. This remains an issue
reducing distress and fear related to these sensations (Craske to be explored in future theoretical and empirical work.
and Barlow 2007). In IE, these physical sensations can be Child sex likely influences engagement in adventurous
induced in a number of ways including via exercise, spinning play as well as adult responses to and encouragement of
and tensing the body (Boswell et al. 2013a, b). their adventurous play. Boys and girls use playgrounds
differently, although their overall activity levels are com-
parable; boys are more likely to play sports games and
Child Individual Difference Factors active games such as chase, whereas girls are more likely
Hypothesised to Affect Adventurous Play to be sedentary (sitting, reading, playing card games) or
walking/running (Reimers et al. 2018). When it comes to
While not a central focus here, individual differences adventurous play, Little (2010) found that, although boys
between children provide a context within which our model and girls engaged in equivalent amounts of risk-taking
sits. Child individual difference factors such as child age and in their play (defined as high risk, positive play), girls
development, physical ability, sex and temperament likely engaged in almost four times the amount of exploratory
affect the extent to which children engage in adventurous risk appraisal than boys. This indicates sex differences in
play and may also moderate associations between adventur- children’s approach to engaging in risk-taking during play,
ous play and anxiety risk. with girls taking more time to evaluate risk level before
In our model, we focus on early to middle childhood. engaging in adventurous play. This is consistent with
However, even within this age range, we would expect child research showing that boys take more risks in experimen-
age, and stage of development (which in typically develop- tal play-based tasks than girls (Morrongiello and Sedore
ing children is closely, but not always perfectly correlated 2005) as well as data showing that boys experience a
with child age) to impact on engagement in adventurous higher rate of injuries than girls (Hillier and Morrong-
play. While adventurous play and risk-taking activities iello 1998), and these injuries are often more severe (Mor-
have been observed in very young preschool children (e.g. rongiello et al. 2004). It is important though not to make
1–3 years of age; Kleppe et al. 2017), and across early and generalisations on the basis of child sex and to keep in
middle childhood (e.g. 4–13 years of age; Coster and Gleave mind that sex differences are likely determined by cultural
2008; Sandseter 2007; Sandseter et al. 2020), there is some and social norms (Liu and Zuo 2019), which means they
evidence that the prevalence of engagement in adventurous may change with time and depending on context. There
play activities increases with child age (Kleppe et al. 2017; is some evidence to indicate changing gender patterns in
Sandseter et al. 2020). This is likely to be because with children’s participation in organised sports activities with
increasing age most children develop the more advanced increased numbers of girls now participating in sports
gross and fine motor, cognitive and social-emotional skills previously considered to be boys sports (e.g. football,

13

170 Clinical Child and Family Psychology Review (2021) 24:164–181

cricket, basketball, rugby (ChildWise 2017). However, as Environmental Factors Hypothesised

yet, secular changes in boys and girls risk-taking during to Affect Adventurous Play
play have not been explored.
Parent behaviour also appears to differ depending on child A range of social and environmental factors affect chil-
sex, with mothers of daughters more likely to judge play- dren’s play broadly. These have been reviewed elsewhere
ground behaviour as risky and to intervene earlier and more (e.g. Whitebread et al. 2012) and are not a central focus
frequently than mothers of boys (Morrongiello and Dawber here, but they include parent–child attachment, poverty,
2000). It is well established that girls are at increased risk stress and nutrition (Lester and Russell 2010; Panksepp
for anxiety during adolescence and adulthood (Collishaw 2001). Assuming a safe context where these needs are met,
et al. 2010; Remes et al. 2016). Therefore, given that they adventurous play is likely affected by the affordances of
are also more likely to be actively discouraged from playing the play space as well as the social environment, including
in an adventurous way, it may be particularly important to the nature of adult supervision and the rules and policies
encourage adventurous play in girls. Given that boys may, in in place (Fig. 1). In Europe and internationally, there is
general, be more impulsive in their risk-taking during play a concern that safety is often prioritised over children’s
and are more likely to injure themselves (Rosen and Peterson developmental needs, and that ‘surplus safety’ restricts
1990), for them encouragement of more careful risk assess- children’s opportunities for adventurous play (e.g. Brus-
ment may be valuable. soni et al. 2012; Gill 2007; Tremblay et al. 2015) by con-
Individual differences in sensation seeking and behav- straining play spaces and children’s freedom to take risks
ioural inhibition also represent child-level factors that may when they play.
influence engagement in adventurous play. Sensation seek-
ing refers to an individual’s propensity to ‘seek varied,
novel, complex and intense sensations and experiences, and Physical Environment
the willingness to take physical…risks for the sake of such
experiences’ (Zuckerman 1994). Although the construct Children’s physical environments provide opportunity for
was initially investigated in adults, it has subsequently been different types of play and children perceive these affor-
demonstrated to apply to children (e.g. Kafry 1982; Mor- dances as invitations to play in a certain way (Heft 1988).
rongiello et al. 2010). Sensation seeking is higher in male Thus, the affordances offered by children’s physical environ-
children then female children and is not associated with ment are a vital characteristic in determining the extent to
socio-economic status (Haas et al. 2019). Young children which children will engage in adventurous play. Research
who are high in sensation seeking take more risks and are indicates that children spend little time ‘playing out’ in their
more likely to suffer minor and moderate injuries than those local neighbourhoods compared to previous generations
who are lower in sensation seeking (Morrongiello et al. (Loebach and Gilliard 2016) and only a small minority of
2010). Children who are high sensation seekers may create children play in natural outdoor spaces such as woodland
for themselves ample opportunities to play in an adventur- (EnglandMarketing 2009). This is likely due to a range of
ous way and to learn about uncertainty, coping and arousal. factors including an increase in traffic and reduced access to
In contrast, behavioural inhibition (BI) reflects a herit- natural spaces but it means that children’s opportunities to
able temperamental trait, that emerges early in life and is play adventurously are increasingly limited. Even purposely
characterised by a tendency to respond to novel, unfamil- designed play parks are often poorly matched to children’s
iar persons, places and objects with withdrawal, wariness developmental needs and desires and are designed only with
and avoidant behaviours (Kagan et al. 1988; Robinson et al. safety in mind. For example, Herrington and Nichols (2007)
1992). Compared to uninhibited children, inhibited children found that the Canadian standards for children’s playspaces
are fearful, shy and cautious and show increased signs of and equipment did not reflect children’s developmental and
physiological arousal at rest (Fox et al. 2005). They are also play needs, but rather the goals of risk reduction. Similarly,
at heightened risk for developing an anxiety disorder (e.g. Australian research found that children liked to play in a
Clauss and Blackford 2012; Sandstrom et al. 2020). Indi- way that allowed them to experience height and speed (e.g.
viduals who score high on behavioural inhibition may have climbing ropes, slides etc.) but that parks provided few
less propensity to seek out adventurous play experiences. opportunities for children to master these skills or to learn
Given this, and the fact that these children are already at new ones. Again, it was concluded that play spaces had been
heightened risk for anxiety, the opportunity and support to designed with a focus on safety and not on children’s prefer-
play in an adventurous way may be particularly important as ence for adventurous play (Little and Eager 2010).
a means of lowering risk for anxiety. The same may be true Of course, there is no desire to create play spaces that
for children who are at risk for anxiety because they have an are unsafe, but it is appropriate to consider whether play
anxious parent (e.g. Hudson et al. 2019).

13
Clinical Child and Family Psychology Review (2021) 24:164–181 171

spaces can be designed that allow children to engage in et al. 2011). Research has also shown that peers can have
adventurous play while ensuring safety standards are met. an effect on children’s risk-taking behaviour. For example,
Natural-design playgrounds and/or adventure playgrounds research has shown that children engage in greater risk-
may offer this balance, affording opportunities for risk- taking in the presence of another child (Miller and Byrnes
taking and thrilling adventurous play (Brussoni et  al. 1997; Morongiello and Sedore 2005), and that peer social
2012). Several studies have shown that adventurous play norms influence children’s risk-taking decisions (Green and
is increased in natural-design playgrounds. For example, Hart 1998; Morongiello et al. 2013). Taken together, there-
Lee and Christiansen (1999) compared a traditional play- fore, it is clear that parents, other adult caregivers and peers
ground comprising swings, slides, see-saws, etc., with a are likely to have some influence on their child’s risk-taking
natural-design playground containing wild, natural areas in play. Nevertheless, other child factors and environmental
where wood and ropes were used. The natural design play- factors are also likely to play a role.
ground afforded the most challenging play, and on the tra-
ditional playground, children spent more time wandering
and standing still. Children were also most enthusiastic Changing the Physical and Social
about the natural design playground. Environment

