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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
Risk and protective factors among preschool children for future psychosocial problems
– What we know from research and how it can be used in practice
Anna-Karin Andershed
Örebro University
Henrik Andershed
Örebro University
David P. Farrington
University of Cambridge
Contact: Dr. Anna-Karin Andershed, Örebro University. E-mail: annakarin.andershed@oru.se
Summary
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
Despite extensive knowledge from research telling us which traits, behaviors, relations and
circumstances that increases (risk factors) and decreases (protective factors) the risk for long
lasting problems, the actual practical use of this knowledge by professionals working with
children seems very limited. The purpose of this paper is twofold: 1) To review previous
reviews and meta-analyses in order to identify from empirical research risk and protective
factors in preschool age (up to age six) for psychosocial problems, specifically externalizing
and internalizing problems. 2) To discuss how risk and protective factors can be used by
professionals working with children and their families in the framework of concepts such as
evidence based practice, risk focused prevention and treatment, and the Risk, Need, and
Responsivity principles. The review shows that quite many risk and protective factors that are
potentially changeable and thus practically meaningful have been identified via empirical
research. It is concluded that there is an extensive amount of research on risk and protective
factors in preschool age but that this knowledge is not complete or perfect. However, this
extensive amount of research make up the best available evidence and it should be used by
well trained professionals so that they can work in an evidence based way to help more
children to a better life.
How to refer to this paper:
Andershed, A-K., Andershed, H., & Farrington, D. P. (2012). Risk and protective factors
among preschool children for future psychosocial problems. – What we know from research
and how it can be used in practice. Report written on the commission of the Nordic Welfare
Center.
Introduction
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
What happens in the lives of young children can influence their future development,
health and well-being throughout the life span. We now from research that many of the
psychosocial problems of adolescence and adulthood are associated with risk and protective
factors that are evident much earlier in life, in the preschool years. Despite this knowledge
from research telling us which traits, behaviors, relations and circumstances that increases
(risk factors) and decreases (protective factors) the risk for long lasting psychosocial
problems, the actual practical use in health care, preschool, social work, and psychiatry of the
research based knowledge concerning risk and protection has thus far been very limited. The
purpose of this paper is twofold: 1) To review previous reviews and meta-analyses in order to
identify from empirical research risk and protective factors in preschool age (up to age six) for
psychosocial problems, specifically externalizing and internalizing problems. 2) To discuss
how risk and protective factors can be used by professionals working with children and their
families in the framework of concepts such as evidence based practice, risk focused
prevention and treatment, and the Risk, Need, and Responsivity principles.
The Importance of Focusing Externalizing and Internalizing Problems
Two of the most common forms of mental health problems in youths are externalizing
problems, here defined as disruptive, oppositional, defiant, aggressive, and criminal behavior
and substance using/abusing behavior and internalizing problems, here defined as anxious and
depressive symptoms or behaviors. This is the case in many western countries (American
Psychiatric Association, 2000; Kopp & Gillberg, 2003). Both of these problems are associated
with a range of negative outcomes in adulthood. They not only predict future externalizing
and internalizing problems, but also substance abuse and dependence, psychiatric illnesses,
and various types of other psychosocial problems (e.g., Kim-Cohen et al., 2003; Murray &
Farrington, 2010; Rutter et al., 2006). Hence, it is important to identify the risk and protective
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
factors for these psychosocial problems in research and then to use this knowledge in practice
with children and their families. Furthermore, it is important to underscore that studies show
that it is very common among adults with externalizing problems (e.g., criminal behavior) to
also exhibit other problems, for example substance abuse and mental health problems (Moffitt
et al., 2001; Wångby et al., 1999). A Swedish study, for example, of about 500 young adult
women showed that it is statistically typical (significantly more commonly observed than
what would be expected by chance) to simultaneously exhibit criminal behavior, substance
abuse, and mental health problems (Wångby et al., 1999). The same study showed that it in
fact is extremely uncommon (i.e., anti-typical – less commonly observed than expected by
chance) to exhibit criminality only, (i.e., without substance abuse and mental health problems)
in young adulthood (Wångby et al., 1999). The implication of this is that the factors
considered as risk factors externalizing problems can often tend to be risk factors for other
psychosocial problems as well.
What are Risk and Protective Factors?