Social Environment Importantly, there is evidence that the above physical and
social environmental factors can be changed, at least to
In addition to the affordances offered by the play space, some extent. For example, Bundy and colleagues changed
other people inspire or constrain action in the context of play children’s physical play environment at school by intro-
(Gibson 1979). Kyttä (2004) uses the phrase ‘independent ducing materials with no fixed purpose (e.g. old car tyres,
mobility licence’ to describe the extent to which adults allow boxes, also known as loose parts) to a school playground for
children to move around freely and engage in the opportu- 11 weeks (Bundy et al. 2017). They found preliminary evi-
nities their environment offers. For children, this ‘licence’ dence that children’s play changed as a result, and that chil-
is typically determined by adults in a caregiving capacity dren spent more time engaged in physical activity. Along-
(parents or non-parent adults such as teachers and lunchtime side this, qualitative research shows that a risk-reframing
supervisors). These adults may restrict children’s adventur- intervention can help parents and educators to gain more
ous play via policy, rules and procedures and through their realistic perceptions of risk and increase awareness of the
supervision of play. For example, in the UK, a number of benefits of age-appropriate risk-taking during play (Nieheus
playground games have been banned by schools because of et al. 2013). Furthermore, there is qualitative evidence that
health and safety concerns (Association for Teachers and programmes which aim to change the physical environment,
Lecturers 2011). Similarly, in certain regions of Belgium, adult attitudes to risk-taking and policies around play lead
snowball fights have been banned (Sewell 2013). Research to changes in attitude and school culture around play, in
demonstrates that children’s opportunities to engage in the particular in relation to risk-taking in play and adult con-
adventurous play opportunities afforded by their playground trol of play (Lester et al. 2011). To date, there is a lack of
are affected by the mobility licence provided to children by quantitative evaluations, using randomised control designs,
supervising staff (Sandseter 2009). of these programmes. Nevertheless, taken together, these
Outside of school, parents have a vital role to play not studies provide an initial indication that it should be pos-
only in protecting their children but also in encouraging sible to increase children’s opportunities for adventurous
them to take appropriate risks that support positive devel- play by making changes to their physical environment and
opment (Kelley et al. 1998). The majority of children are by changing adult attitudes and behaviours related to child
supervised wherever they play (England Marketing 2009) risk-taking.
and parental concern about child safety is one of the most
significant influences on children’s independent outdoor play
(Aziz and Said 2012; Valentine and McKendrick 1997). This A Conceptual Model of How Adventurous
monitoring of risk-taking by parents has been captured in Play might Affect Children’s Risk for Anxiety
laboratory research on sex differences which showed that
parents who monitor their child more have children who take Our conceptual model is shown in Fig. 1. It builds on
fewer risks (Hagan and Kuebli 2007). Furthermore, parent theoretical accounts of the function of adventurous play
attitudes towards children’s risk-taking are correlated with and developmental psychopathological models of anxiety.
their child’s engagement in adventurous play such that par- Our model acknowledges that children’s engagement in
ents who feel more positive about the benefits of risk-taking adventurous play and the impact of adventurous play on
in play have children who play more adventurously (Little children’s risk for anxiety will likely be affected by child

13

172 Clinical Child and Family Psychology Review (2021) 24:164–181

individual difference factors, represented by the grey Supporting (Indirect) Evidence

shaded area. It includes pathways through which adven-
turous play might affect children’s risk for anxiety as well Scientific research into the psychological benefits of
as environmental and social factors that might affect each adventurous or risky play in children is scarce. A sys-
other as well as children’s engagement in adventurous tematic review conducted in 2015 identified 21 papers
play. Each of these paths is outlined in turn below. A that examined associations between risky play and child
direct, bidirectional path from adventurous play to anxiety health related outcomes. This review found significant,
symptoms is also included to acknowledge that the medi- but mostly small, associations between risky play and
ating risk mechanisms shown are unlikely to be exhaus- increased physical activity as well as social competence
tive and that children with lower anxiety may be likely but found no papers that evaluated mental health outcomes
to engage in more adventurous play. There is also a path (Brussoni et al. 2015). Although the hypothesised asso-
from decreased anxiety symptoms back to social environ- ciation between adventurous play and anxiety in children
ment to acknowledge that children’s anxiety is likely to has not yet been directly evaluated, there are three lines
affect the behaviour and attitudes of those around them. of research that provide evidence which is consistent with
As outlined above, the model focuses on risk mechanisms this theorised relationship: research on play in nature,
that are linked to anxiety risk, are well-grounded in psy- research on the role of parents in child anxiety risk and
chological theory and that can plausibly be affected by research on sensation seeking. Each will be discussed
adventurous play. briefly in turn.
We hypothesise that ample opportunities to engage
in adventurous play during early and middle childhood
will decrease children’s risk for problematic anxiety by Outdoor Play in Nature
providing children with exposure to fear-provoking situ-
ations during play which, in turn, provides opportunities Outdoor, natural space lends itself to adventurous play and
for children to learn about coping, uncertainty and physi- adventurous play is most likely to occur outdoors. This is
ological arousal. Relative to play that is not adventur- because the diverse, dynamic and flexible features found in
ous, adventurous play exposes children to higher levels natural spaces afford many opportunities for adventurous
of uncertainty and risk which, in turn, exposes children play encouraging risk-taking, exploration, independence
to greater physiological arousal and fear. Successful and autonomy (Bixler et al. 2002; Kellert 2002). As a con-
handling of this uncertainty, arousal and fear will, we sequence, there is overlap between adventurous play and
hypothesise, lead to an adaptive coping template, reduced both outdoor and nature play. These terms are not synony-
intolerance of uncertainty and realistic interpretations of mous though; there are likely benefits to being outdoors
physiological arousal in the future (Kendall et al. 2016). and in nature that are independent of benefits that come
Overcoming avoidance of fear-provoking situations from adventurous play in those spaces. Similarly, children
through playful exposure is key to unlocking these ben- can be outdoors but not playing in an adventurous way.
efits, and this is reflected in our model. And, with some creativity, adventurous play can happen
We hypothesise that adventurous play facilitates indoors. Nevertheless, given this overlap, research on the
approach behaviour (decreases avoidance, increases expo- mental health benefits of time outdoors and in nature is
sure) because the positive, thrilling and playful emotion relevant. Broadly speaking, exposure to nature and green
associated with this type of child-led play facilitates and spaces is beneficial for children’s mental, physical and
motivates exposure to feared stimuli. This is supported social health and well-being (e.g. Chawla 2015; Gill 2014;
by qualitative research showing that children are moti- Mygind et al. 2019; Tillman et al. 2018). More specifically,
vated to engage in play where they can experience the when outdoor spaces in childcare settings and schools are
ambiguity of simultaneous exhilaration, joy and fear, or ‘greened’ (modified to improve biodiversity and increase
what they label “scary-funny” feelings. This motivated affordances and access to natural elements), this improves
feeling comes from the balance between fear and fun. If mental health and well-being, reduces stress, and promotes
the level of risk or fear is too high, the play will no longer social and emotional skills (Bell and Dyment 2008; Brus-
be motivating and enjoyable. What constitutes adventur- soni et al. 2017; Chawla et al. 2014; Dankiw et al. 2020;
ous play will therefore vary between children according van Dijk-Wesselius et al. 2018). It is theorised that these
to individual differences in propensity to take risks and benefits come from the restoration of attention (see Kaplan
experience fear; adventurous play happens when a child and Kaplan 1989; Kaplan 1995) or stress reduction (see
is playing at the edge of their comfort zone and experi- Ulrich et al. 1991) but it is also possible that some of this
encing these simultaneous feelings of excitement, thrill benefit comes from an increase in children’s adventurous
and fear. play in these ‘greened’ spaces.

13
Clinical Child and Family Psychology Review (2021) 24:164–181 173

The Role of Parents in Child Anxiety risk individual differences in sensation seeking would represent a
child-level factor that influences engagement in adventurous
When parents have higher levels of anxiety, their child is at play. If the conceptual model is correct then these children
increased risk for having an anxiety disorder (Turner et al. should have ample opportunities to learn about uncertainty,
1987). This association is particularly strong for maternal coping and arousal and, as a result, have lower levels of
anxiety (Cooper et al. 2006). Overall, it also appears that anxiety. Evidence supports this link; children who are higher
when mothers are overprotective and attempt to protect their in sensation seeking have fewer internalising symptoms
child from potential harm by controlling their behaviour, this (Haas et al. 2019), which includes anxiety and depression.
increases children’s risk for anxiety disorders (Hudson et al. It seems likely that children who are high sensation seekers
2019; McLeod et al. 2007), although findings are somewhat will not require the same level of environmental and social
mixed (van der Bruggen et al. 2008). In contrast, challeng- support to engage in adventurous play as children who are
ing parenting encompasses physical and verbal behaviours low sensation seekers. In fact, in extreme cases, it could be
that encourage the child to stretch themselves physically and argued that risk-taking needs to be restricted in order to keep
mentally through physical play and exposure to risk. It is them safe. An alternative perspective would be that children
theorised that fathers are particularly well-placed to engage who are high sensation seekers require an environment that
in challenging parenting and that when they do they lower matches their needs, rather than an environment that does
their child’s anxiety risk (Bogels and Phares 2008). There not facilitate adventurous play and where it may be actively
is some support for the hypothesis that challenging parent- restricted by adults. Where this mismatch exists, we might
ing decreases children’s anxiety risk, but findings regarding anticipate behaviour problems as a result, which could offer
parent gender are less clear. For example, Lazarus and col- some explanation for the correlation between high sensation
leagues (Lazarus et al. 2016) found that both maternal and seeking and conduct problems in children.
paternal challenging parenting were associated with lower
anxiety symptoms but only maternal challenging parenting
was associated with decreased risk for anxiety diagnosis. Research Agenda
This literature on parent anxiety and parenting styles is
relevant to our conceptual model because, as discussed, a In the following paragraphs, we outline an agenda for future
key environmental factor affecting children’s adventurous research that will allow our conceptual model to be evalu-
play is adult supervision, and the licence adults give children ated. The first important step is to focus on how to measure
to take risks when they play. The extent to which parents children’s adventurous play reliably. The most direct means
encourage their children to engage in adventurous play and of measuring adventurous play is through the observation
to take appropriate risks is very likely to be affected by the and coding of children’s play behaviours. Direct observation
parents’ own anxiety and their parenting style. We would coding schemes have been developed for preschool children
expect that parents who are highly anxious and/or more (e.g. Little 2010; Sandseter 2007), but these schemes may
inclined toward overprotective, overcontrolling parenting need adjusting to capture the adventurous play of older chil-
may be more likely to restrict their children’s adventurous dren, or to be appropriate for observing adventurous play in
play via rules or more intense supervision and monitoring different environments. Given the subjectivity of what con-
of play. In contrast, we would expect parents who display stitutes adventurous in different children, it may be neces-
greater challenging parenting behaviours to actively encour- sary to incorporate some child self-report into observational
age adventurous play and facilitate greater risk-taking via measures of adventurous play. In addition to observational
less intense supervision. Empirical research is lacking in this measures, which will provide in depth data but are time-
area although one study reported that parents who engaged consuming and costly, this area of research would benefit
in more overprotective parenting were less encouraging of from a questionnaire measure that captures children’s oppor-
their child engaging in adventurous play and perceived fewer tunities for and engagement in adventurous play. Developing
benefits of adventurous play (Cevher-Kalburan and Ivrendi measures that capture the quantity (e.g. frequency, duration)
2016). and quality (e.g. location, degree of risk-taking) of children’s
adventurous play are therefore an initial research priority.
Research on Sensation Seeking Next, correlational studies incorporating measures of
engagement in adventurous play, alongside measures of anx-
As outlined above, individuals differ in the extent to which iety risk mechanisms, and anxiety symptoms can provide an
they seek out risky and thrilling experiences, with individu- initial ‘proof of principle’ test of our hypothesis. Such stud-
als who are high on sensation seeking having a propensity to ies are relatively cost- and time-efficient, and if conducted
seek out more risky, exciting, thrilling experiences. Within with sufficiently large numbers of participants would allow
our conceptual model, and as we have acknowledged above, some moderators to be examined. For example, it should be

13

174 Clinical Child and Family Psychology Review (2021) 24:164–181

possible to explore whether the association between engage- model is correct, then we would expect that children who
ment in adventurous play and children’s anxiety differs for have increased opportunities for adventurous play will be
girls and boys. The results of these studies should be treated at decreased risk of elevated anxiety symptoms because
with some caution because it is likely that children who they are provided with exposure to and opportunities to
are more anxious will engage in less adventurous play (see learn about coping, uncertainty and physiological arousal.
Fig. 1) so a correlation could indicate this direction of effect. Not only would this research address important questions
Determining whether there is a causal relationship of causality but it would also have implications for preven-
between adventurous play and decreased risk for child tion. Preventative interventions that increase adventurous
anxiety will require longitudinal and experimental research play do not need to be highly resource-intensive, and even
designs. Longitudinal designs can track adventurous play a small effect size of adventurous play on children’s anxi-
engagement, anxiety risk mechanisms, and anxiety symp- ety may offer an opportunity to make a significant change
toms across multiple time points and test whether the in children’s risk for anxiety at a population level (Crutzen
relationship between engagement in adventurous play and 2010).
decreased anxiety risk occurs via the mediating risk mecha- Research that focuses on preventative interventions
nisms outlined in our model. Experimental designs where should ideally examine the impact of any intervention on
children are provided with opportunity for adventurous play anxiety risk within children who are at risk for anxiety
with specific cognitive and behavioural factors evaluated disorders, for example those with a family history or anxi-
before and after could provide an efficient and robust way ety or who have a behaviourally inhibited temperament.
to examine the causal hypotheses from the model. There Because these children are at elevated risk for problem-
are some limitations to both longitudinal and experimental atic anxiety, they have the most to gain from preventa-
designs though. For longitudinal research, the main limita- tive interventions. With this in mind, it is important to
tion is that it will not be possible to rule out entirely that a evaluate whether adventurous play interventions are able
confounding factor might affect both play and anxiety over to effectively change play and anxiety risk for these chil-
time, leading to an association that is not causal. For experi- dren specifically.
mental designs, the main limitation is that effects would only As we have noted, there is overlap between adventurous
be found if adventurous play has an effect after only a short play and outdoor and nature play. There is also overlap
period. Furthermore, only state-like variables that change with the constructs of free play, independent mobility, and
quickly over time could be evaluated for change from pre physical activity. However, these constructs are not synon-
to post. ymous. We propose that there are likely benefits of adven-
The most rigorous way to address questions of causal- turous play for children’s anxiety risk that operate via the
ity and to test the fundamental hypotheses in our model mediating cognitive–behavioural pathways outlined in our
would be to conduct a randomised control trial in which model. From a theoretical perspective, it will therefore be
children’s adventurous play is increased in an interven- important for future research to tease apart the effects of
tion group, and the effect on anxiety risk mechanisms adventurous play from any effects due to time spent play-
and anxiety symptoms is compared with a control group. ing outdoors and in nature (e.g. Dankiw et al. 2020), of
This will require the development of interventions that unstructured child-led play (e.g. Weikart 1998), of greater
can successfully increase adventurous play, particularly in independent mobility (e.g. Marzi and Reimers 2018) and
children who have the lowest levels of engagement in this of higher levels of physical activity (e.g. Rodriguez-Ayllon
type of play. Our model points to changes to the physical et al. 2019; Zhu et al. 2019).
play space, and changes to adult attitudes and behaviours There are also important questions around moderators
related to child risk-taking as key environmental factors of any association between adventurous play and anxiety
that are likely to lead to increases in children’s adventur- (e.g. child gender, child temperament, child age) as well
ous play. There is evidence that these environmental fac- as the hypothesised partial mediation pathways shown in
tors can be changed effectively via modifications to school Fig. 1. Both moderators and mediators could be examined
playgrounds, and via risk-reframing workshops, and that in the context of large-scale survey studies and/or RCTs.
doing so leads to changes in children’s play, physical It will be of particular interest to examine the impact
activity levels and well-being (e.g. Brussoni et al. 2017; of adventurous play on anxiety for children who are at
Bundy et al. 2017; Lee and Christiansen 1999; Van Dijk- increased risk for anxiety disorders, for example, children
Wesselius et al. 2018) as well as to changes in parents and who have a family history of anxiety disorders or who have
educators attitudes toward risk-taking in play (Niehues a behaviourally inhibited temperament. Initial research
et al. 2013). However, as yet no randomised controlled though should focus on the main hypothesis that engag-
studies exist that have manipulated adventurous play and ing in more adventurous play will decrease children’s risk
examined the impact on child anxiety. If our conceptual for elevated anxiety.