A risk factor is something, for example a characteristic, relationship, trait, behavior,
event or circumstance that increases the probability for a certain outcome. When researchers
label something as a risk factor, this usually means that there is a statistical relationship
between the factor and the outcome, showing that the two can be observed to exist at the same
time or change in a parallel fashion. A limitation of most risk factor research is that we cannot
be sure whether the risk factor will cause the outcome or vice versa. Thus, we cannot be sure
based on research that an identified risk factor is a cause of externalizing or internalizing
problems. We can usually only tell that the factor and the outcome in some way co-vary or are
correlated. A statistically significant association may indicate that the risk factor and the
outcome indeed are dependent of each other, but, in fact, the risk factor and the outcome may
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
also be related to each other because they both are caused by a third factor and actually are
not at all causally related to each other.
A protective factor is something, for example a characteristic, relationship, trait,
behavior, event or circumstance that decreases the probability for a certain outcome in the
presence of risk. Thus, the presence of one or several protective factors can make the child
more resilient against risk factors, i.e., can make it possible for the individual to develop well
despite the presence of risks. Many, perhaps most children are likely to experience at least one
risk factor during development. Children growing up in adverse environments will experience
many risk factors. Thus, strengthening and maximizing protective factors in children is a very
important task both for parents and professionals working with children. One can also talk
about promotive factors, which are usually defined as factors being associated with positive
development regardless of the level of risk of the child. In this paper, the focus will be on
protective rather than promotive factors.
Risk and Protective Factors May Exist in Many Layers
To understand the development of behaviors in general, a perspective that encompasses
the individual in his or her context is necessary. The holistic-interactionistic perspective
provides such a point of view (see e.g., Stattin & Magnusson, 1996). It implies that behavior
develops through continuous interactions between the individual and his or her social
environment. Hence, characteristics, experiences and conditions of the individual, as well as
circumstances and conditions of the environment need to be considered when we want to
explain the development of psychosocial problems. This can be illustrated via a model such as
the one presented in Figure 1, which shows the different levels /layers in which risk and
protective factors potentially can be found affecting the development of externalizing and
internalizing problems. The arrows show that factors on different levels can affect each other
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
(e.g., that the child can affect the family/care-givers and that the care-givers in turn can affect
the child, etc.).
Figure 1. An ecological model of reciprocal effects between levels or layers in which risk and
protective factors can exist.
Different types of risk and protective factors
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
There are several ways of categorizing risk- and protective factors and these ways of
categorizing can have practical implications. First of all, there are factors that are changeable
(dynamic) and factors that cannot be changed (static). Dynamic factors such as certain
behaviors of the child or certain relationship qualities, can be affected via interventions
whereas static factors such as gender or ethnicity cannot. Second, there are direct (proximal)
and indirect (distal) factors. Direct factors are more directly and causally related to the
outcome (here defined as externalizing or internalizing problems), while indirect factors are
more likely to be related to the outcome through their relation to the direct factors. For
example, a child’s problems with disinhibition could be directly related to a child’s
externalizing behavior problems, while young motherhood probably is more indirectly related
to the child’s problem behavior through its potential relation to problems with parenting
skills, low education, low socioeconomic status, single motherhood, etcetera. Third, there are
initiating and maintaining factors, where the initiating factors can cause the first appearance
of externalizing or internalizing problems, while the maintaining factors make the behavior
continue over time. These factors can be, but are not necessarily always the same. For
example, shop lifting can be initiated as a consequence of peer pressure, but maintained
through individual needs of thrill seeking activities.
The first purpose of the present paper is to review previous reviews and meta-analyses
in order to identify from empirical research risk and protective factors in preschool age (up to
age six) for psychosocial problems, specifically externalizing and internalizing problems. The
second purpose is to discuss how risk and protective factors can be used by professionals
working with children and their families in the framework of concepts such as evidence based
practice, risk focused prevention and treatment, and the Risk, Need, and Responsivity
principles.
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
Method
The present review of risk and protective factors for externalizing and internalizing
problems is a review of previous reviews (i.e., narrative compilations, systematic reviews, or
meta-analyses). A number of concepts have been used in these publications to describe
externalizing problems: Delinquency, antisocial behavior, offending, arrests, convictions,
police contacts, aggression, alcohol use/abuse, conduct disorder oppositional behaviors,
disruptive behavior disorder, comorbid ADHD and conduct problems. A number of concepts
have been used in these publications to describe internalizing problems: Anxiety, anxiety
disorders, depression, mood disorder, poor psychiatric adjustment, internalizing problems. We
have included clinical (diagnosis) as well as subclinical levels of these problems in our
review.