13
Clinical Child and Family Psychology Review (2021) 24:164–181 175

Concluding Remarks References

Until now the fields of child anxiety and adventurous/risky Apter, M. J. (1992). The dangerous edge: The psychology of excite-
ment. New York: Free Press.
play have proceeded in isolation from each other despite Askew, C., & Field, A. P. (2008). The vicarious learning pathway to
good theoretical reasons to believe that they have relevance fear 40 years on. Clinical Psychology Review, 28(7), 1249–1265.
to one another. For the first time, in this conceptual article, https​://doi.org/10.1016/j.cpr.2008.05.003.
we bring together these two research areas. We draw upon Association for Teachers and Lecturers. (2011). Over-zealous schools
ban British bulldog and conkers [press release]. https​://www.
the literature regarding cognitive and behavioural factors atl.org.uk/lates​t/press​-relea​se/over-zealo​us-schoo​ls-ban-briti​sh-
that underpin child anxiety to propose a novel theory of how bulld​og-and-conke​rs-atl. Accessed May 25th 2018.
children’s risk for anxiety might be reduced by providing Aziz, N. F., & Said, I. (2012). The trends and influential factors of
children with ample opportunity to play in an adventurous children’s use of outdoor environments: A review. Procedia—
Social and Behavioural Sciences, 38, 204–212. https​://doi.
way. We set out an agenda for future research, identifying org/10.1016/j.sbspr​o.2012.03.341.
research priorities and designs that address the core hypothe- Balan, B., & Lingam, L. (2012). Unintentional injuries among children
ses derived from our conceptual model. Through our model, in resource poor settings: Where do the fingers point? Archives
and the research we hope it stimulates, there is significant of Disease in Childhood, 97(1), 35–38. https​://doi.org/10.1136/
archd​ischi​ld-2011-30058​9.
potential to broaden our understanding of the benefits of Ball, D., Gill, T., & Spiegal, B. (2012). Managing risk in play provi-
adventurous play, moving beyond the dominant focus on sion: Implementation guide. London, UK: National Children’s
physical health to also consider mental health outcomes, and Bureau.
to extend our understanding of the prevention of childhood Bardeen, J. R., Fergus, T. A., & Wu, K. D. (2013). The interactive
effect of worry and intolerance of uncertainty on posttraumatic
anxiety. stress symptoms. Cognitive Therapy and Research, 37(4), 742–
751. https​://doi.org/10.1007/s1060​8-012-9512-1.
Acknowledgements  HD is funded by a UKRI Future Leaders Fellow- Barnes, S. (2012). Reducing childhood obesity in ontario through a
ship (Ref: MR/S017909/1). KL receives funding from a Jacobs Founda- health equity lens. Wellesley Institute: Toronto, Canada. https​://
tion Independent Scholar Project Award and a British Academy Small www.welles​ leyin​ stitu​ te.com/wp-conten​ t/upload​ s/2012/10/Reduc​
Grant Award (SG161257). The authors are grateful to Cathy Creswell, ing-Child​hood-Obesi​ty-in-Ontar​io.pdf.
Sam Cartwright-Hatton, Lily Fitzgibbon, Rachel Nesbit and Tim Gill Beckoff, M., & Byers, J. A. (1981). A critical re-analysis of the ontog-
for their feedback on earlier drafts. eny and phylogeny of mammalian social and locomotor play. In
K. Immelmann, G. Barlow, L. Petronovich, & M. Main (Eds.),
Funding  HD is funded by a UKRI Future Leaders Fellowship (Ref: Behavioural development (pp. 296–337). Cambridge: Cambridge
MR/S017909/1). KL receives funding from a Jacobs Foundation Inde- University Press.
pendent Scholar Project Award and a British Academy Small Grant Bell, A. C., & Dyment, J. E. (2008). Grounds for health: The inter-
Award (SG161257). section of green school grounds and health-promoting schools.
Environmental Education Research, 14(1), 77–90. https​://doi.
org/10.1080/13504​62070​18434​26.
Compliance with Ethical Standards  Bixler, R. D., Floyd, M. F., & Hammitt, W. E. (2002). Environmental
socialization: Quantitative tests of the childhood play hypoth-
Conflict of interest  Play England, Play Wales, PlayBoardNI, HAGS esis. Environment and Behaviour, 34(6), 795–818. https​://doi.
and the Association of Play Industries (API) are partners on HD’s org/10.1177/00139​16022​37248​.
UKRI Future Leaders fellows. Outdoor Play and Learning and Learn- Boelen, P. A., & Reijntjes, A. (2009). Intolerance of uncertainty and
ing through Landscapes are collaborators on this same fellowship. HD social anxiety. Journal of Anxiety Disorders, 23(1), 130–135.
does not receive any direct funding from these organisations. https​://doi.org/10.1016/j.janxd​is.2008.04.007.
Boelen, P. A., Reijntjes, A., & Carleton, R. N. (2014). Intolerance
Ethical Approval  This study used data from published studies and no of uncertainty and adult separation anxiety. Cognitive Behav-
data was collected from individual participants. iour Therapy, 43(2), 133–144. https​://doi.org/10.1080/16506​
073.2014.88875​5.
Bögels, S., & Phares, V. (2008). Fathers’ role in the etiology, prevention
Open Access  This article is licensed under a Creative Commons Attri-
and treatment of child anxiety: A review and new model. Clinical
bution 4.0 International License, which permits use, sharing, adapta-
Psychology Review, 28(4), 539–558. https​://doi.org/10.1016/j.
tion, distribution and reproduction in any medium or format, as long
cpr.2007.07.011.
as you give appropriate credit to the original author(s) and the source,
Bomyea, J., Ramsawh, H., Ball, T. M., Taylor, C. T., Paulus, M. P.,
provide a link to the Creative Commons licence, and indicate if changes
Lang, A. J., & Stein, M. B. (2015). Intolerance of uncertainty
were made. The images or other third party material in this article are
as a mediator of reductions in worry in a cognitive behavioral
included in the article’s Creative Commons licence, unless indicated
treatment program for generalized anxiety disorder. Journal of
otherwise in a credit line to the material. If material is not included in
Anxiety Disorders, 33, 90–94. https​://doi.org/10.1016/j.janxd​
the article’s Creative Commons licence and your intended use is not
is.2015.05.004.
permitted by statutory regulation or exceeds the permitted use, you will
Boswell, J. F., Farchione, T. J., Sauer-Zavala, S., Murray, H. W.,
need to obtain permission directly from the copyright holder. To view a
Fortune, M. R., & Barlow, D. H. (2013a). Anxiety sensitivity
copy of this licence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/.
and interoceptive exposure: A transdiagnostic construct and
change strategy. Behavior Therapy, 44(3), 417–431. https​://doi.
org/10.1016/j.beth.2013.03.006.

13

176 Clinical Child and Family Psychology Review (2021) 24:164–181

Boswell, J. F., Thompson-Hollands, J., Farchione, T. J., & Barlow, D. childhood and adolescence. Health & Place, 28, 1–13. https​://
H. (2013b). Intolerance of uncertainty: A common factor in the doi.org/10.1016/j.healt​hplac​e.2014.03.001.
treatment of emotional disorders. Journal of Clinical Psychology, ChildWise (2017). ChildWise Monitor Report 2017: Sport and Activi-
69(6), 630–645. https​://doi.org/10.1002/jclp.21965​. ties. Retrieved from November 5, 2020 http://www.child​wise.
Bouchard, S., Mendlowitz, S., Coles, M., & Franklin, M. (2004). Con- co.uk/uploa​ds/3/1/6/5/31656​353/press​_relea​se_sport​_2018.pdf.
siderations in the use of exposure with children. Cognitive and Child Accident Prevention Trust. (2013). Tackling inequalities in child-
Behavioral Practice, 11(56), 65. https​://doi.org/10.1016/S1077​ hood accidents. http://www.making​ theli​ nk.net/sites/​ defaul​ t/files/​
-7229(04)80007​-5. resou​rces/PHE-exter​nal-tackl​ing-inequ​aliti​es-facts​heet.pdf.
Brussoni, M., Gibbons, R., Gray, C., Ishikawa, T., Sandseter, E. B., Christensen, P., & Mikkelsen, M. R. (2008). Jumping off and being
Bienenstock, A., et al. (2015). What is the relationship between careful: Children’s strategies of risk management in everyday
risky outdoor play and health in children? A systematic review. life. Sociology of Health & Illness, 30(1), 112–130. https​://doi.
International Journal of Environmental Research and Public org/10.1111/j.1467-9566.2007.01046​.x.
Health, 12(6), 6423–6454. https​://doi.org/10.3390/ijerp​h1206​ Chronis-Tuscano, A., Degnan, K. A., Pine, D. S., Perez-Edgar, K., Hen-
06423​. derson, H. A., Diaz, Y., et al. (2009). Stable early maternal report
Brussoni, M., Ishikawa, T., Brunelle, S., & Herrington, S. (2017). of behavioral inhibition predicts lifetime social anxiety disorder
Landscapes for play: Effects of an intervention to promote in adolescence. Journal of the American Academy of Child &
nature-based risky play in early childhood centres. Jour- Adolescent Psychiatry, 48(9), 928–935. https​://doi.org/10.1097/
nal of Environmental Psychology, 54, 139–150. https​://doi. CHI.0b013​e3181​ae09d​f.
org/10.1016/j.jenvp​.2017.11.001. Chronis-Tuscano, A., Rubin, K. H., O’Brien, K. A., Coplan, R. J.,
Brussoni, M., Olsen, L. L., Pike, I., & Sleet, D. A. (2012). Risky play Thomas, S. R., Dougherty, L. R., et al. (2015). Preliminary evalu-
and children’s safety: Balancing priorities for optimal child ation of a multimodal early intervention program for behavio-
development. International Journal of Environmental Research rally inhibited preschoolers. Journal of Consulting and Clinical
and Public Health, 9(9), 3134–3148. https​://doi.org/10.3390/ Psychology, 83(3), 534–540. https​://doi.org/10.1037/a0039​043.
ijerp​h9093​134. Clark, D. M. (1986). A cognitive approach to panic. Behav-
Bundy, A., Engelen, L., Wyver, S., Tranter, P., Ragen, J., Bauman, iour Research and Therapy, 24(4), 461–470. https ​ : //doi.
A., et al. (2017). Sydney playground project: A cluster-ran- org/10.1016/0005-7967(86)90011​-2.
domized trial to increase physical activity, play, and social Clauss, J. A., & Blackford, J. U. (2012). Behavioral inhibition and
skills. Journal of School Health, 87(10), 751–759. https​://doi. risk for developing social anxiety disorder: A meta-analytic
org/10.1111/josh.12550​. study. Journal of the American Academy of Child and Ado-
Calkins, A. W., Otto, M. W., Cohen, L. S., Soares, C. N., Vitonis, lescent Psychiatry, 51, 1066–1075. https​://doi.org/10.1016/j.
A. F., Hearon, B. A., & Harlow, B. L. (2009). Psychosocial jaac.2012.08.002.
predictors of the onset of anxiety disorders in women: Results Collishaw, S., Maughan, B., Natarajan, L., & Pickles, A. (2010). Trends
from a prospective 3-year longitudinal study. Journal of Anxi- in adolescent emotional problems in England: A comparison of
ety Disorders, 23(8), 1165–1169. https​: //doi.org/10.1037/ two national cohorts twenty years apart. The Journal of Child
a0017​428. Psychology and Psychiatry, 51(8), 885–894. https​://doi.org/10
Carleton, R. N. (2016a). Fear of the unknown: One fear to rule .1111/j.1469-7610.2010.02252​.x.
them all? Journal of Anxiety Disorders, 41, 5–21. https​://doi. Compas, B. E., Connor-Smith, J. K., Saltzman, H., Thomsen, A. H., &
org/10.1016/j.janxd​is.2016.03.011. Wadsworth, M. E. (2001). Coping with stress during childhood
Carleton, R. N. (2016b). Into the unknown: A review and synthe- and adolescence: Problems, progress, and potential in theory
sis of contemporary models involving uncertainty. Journal of and research. Psychological Bulletin, 127(1), 87–127. https​://
Anxiety Disorders, 39, 30–43. https​://doi.org/10.1016/j.janxd​ doi.org/10.1037/0033-2909.127.1.87.
is.2016.02.007. Consumer Safety Unit. (2002). 24th annual report, home accident sur-
Carleton, R. N., Collimore, K. C., & Asmundson, G. J. G. (2010). veillance system. London: Department of Trade and Industry.
“It’s not just the judgements—It’s that I don’t know”: Intolerance Cooper, P. J., Fearn, V., Willetts, L., Seabrook, H., & Parkinson, M.
of uncertainty as a predictor of social anxiety. Journal of Anxi- (2006). Affective disorder in the parents of a clinic sample of
ety Disorders, 24(2), 189–195. https​://doi.org/10.1016/j.janxd​ children with anxiety disorders. Journal of Affective Disorders,
is.2009.10.007. 93, 205–212. https​://doi.org/10.1016/j.jad.2006.03.017.
Carleton, R. N., Duranceau, S., Freeston, M. H., Boelen, P. A., McCabe, Coster, D., & Gleave, J. (2008). Give us a go! Children and young
R. E., & Antony, M. M. (2014). “But it might be a heart attack”: people’s views on play and risk-taking. https:​ //www.playda​ y.org.
Intolerance of uncertainty and panic disorder symptoms. Journal uk/wp-conten​ t/upload​ s/2015/11/give_us_a_go___childr​ en_and_
of Anxiety Disorders, 28(5), 463–470. https​://doi.org/10.1016/j. young​_peopl​es_views​_on_play_and_risk_takin​g.pdf.
janxd​is.2014.04.006. Craske, M. G. (2003). Anxious processes. In M. G. Craske (Ed.), Ori-
Caspi, A., Elder, G. H., & Bem, D. J. (1988). Moving away gins of phobias and anxiety disorders: Why more women than
from the world: Life-course patterns of shy children. men? (pp. 71–98). Oxford: Elsevier.
Developmental Psychology, 24(6), 824–831. https ​ : //doi. Craske, M. G., & Barlow, D. H. (2007). Mastery of your anxiety and
org/10.1037/0012-1649.24.6.824. panic: Therapist guide (Vol. 2). Oxford: Oxford University Press.
CDC. (2019). Fall prevention. Retrieved May 15, 2019, from https​:// Creswell, C., & O’Connor, T. G. (2011). Interpretation bias and anxiety
www.cdc.gov/safec​hild/falls​/index​.html. in childhood: Stability, specificity and longitudinal associations.
Cevher-Kalburan, N., & Ivrendi, A. (2016). Risky play and parenting Behavioural and Cognitive Psychotherapy, 39(2), 191–204. https​
styles. Journal of Child and Family Studies, 25, 355–366. https​ ://doi.org/10.1017/S1352​46581​00004​94.
://doi.org/10.1007/s1082​6-015-0236-1. Crutzen, R. (2010). Adding effect sizes to a systematic review on inter-
Chawla, L. (2015). Benefits of nature contact for children. Jour- ventions for promoting physical activity among European teenag-
nal of Planning Literature, 30(4), 433–452. https ​ : //doi. ers. International Journal of Behavioral Nutrition and Physical
org/10.1177/08854​12215​59544​1. Activity, 7(1), 29. https​://doi.org/10.1186/1479-5868-7-29.
Chawla, L., Keena, K., Pevec, I., & Stanley, E. (2014). Green school- Dankiw, K. A., Tsiros, M. D., Baldock, K. L., & Kumar, S. (2020). The
yards as havens from stress and resources for resilience in impacts of unstructured nature play on health in early childhood

13
Clinical Child and Family Psychology Review (2021) 24:164–181 177

development: A systematic review. PLoS ONE, 15(2), e0229006. difficulties. BMC Pediatrics, 19(1), 77. https​://doi.org/10.1186/
https​://doi.org/10.1371/journ​al.pone.02290​06. s1288​7-019-1450-6.
Dodd, H. F., Stuijfzand, S., Morris, T., & Hudson, J. L. (2015). Child Hagan, L. K., & Kuebli, J. (2007). Mothers’ and fathers’ socialisa-
anxiety and the processing of ambiguity. Cognitive Therapy tion of preschoolers’ physical risk-taking. Journal of Applied
and Research, 39(5), 669–677. https​://doi.org/10.1007/s1060​ Developmental Psychology, 28, 2–14. https​://doi.org/10.1016/j.
8-015-9689-1. appde​v.2006.10.007.
Eisenberg, N., Fabes, R. A., & Guthrie, I. K. (1997). Coping with Hebert, E. A., & Dugas, M. J. (2019). Behavioral experiments for intol-
stress. In S. A. Wolchik & I. N. Sandler (Eds.), Handbook of erance of uncertainty: Challenging the unknown in the treatment
children’s coping (pp. 41–70). Boston, MA: Springer. of generalized anxiety disorder. Cognitive and Behavioral Prac-
EnglandMarketing. (2009). Report to natural england on child- tice, 26, 421–436. https​://doi.org/10.1016/j.cbpra​.2018.07.007.
hood and nature. publications.naturalengland.org.uk/ Heft, H. (1988). Affordances of children’s environments: A functional
file/5495287317528576. Accessed 28th July 2020. approach to environmental description. Children’s Environment
Fagen, R. (1981). Animal play behaviour. New York: Oxford Univer- Quality, 5, 29–37.
sity Press. Herrington, S., & Nicholls, J. (2007). Outdoor play spaces in Canada:
Fetzner, M. G., Horswill, S. C., Boelen, P. A., & Carleton, R. N. The safety dance of standards as policy. Critical Social Policy,
(2013). Intolerance of uncertainty and PTSD symptoms: 27, 128–138. https​://doi.org/10.1177/02610​18307​07221​0.
Exploring the construct relationship in a community sam- Hillier, L. M., & Morrongiello, B. A. (1998). Age and gender differ-
ple with a heterogeneous trauma history. Cognitive Therapy ences in school-age children’s appraisals of injury risk. Journal
and Research, 37(4), 725–734. https​://doi.org/10.1007/s1060​ of Pediatric Psychology, 23, 229–238. https​://doi.org/10.1093/
8-013-9531-6. jpeps​y/23.4.229.
Field, A. P., & Lester, K. J. (2010). Is there room for ‘development’ Hoffman, S. G. (2008). Cognitive processes during fear acquisition
in developmental models of information processing biases to and extinction in animals and humans: Implications for exposure
threat in children and adolescents. Clinical Child and Family therapy of anxiety disorders. Clinical Psychology Review, 28,
Psychology Review, 13(4), 315–332. https​://doi.org/10.1007/ 199–210. https​://doi.org/10.1016/j.cpr.2007.04.009.
s1056​7-010-0078-8. Hovenkamp-Hermelink, J. H. M., van der Veen, D. C., Oude Voshaar,
Fox, N. A., Henderson, H. A., Marshall, P. J., Nichols, K. E., & Ghera, R. C., Batelaan, N. M., Pemminx, B. W. J. H., Jeronimus, B.
M. M. (2005). Behavioral inhibition: Linking biology and behav- F., et al. (2019). Anxiety sensitivity, its stability and longitu-
ior within a developmental framework. Annual Review of Psy- dinal association with severity of anxiety symptoms. Scientific
chology, 56, 235–262. https​://doi.org/10.1146/annur​ev.psych​ Reports, 9, 4314. https​://doi.org/10.1038/s4159​8-019-39931​-7.
.55.09090​2.14153​2. Hudson, J. L., & Dodd, H. F. (2012). Informing early intervention: Pre-
Gardner, M., & Steinberg, L. (2005). Peer influence on risk taking, school predictors of anxiety disorders in middle childhood. PLoS
risk preference, and risky decision making in adolescence and ONE, 7(8), e42359. https​://doi.org/10.1371/journ​al.pone.00423​
adulthood: An experimental study. Developmental Psychology, 59.
41, 625–635. https​://doi.org/10.1037/0012-1649.41.4.625. Hudson, J. L., Dodd, H. F., Lyneham, H. J., & Bovopoulous, N. (2011).
Garnefski, N., Rieffe, C., Jellesma, F., Terwogt, M. M., & Kraaij, V. Temperament and family environment in the development of
(2007). Cognitive emotion regulation strategies and emotional anxiety disorder: Two-year follow-up. Journal of the American
problems in 9–11-year-old children. European Child and Ado- Academy of Child & Adolescent Psychiatry, 50(12), 1255–1264.
lescent Psychiatry, 16, 1–9. https​: //doi.org/10.1007/s0078​ https​://doi.org/10.1016/j.jaac.2011.09.009.
7-006-0562-3. Hudson, J. L., Murayama, K., Meteyard, L., Morris, T., & Dodd, H.
Gibson, J. J. (1979). The ecological approach to visual perception. F. (2019). Early childhood predictors of anxiety in early adoles-
Boston: Houghton-Mifflin. cence. Journal of Abnormal Child Psychology, 47, 1121–1133.
Giles, A. R., Bauer, M. E. E., & Darroch, F. E. (2019). Risky statement? https​://doi.org/10.1007/s1080​2-018-0495-6.
A critique of the position statement on active outdoor play. World Hudson, J. L., & Rapee, R. M. (2004). From anxious temperament to
Leisure Journal, 61(1), 58–66. https​://doi.org/10.1080/16078​ disorder: An etiological model. In R. G. Heimberg, C. L. Turk,
055.2018.15495​90. & D. S. Mennin (Eds.), Generalised anxiety disorder: Advances
Gill, T. (2007). No gear. Growing up in a risk averse society. Lisbon: in research and practice (pp. 51–74). New York: The Guildford
Calouste Gulbenkian Foundation. Press.
Gill, T. (2014). The benefits of children’s engagement with nature: A Kafry, D. (1982). Sensation seeking of young-children. Personality and
systematic literature review. Children, Youth and Environments, Individual Differences, 3, 161–166. https:​ //doi.org/10.1016/0191-
24(2), 10–34. https​://doi.org/10.7721/chily​outen​vi.24.2.0010. 8869(82)90030​-7.
Gill, T. (2018). Playing it Safe? A global white paper on risk, liability Kagan, J., Reznick, J. S., Clarke, C., Snidman, N., & Garcia-Coll, C.
and children’s play in public space. https​://timrg​ill.files​.wordp​ (1984). Behavioral inhibition to the unfamiliar. Child Develop-
ress.com/2018/05/bvlf-playi​ngits​afe-04.pdf. ment, 55, 2212–2225. https​://doi.org/10.2307/11297​93.
Gray, P. (2011). The decline of play and the rise of psychopathology Kagan, J., Reznick, J. S., Snidman, N., Gibbons, J., & Johnson, M. O.
in children and adolescents. American Journal of Play, 3(4), (1988). Childhood derivatives of inhibition and lack of inhibition
443–463. to the unfamiliar. Child Development, 59, 1580–1589. https:​ //doi.
Gray, P. (2013). Free to learn. New York: Basic Books. org/10.2307/11306​72.
Green, J. (1997). Risk and the construction of social identity: Chil- Kaplan, R., & Kaplan, S. (1989). The experience of nature: A psycho-
dren’s talk about accidents. Sociology of Health & Illness, 19(4), logical perspective. New York, NY: Cambridge University Press.
457–479. https​://doi.org/10.1111/j.1467-9566.1997.tb004​13.x. Kaplan, S. (1995). The restorative benefits of nature: Toward an inte-
Green, J., & Hart, L. (1998). Children’s views of accident risks and pre- grative framework. Journal of Environmental Psychology, 15,
vention: A qualitative study. Injury Prevention, 4, 14–21. https:​ // 169–182. https​://doi.org/10.1016/0272-4944(95)90001​-2.
doi.org/10.1136/ip.4.1.14. Kellert, S. R. (2002). Experiencing nature: Affective, cognitive, and
Haas, M., Hiemisch, A., Vogel, M., Wagner, O., Kiess, W., & Poulain, evaluative development in children. In P. H. Kahn Jr. & S. R. Kel-
T. (2019). Sensation seeking in 3- to 6-year-old children: Asso- lert (Eds.), Children and nature: Psychological, sociocultural,
ciations with socio-demographic parameters and behavioural