The main literature searches were conducted in PsycINFO, the Campbell Collaboration and
Cochrane Collaboration libraries, Biological Abstracts and Medline looking for papers classified as
literature reviews, systematic reviews, or meta-analyses published from 1990 an onward. To be as
inclusive as possible in this first stage, the search terms were built on overarching and common
descriptions, rather than specific concepts and narrow syndromes. Consequently, the terms internaliz*,
externaliz*, conduct*, crim*, antisocial*, delinquen*, depress*, or anxi* were included to capture
potential outcomes, in combination with the terms risk*, protect*, or resilien* to capture the area of
research, and child* or preschool* to capture research on children in the target age period. The terms
were not restricted to titles or keywords, but could be present anywhere in the database records.
However, we added the restriction that the papers had to be classified either as reviews or metaanalyses, and be written in English. Based on title information, the records were more closely
scrutinized, and the potentially relevant titles were retrieved in full text. Additional papers were added
through suggestions from participants of a reference group of researchers in the field.
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
We have included recent literature reviews, published since 2006, and meta-analyses
(no time limit) focusing on prospective, longitudinal research (follow up periods > 2 years) on
risk and protective factors among children up to age 6 for long-lasting psychosocial problems,
with a specific focus on externalizing and internalizing problems. The research presented here
is based exclusively on empirical quantitative scientific studies of risk and protective factors.
We also use individual, original empirical studies when necessary, to exemplify certain
important points (e.g., showing that several risk factors are worse than a few).
It should be noted that studies specifically studying or separating out children in this
particular age group are not very common, especially in comparison to research on older
children and adolescents. Actually, the primary reason for exclusion of papers that were
relevant in topic, was the sample used or the way information was presented. Mostly, samples
included older children or the papers did not differentiate between children of different ages
making it impossible to determine whether a certain risk- or protective factor could be
considered valid for the preschool population or not. Most studies are initiated when children
are starting to be able to self-report on their feelings, thoughts and behaviors through
questionnaire responses – usually at school age (approx. age 7 or later). In addition, as
research is being compiled in reviews or meta-analyses, there is often a lack of differentiation
between children of different ages. Associations between risks and outcomes for preschoolers
are rather rarely kept separate from similar associations for older children. For example, a
common distinction is that of childhood, which usually encompasses all children up to the age
of 12. In this review, such studies, when the preschool population has not been separated out
from children of other ages, have not been included.
A second common reason for excluding a review or meta-analysis from our review was
the lack of prospective analyses, or lack of possibilities to disentangle cross sectional from
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
longitudinal research due to insufficient presentation of data. We required a minimum follow
up time of 2 years, since the scope of our review was to describe research on risk and
protective factors that are related to future psychosocial problems. The entire search
procedure resulted in that 31 reviews or meta-analyses that met our criteria were included in
the present review.
Results
Which are the Risk and Protective Factors Among Preschool Children?
Table 1 displays the risk and protective factors identified in our present review of
previous reviews and meta-analyses. Important to note is that the table in no way rank the risk
and protective factors. This was not possible to do. Thus, Table 1 is merely a list of risk and
protective factors that have been shown to significantly be associated with future
externalizing or internalizing problems.
What is clear from Table 1 is that quite many factors have been identified as risk and
protective factors in the preschool years, and that the factors exists primarily in the child and
the closest social environment, e.g., in the family and among peers. Clear is also that many
but not all identified factors seem practically useful in that they seem to be potentially
dynamic/changeable. Moreover, an important finding to highlight is that the opposite side of a
risk factor is not always a protective factor. This is clear in the results because we do not
identify with the included reviews and meta-analyses, the same amount of protective factors
as risk factors.
Table 1. Risk and Protective Factors among Children up to 6 Years of Age for Future
Externalizing and Internalizing Problems.