13

178 Clinical Child and Family Psychology Review (2021) 24:164–181

and evolutionary investigations (pp. 117–151). Cambridge: MIT disorders. European Child and Adolescent Psychiatry, 19, 143–
Press. 150. https​://doi.org/10.1007/s0078​7-009-0051-6.
Kelley, P., Hood, S., & Mayall, B. (1998). Children, parents and risk. Lester, S., Jones, O., & Russell, W. (2011). Supporting school improve-
Health & Social Care in the Community, 6(1), 16–24. https:​ //doi. ment through play: an evaluation of South Gloucestershire’s
org/10.1046/j.1365-2524.1998.00094​.x. Outdoor Play and Learning programme. Retrieved from: http://
Kendall, P. C. (1994). Treating anxiety disorders in children: outdo​orpla​yandl​earni​ng.org.uk/wp-conte​nt/uploa​ds/2016/07/
Results of a randomized clinical trial. Journal of Consult- suppo​rting​-schoo​l-impro​vemen​t-throu​gh-play-1.pdf.
ing and Clinical Psychology, 62, 100–110. https ​ : //doi. Lester, S., & Russell, W. (2010). Children’s right to play: An examina-
org/10.1037/0022-006X.62.1.100. tion of the importance of play in the lives of children worldwide.
Kendall, P. (2011). Guiding theory for therapy. Child and adolescent The Hague, the Netherlands: Bernard van Leer Foundation.
therapy cognitive-behavioural procedures. New York: Guilford Lillard, A. S., Lerner, M. D., Hopkins, E. J., Dore, R. A., Smith, E.
Press. D., & Palmquist, C. M. (2013). The impact of pretend play on
Kendall, P. C., Cummings, C. M., Villabø, M. A., Narayanan, M. K., children’s development: A review of the evidence. Psychological
Treadwell, K., Birmaher, B., et al. (2016). Mediators of change in Bulletin, 139(1), 1–34. https​://doi.org/10.1037/a0029​321.
the child/adolescent anxiety multimodal treatment study. Journal Little, H. (2010). Relationship between parents’ beliefs and their
of Consulting and Clinical Psychology, 84(1), 1–14. https​://doi. responses to children’s risk-taking behaviour during outdoor play.
org/10.1037/a0039​773. Journal of Early Childhood Research, 8(3), 315–330. https:​ //doi.
Kendall, P. C., Robin, J., Hedtke, K., Suveg, C., Flannery-Schroeder, org/10.1177/14767​18X10​36858​7.
E., & Gosch, E. (2005). Considering CBT with anxious youth? Little, H., & Eager, D. (2010). Risk, challenge and safety: Implica-
Think exposures. Cognitive and Behavioral Practice, 12, 136– tions for play quality and playground design. European Early
150. https​://doi.org/10.1016/S1077​-7229(05)80048​-3. Child Education Research Journal, 18, 497–513. https​://doi.
Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009). A selective org/10.1080/13502​93X.2010.52594​9.
intervention program for inhibited preschool-aged children of Little, H., Wyver, S., & Gibson, F. (2011). The influence of play con-
parents with an anxiety disorder: Effects on current anxiety text and adult attitudes on young children’s physical risk-taking
disorders and temperament. Journal of the American Academy during outdoor play. European Early Childhood Education
of Child & Adolescent Psychiatry, 48(6), 602–609. https​://doi. Research Journal, 19(1), 113–131. https:​ //doi.org/10.1080/13502​
org/10.1097/CHI.0b013​e3181​9f6fa​9. 93X.2011.54895​9.
Kessler, R. C., Berglund, P., Demier, O., Jin, R., Merikangas, K. R., Liu, E. M., & Zuo, S. X. (2019). Measuring the impact of interac-
& Walters, E. E. (2005). Lifetime prevalence and age-of-onset tion between children of a matrilineal and a patriarchal cul-
distributions of DSM-IV disorders in the National Comorbid- ture on gender differences in risk aversion. Proceedings of the
ity Survey Replication. Archives of General Psychiatry, 62, National Academy of Sciences, 116(14), 6713–6719. https​://doi.
593–602. https​://doi.org/10.1001/archp​syc.62.6.593. org/10.1073/pnas.18083​36116​.
Kleppe, R., Melhuish, E., & Sandseter, E. B. H. (2017). Identifying Loebach, J., & Gilliland, J. (2016). Neighbourhood play on the endan-
and characterizing risky play in the age one-to-three years. gered list: Examining patterns in children’s local activity and
European Early Childhood Education Research Journal, 25, mobility using GPS monitoring and qualitative GIS. Children’s
370–385. https​://doi.org/10.1080/13502​93X.2017.13081​63. Geographies, 14, 573–589. https ​ : //doi.org/10.1080/14733​
Kuczynski, L., Pitman, R., & Twigger, K. (2018). Flirting with 285.2016.11401​26.
resistance: Children’s expressions of autonomy during mid- Manassis, K., & Bradley, S. J. (1994). The development of child-
dle childhood. International Journal of Qualitative Studies hood anxiety disorders: Toward an integrated model. Journal of
on Health and Well-being. https​: //doi.org/10.1080/17482​ Applied Developmental Psychology, 15(3), 345–366. https​://doi.
631.2018.15645​19. org/10.1016/0193-3973(94)90037​-X.
Kyttä, M. (2004). The extent of children’s independent mobility and Marzi, I., & Reimers, A. K. (2018). Children’s independent mobility:
the number of actualized affordances as criteria for child-friendly Current knowledge, future directions, and public health impli-
environments. Journal of Environmental Psychology, 24, 179– cations. International Journal of Environmental Research and
198. https​://doi.org/10.1016/S0272​-4944(03)00073​-2. Public Health, 15, 2441. https:​ //doi.org/10.3390/ijerph​ 15112​ 441.
Lahat, A., Hong, M., & Fox, N. A. (2011). Behavioural inhibition: Is McGrew, W. C. (1972). An ethological study of children’s behaviour.
it a risk factor for anxiety? International Review of Psychiatry, London: Metheun.
23(3), 248–257. https:​ //doi.org/10.3109/095402​ 61.2011.590468​ . McLaughlin, K. A., & Hatzenbuehler, M. L. (2009). Stressful life
Lau, W. Y., Chan, C. K. Y., Li, J. C. H., & Au, T. K. F. (2010). Effec- events, anxiety sensitivity, and internalizing symptoms in adoles-
tiveness of group cognitive-behavioral treatment for childhood cents. Journal of Abnormal Psychology, 118(3), 659–669. https​
anxiety in community clinics. Behaviour Research and Therapy, ://doi.org/10.1037/a0016​499.
48(11), 1067–1077. https​://doi.org/10.1016/j.brat.2010.07.007. McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examining the
Lazarus, R. S., Dodd, H. F., Majdandžić, M., Vente, W., Morris, T., association between parenting and childhood anxiety: A meta-
Byrow, Y., et al. (2016). The relationship between challenging analysis. Clinical Psychology Review, 27(2), 155–172. https​://
parenting behaviour and childhood anxiety disorders. Journal doi.org/10.1016/j.cpr.2006.09.002.
of Affective Disorders, 190, 784–791. https​://doi.org/10.1016/j. McNally, R. J. (2002). Anxiety sensitivity and panic disorder. Bio-
jad.2015.11.032. logical Psychiatry, 52, 938–946. https​://doi.org/10.1016/S0006​
Lee, S. H., & Christiansen, M. (1999). The cognition of playground -3223(02)01475​-0.
safety and children’s play-A comparison of traditional, contem- Miller, D. C., & Byrnes, J. P. (1997). The role of contextual and per-
porary, and naturalized playground types. In S. Lee (Ed.), Pro- sonal factors in children’s risk taking. Developmental Psychol-
ceedings of the International Conference of Playground Safety. ogy, 33, 814–823. https​://doi.org/10.1037/0012-1649.33.5.814.
Pennsylvania: Penn State University, Center for Hospitality, Milteer, R. M., Ginsburg, K. R., Council on Communications and
Tourism & Recreation Research. Media Committee on Psychosocial Aspects of Child and Fam-
Legerstee, J. S., Garnefski, N., Jellesma, F. C., Verhulst, F. C., & Utens, ily Health, & Mulligan, D. A. (2012). The importance of play
E. M. W. J. (2010). Cognitive coping and childhood anxiety in promoting healthy child development and maintaining strong

13
Clinical Child and Family Psychology Review (2021) 24:164–181 179

parent-child bond: Focus on children in poverty. Pediatrics, anxiety sensitivity: A randomized controlled trial. Journal of
129(1), e204–e213. https​://doi.org/10.1542/peds.2011-2953. Consulting and Clinical Psychology, 82(6), 1005–1022. https​://
Morongiello, B. A., & Dawber, T. (2000). Mothers’ responses to doi.org/10.1037/a0037​027.
sons and daughters engaging in injury-risk behaviors on a play- Osmanağaoğlu, N., Creswell, C., & Dodd, H. F. (2018). Intolerance of
ground: Implications for sex differences in injury rates. Journal Uncertainty, anxiety, and worry in children and adolescents: A
of Experimental Child Psychology, 76(2), 89–103. https​://doi. meta-analysis. Journal of Affective Disorders, 225, 80–90. https​
org/10.1006/jecp.2000.2572. ://doi.org/10.1016/j.jad.2017.07.035.
Morrongiello, B. A., & Lasenby-Lessard, J. (2007). Psychological Panksepp, J. (2001). The long term psychobiological consequences
determinants of risk taking by children: An integrative model and of infant emotions: Prescriptions for the twenty-first cen-
implications for interventions. Injury Prevention, 13(1), 20–25. tury. Infant Mental Health Journal, 22, 132–173. https​://doi.
https​://doi.org/10.1136/ip.2005.01129​6. org/10.1002/1097-0355(20010​1/04)22:1%3c132​::AID-IMHJ5​
Morrongiello, B. A., McArthur, B. A., Kane, A., & Fleury, R. (2013). %3e3.0.CO;2-9.
Only kids who are fools would do that!: Peer social norms influ- Peden, M., Oyegbite, K., Ozanne-Smith, J., Hyder, A.A., Branche, C.,
ence children’s risk-taking decisions. Journal of Pediatric Psy- Rahman, A.K.M.F, Rivara, F., & Bartolomeos. (2008). World
chology, 38, 744–755. https​://doi.org/10.1093/jpeps​y/jst01​9. report on child injury prevention. World Health Organisation.
Morrongiello, B. A., Ondejko, L., & Littlejohn, A. (2004). Understand- Retrieved from November 5, 2020 https​://www.who.int/viole​
ing toddlers’ in-home injuries: I. Context, correlates, and deter- nce_injur​y_preve​ntion​/child​/injur​y/world​_repor​t/en/.
minants. Journal of Pediatric Psychology, 29, 415–431. https​:// Pellegrini, A. D. (2009). The role of play in human development.
doi.org/10.1093/jpeps​y/jsh04​6. Oxford: Oxford University Press.
Morrongiello, B. A., Sandomierski, M., & Valla, J. (2010). Early iden- Pelligrini, A. D., Dupuis, D., & Smith, P. K. (2007). Play in evolution
tification of children at risk of unintentional injury: A sensation and development. Developmental Review, 27, 261–276. https​://
seeking scale for children 2–5 years of age. Accident Analy- doi.org/10.1016/j.dr.2006.09.001.
sis and Prevention, 42, 1332–1337. https​://doi.org/10.1016/j. Pellis, V., & Pellis, V. (2009). The playful brain: Venturing to the limits
aap.2010.02.014. of neuroscience. Oxford, UK: Oneworld.
Morrongiello, B. A., & Sedore, L. (2005). The influence of child Poulton, R., Davies, S., Menzies, R. G., Langley, J. D., & Silva, P. A.
attributes and social-situational context on school-age chil- (1998). Evidence for a non-associative model of the acquisition
dren’s risk taking behaviors that can lead to injury. Journal of of a fear of heights. Behaviour Research and Therapy, 36(5),
Applied Developmental Psychology, 26, 347–361. https​://doi. 537–544. https​://doi.org/10.1016/S0005​-7967(97)10037​-7.
org/10.1016/j.appde​v.2005.02.003. Poulton, R., Milne, B. J., Craske, M. G., & Menzies, R. G. (2001). A
Muris, P., & Field, A. P. (2010). The role of verbal threat information longitudinal study of the etiology of separation anxiety. Behav-
in the development of childhood fear. “Beware the Jabberwock!” iour Research and Therapy, 39(12), 1395–1410. https​://doi.
Clinical Child and Family Psychology Review, 13(2), 129–150. org/10.1016/S0005​-7967(00)00105​-4.
https​://doi.org/10.1007/s1056​7-010-0064-1. Povinelli, D. J., & Cant, J. G. H. (1995). Arboreal clambering and the
Mygind, L., Kjeldsted, E., Hartmeyer, R., Mygind, E., Bolling, M., & evolution of self-conception. Quarterly Review of Biology, 70,
Bentsen, P. (2019). Mental, physical and social health benefits 393–421. https​://doi.org/10.1086/41917​0.
of immersive nature-experience for children and adolescents: Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney,
A systematic review and quality assessment of the evidence. L. (2005). Prevention and early intervention of anxiety dis-
Health and Place, 58, 102136. https​://doi.org/10.1016/j.healt​ orders in inhibited preschool children. Journal of Consult-
hplac​e.2019.05.014. ing and Clinical Psychology, 73(3), 488–497. https​: //doi.
Nauta, J., Martin-Diener, E., Martin, B. W., van Mechelen, W., & Ver- org/10.1037/0022-006x.73.3.488.
hagen, E. (2015). Injury risk during different physical activity Reimers, A. K., Schoeppe, S., Demetriou, Y., & Knapp, G. (2018).
behaviours in children: A systematic review with bias assess- Physical activity and outdoor play of children in public play-
ment. Sports Medicine, 45, 327–336. https​://doi.org/10.1007/ grounds-do gender and social environment matter? International
s4027​9-014-0289-0. Journal of Environmental Research and Public Health, 15(7),
Nieheus, A. N., Bundy, A., Broom, A., Tranter, P., Ragen, J., & Enge- 1356. https​://doi.org/10.3390/ijerp​h1507​1356.
len, L. (2013). Everyday uncertainties: Reframing perceptions of Remes, O., Brayne, C., van der Linde, R., & Lafortune, L. (2016). A
risk in outdoor free play. Journal of Adventure Education & Out- systematic review of reviews on the prevalence of anxiety dis-
door Learning, 13(3), 223–237. https​://doi.org/10.1080/14729​ orders in adult populations. Brain and Behaviour, 6(7), e00497.
679.2013.79858​8. https​://doi.org/10.1002/brb3.497.
Noël, V. A., & Francis, S. E. (2011). A meta-analytic review of the role Robinson, J. L., Reznick, J. S., Kagan, J., & Corley, R. (1992). The
of child anxiety sensitivity in child anxiety. Journal of Abnormal heritability of inhibited and uninhibited behavior—A twin
Child Psychology, 39(5), 721–733. https:​ //doi.org/10.1007/s1080​ study. Developmental Psychology, 28, 1030–1037. https​://doi.
2-011-9489-3. org/10.1037/0012-1649.28.6.1030.
Oglesby, M. E., Boffa, J. W., Short, N. A., Raines, A. M., & Schmidt, Rodriguez-Ayllon, M., Cadenas-Sánchez, C., Estévez-López, F., et al.
N. B. (2016). Intolerance of uncertainty as a predictor of post- (2019). Role of physical activity and sedentary behavior in the
traumatic stress symptoms following a traumatic event. Journal mental health of preschoolers, children and adolescents: A sys-
of Anxiety Disorders, 41, 82–87. https​://doi.org/10.1016/j.janxd​ tematic review and meta-analysis. Sports Medicine, 49, 1383–
is.2016.01.005. 1410. https​://doi.org/10.1007/s4027​9-019-01099​-5.
Ollendick, T. H., Ryan, S. M., Capriola-Hall, N. N., Reuterskiöld, L., & Rosen, B. N., & Peterson, L. (1990). Gender differences in children’s
Öst, L. G. (2017). The mediating role of changes in harm beliefs outdoor play injuries: A review and an integration. Clinical Psy-
and coping efficacy in youth with specific phobias. Behaviour chology Review, 10, 187–205.
Research and Therapy, 99, 131–137. https​://doi.org/10.1016/j. Royal College of Paediatrics and Child Health and University College
brat.2017.10.007. London. (2013). Child Health Research UK—Clinical outcomes
Olthuis, J. V., Watt, M. C., Mackinnon, S. P., & Stewart, S. H. (2014). review programme. Overview of child deaths in four UK coun-
Telephone-delivered cognitive behavioral therapy for high tries. London: RPCPH.

13

180 Clinical Child and Family Psychology Review (2021) 24:164–181

Royal Society for the Prevention of Accidents. (n.d.). Accidents to Chil- Sensitivity Index-3. Psychological assessment, 19(2), 176–188.
dren. Retrieved from November 5, 2020 https​://www.rospa​.com/ https​://doi.org/10.1037/1040-3590.19.2.176.
home-safet​y/Advic​e/Accid​ents-to-Child​ren#cost. Tillman, S., Tobin, D., Avison, W., & Gilliland, J. (2018). Men-
Rudaz, M., Ledermann, T., Margraf, J., Becker, E. S., & Craske, M. G. tal health benefits of interactions with nature in children and
(2017). The moderating role of avoidance behavior on anxiety teenagers: A systematic review. Journal of Epidemiology and
over time: Is there a difference between social anxiety disorder Community Health, 72, 958–966. https​://doi.org/10.1136/jech-
and specific phobia? PLoS ONE, 12(7), e0180298. https​://doi. 2018-21043​6.
org/10.1371/journ​al.pone.01802​98. Towner, E., Therese, D., Errington, G., Burkes, M., & Towner, J.
Sandseter, E. B. (2007). Categorising risky play—How can we iden- (2005). Injuries in children aged 0–14 years and inequalities.
tify risk-taking in children’s play? European Early Childhood Health Development Agency, London. http://www.nice.org.uk/
Education Research Journal, 15(2), 237–252. https ​ : //doi. niceM​edia/pdf/injur​ies_in_child​ren_inequ​aliti​es.pdf.
org/10.1080/13502​93070​13217​33. Tremblay, M. S., Gray, C., Babcock, S., Barnes, J., Bradstreet, C. C.,
Sandseter, E. B. H. (2009). Risky play and risk management in Nor- Carr, D., ... & Herrington, S. (2015). Position statement on active
wegian preschools—A qualitative observational study. Safety outdoor play. International Journal of Environmental Research
Science Monitor, 13(1), 2. and Public Health, 12(6), 6475–6505. https​://doi.org/10.3390/
Sandseter, E., & Kennair, L. (2011). Children’s risky play from an ijerp​h1206​06475​
evolutionary perspective: The anti-phobic effects of thrilling Turner, S. M., Beidel, D. C., & Costello, A. (1987). Psychopathol-
experiences. Evolutionary Psychology, 9(2), 257–284. https​:// ogy in the offspring of anxiety disorders patients. Journal of
doi.org/10.1177/14747​04911​00900​212. Consulting and Clinical Psychology, 55(2), 229–235. https:​ //doi.
Sandseter, E. B. H., Kleppe, R., & Sando, O. J. (2020). The prevalence org/10.1037/0022-006X.55.2.229.
of risky play in young children’s indoor and outdoor free play. Ulrich, R. S., Simons, R. F., Losito, B. D., Fiorito, E., Miles, M. A.,
Early Childhood Education Journal. https​://doi.org/10.1007/ & Zelson, M. (1991). Stress recovery during exposure to natural
s1064​3-020-01074​-0. and urban environments. Journal of Environmental Psychology,
Sandstrom, A., Uher, R., & Pavlova, B. (2020). Prospective association 11(3), 201–230. https​://doi.org/10.1016/S0272​-4944(05)80184​
between childhood behavioral inhibition and anxiety: A meta- -7.
analysis. Journal of Abnormal Child Psychology, 48, 57–66. Valentine, G., & McKendrick, J. (1997). Children’s outdoor play:
https​://doi.org/10.1007/s1080​2-019-00588​-5. Exploring parental concerns about children’s safety and the
Schmidt, N. B., Zvolensky, M. J., & Maner, J. K. (2006). Anxiety changing nature of childhood. Geoforum, 28, 219–235. https​://
sensitivity: Prospective prediction of panic attacks and Axis I doi.org/10.1016/S0016​-7185(97)00010​-9.
pathology. Journal of Psychiatric Research, 40(8), 691–699. van der Bruggen, C. O., Stams, G. J. J. M., & Bögels, S. M. (2008).
https​://doi.org/10.1016/j.jpsyc​hires​.2006.07.009. Research review: The relation between child and parent anxiety
Sewell, A. (2013). Snowball fights banned in some Belgian communi- and parental control: A meta-analytic review. The Journal of
ties. Digital Journal. Retrieved from: http://www.digit​aljou​rnal. Child Psychology and Psychiatry, 49(12), 1257–1269. https​://
com/. doi.org/10.1111/j.1469-7610.2008.01898​.x.
Shanon, A., Bashaw, B., Lewis, J., & Feldman, W. (1992). Nonfatal Van der Heiden, C., Muris, P., & van der Molen, H. T. (2012). Ran-
childhood injuries: A survey at the Children’s Hospital of east- domized controlled trial on the effectiveness of metacognitive
ern Ontario. Canadian Medical Association Journal, 146(3), therapy and intolerance-of-uncertainty therapy for generalized
361–365. anxiety disorder. Behaviour Research and Therapy, 50, 100–109.
Sherman, J. A., Braun, D. A., & Ehrenreich-May, J. (2019). Anxiety https​://doi.org/10.1016/j.brat.2011.12.005.
sensitivity treatment for children and adolescents. In M. Otto, M. Van Dijk-Wesselius, J. E., Maas, J., Hoving, D., van Vugt, M., & van
Powers, S. Baird, & J. A. J. Smits (Eds.), The clinician’s guide den Berg, A. E. (2018). The impact of greening schoolyards
to anxiety sensitivity treatment and assessment (pp. 121–144). on the appreciation, and physical, cognitive and social-emo-
Cambridge: Academic Press. tional well-being of schoolchildren: A prospective intervention
Silverman, W. K., Fleisig, W., Rabian, B., & Peterson, R. A. (1991). study. Landscape and Urban Planning, 180, 15–26. https​://doi.
Childhood anxiety sensitivity index. Journal of Clinical Child org/10.1016/j.landu​rbpla​n.2018.08.003.
and Adolescent Psycholology, 20, 162–168. Vasey, M. W., & Dadds, M. R. (Eds.). (2001). The developmental psy-
Smith, P. K., & Connolly, K. (1980). The ecology of preschool behav- chopathology of anxiety. Oxford: Oxford University Press.
iour. London: Cambridge University Press. Waters, A. M., Wharton, T. A., Zimmer-Gembeck, M. J., & Craske,
Smits, J. A., Berry, A. C., Tart, C. D., & Powers, M. B. (2008). The M. G. (2008). Threat-based cognitive biases in anxious children:
efficacy of cognitive-behavioral interventions for reducing anxi- Comparison with non-anxious children before and after cognitive
ety sensitivity: A meta-analytic review. Behaviour Research behavioural treatment. Behaviour Research and Therapy, 46(3),
and Therapy, 46(9), 1047–1054. https​: //doi.org/10.1016/j. 358–374. https​://doi.org/10.1016/j.brat.2008.01.002.
brat.2008.06.010. Weikart, D. P. (1998). Changing early childhood development through
Spinka, M., Newberry, R. C., & Bekoff, M. (2001). Mammalian play: educational intervention. Preventative Medicine, 27(2), 233–237.
Can training for the unexpected be fun? Quarterly Review of https​://doi.org/10.1006/pmed.1998.0280.
Biology, 76, 141–168. https​://doi.org/10.1086/39386​6. Whitebread, D., Basilio, M., Kuvalja, M., & Verma, M. (2012).
Stuijfzand, S., Creswell, C., Field, A. P., Pearcey, S., & Dodd, H. The importance of play. Brussels: Toy Industries of Europe.
(2018). Research Review: Is anxiety associated with negative Retrieved from 25 July 2020 https:​ //www.waldor​ f-resour​ ces.org/
interpretations of ambiguity in children and adolescents? A sys- filea​dmin/files​/pictu​res/Early​_Child​hood/dr_david​_white​bread​
tematic review and meta-analysis. Journal of Child Psychology _-_the_impor​tance​_of_play.pdf.
and Psychiatry, and Allied Disciplines, 59(11), 1127–1142. https​ Whiteside, S. P. H., Ollendick, T. H., & Biggs, B. K. (2020). Expo-
://doi.org/10.1111/jcpp.12822​. sure therapy for child and adolescent anxiety and OCD. Oxford:
Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. Oxford University Press.
G., Ledley, D. R., et al. (2007). Robust dimensions of anxiety Zhu, X., Haegele, A., & Healy, S. (2019). Movement and mental health:
sensitivity: Development and initial validation of the Anxiety Behavioral correlates of anxiety and depression among children

13
Clinical Child and Family Psychology Review (2021) 24:164–181 181

of 6–17 years old in the U.S. Mental Health and Physical Activ-
ity, 16, 60–65. https​://doi.org/10.1016/j.mhpa.2019.04.002.
Zuckerman, M. (1994). Behavioral expressions and biosocial bases
of sensation seeking. Cambridge: Cambridge University Press.

Publisher’s Note Springer Nature remains neutral with regard to

jurisdictional claims in published maps and institutional affiliations.

13