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
●
●
●
●
●
●
●
Adulthood
Adulthood
●
●
●
Risk factors in
preschool age for
internalizing
problems in:b
Childhood/
Adolescence
Risk factors
Adoptee2, 30
Sleep problems, malnutrition19, 31
Cognitive factors10, 20, 21, 22, 29
Neurological abnormalities, low verbal and performance IQ, low
IQ, low cognitive ability
Conduct problems 14, 22, 23, 29
Externalizing problems, behavior problems, conduct disorder,
oppositional behaviors, disruptive behavior disorder
ADHD-symptoms 20, 22, 28, 29, 31 Hyperactivity, attention problems,
impulsivity, restlessness, poor motor coordination, delayed motor
development
Temperamental factors20, 22, 29, 31 Difficult temperament,
irritability, disinhibition, undercontrol, aggression, sensation
seeking, fearlessness, low harm avoidance
Early behavioral inhibition, Oppositional defiant disorder3, 6, 8,
Childhood/
Adolescence
Risk factors in
preschool age for
externalizing
problems in:a
●
●
●
12
Internalizing problems, depression22, 25, 29
Marital conflict, home discord, family stress7, 22
Abuse and neglect1, 7, 10, 11, 14, 16, 19, 22, 29 Maltreatment, neglect,
physical punishment, physical abuse, family violence, witnessing
violence
Demographic factors7, 10, 14, 21, 22, 29
Family structure, large family size, young motherhood, marital
disruption, early broken home, single parenthood, parental
separation, foster care
Socioeconomic factors10, 21, 22, 27, 29
Low SES, low income, overcrowding, social dependency
Parents’ characteristics and behaviors
Mothers’ low IQ, parents’ low education7, 22
Mothers’ alcohol use, parents’ alcoholism, parents’ criminality7,
●
●
●
●
●
●
●
●
●
●
●
●
●
22, 31
Mothers’ depression, parents’ psychopathology6, 7
●
●
Parent-child relationship factors4, 6, 7, 8, 26, 13, 15, 19, 22, 24, 31
●
●
●
Poor parenting, deviant parent-child interaction, coercive
interactions, insecure attachment, poor monitoring/supervision,
low involvement, mothers’ negative control, low affect, low
responsiveness, rejection, low warmth
Protective factors
Child factors5, 9, 10, 15, 17, 18, 27
Effective self-regulation, emotion regulation, easy temperament, high IQ
Parent-child relationship factors4, 5, 9, 15, 17, 18, 27
Parental acceptance and responsivity, warmth, secure attachment, positive family relationships, few infantcaregiver separations
Environmental factors27
Physical aspects of caregiving environment (safety, stimulation)
a
e.g., Delinquency, antisocial behavior, offending, arrests, convictions, police contacts, aggression, alcohol
use/abuse, conduct disorder oppositional behaviors, disruptive behavior disorder, comorbid ADHD and
conduct problems,
b
e.g., Anxiety, anxiety disorders, depression, mood disorder, poor psychiatric adjustment, internalizing problems
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The number given at the risk and protective factors in the table means that the corresponding review has shown
that this factor is a risk or protective factor.
1
Bedi & Goddard, 2007; 2Bimmel et al., 2003; 3Boylan et al., 2007; 4Brumariu & Kerns, 2010 ; 5Condly, 2006; 6Degnan et
al., 2010; 7Derzon, 2010; 8Epkins & Heckler, 2011; 9Eriksson et al., 2011; 10Farrington et al., in press; 11Gewirtz & Edleson,
2007; 12Kertz & Woodruff-Borden, 2011; 13Kroneman et al., 2009; 14Leschied et al., 2008; 15Luthar, 2006; 16Maas et al.,
2008; 17Masten & Obradović, 2008; 18Masten & Wright, 2010; 19Mendes et al., 2009; 20Moffitt, 2006; 21Murray &
Farrington, 2010; 22Murray et al., 2010; 23Petitclerc & Tremblay, 2009; 24Rothbaum & Weisz, 1994; 25Tandon et al., 2009;
26
van IJzendoorn et al., 1999; 27Vanderbilt-Adriance & Shaw, 2008 ; 28Waschbusch, 2002; 29Welsh & Farrington, 2007;
30
Wierzbicki, 1993; 31Zucker et al., 2008
Several Perhaps Many Risk Factors of Limited Predictive Value Before Age 3
An important observation we make via some of the reviews and their included
longitudinal studies is that predictions are difficult from observations and assessments of very
young children, below 2-3 years of age (Moffitt, 2003; Rutter et al., 2006) and the predictions
become increasingly reliable with age (Leschied et al., 2008; Rothbaum & Weisz, 1994). For
example, behavior problems assessed before the child’s age of 3 are less enduring than when
assessments are made between ages 3 to 6 (Cai, 2004). Thus, this indicates that one should be
careful in using these kinds of risk factors for risk assessment purposes before age 3.
Generalizability of the Risk and Protective Factors?
Most of the research included in the reviews summarized in Table 1 has been conducted
in the United States. There are, however, few reasons to believe that the underlying processes
connecting risk and protective factors to outcomes are substantially different between children
in different western countries. This is probably particularly true for risk and protective factors
on the individual- and family levels. Contextual factors, partly dependent on differences in
conditions applicable to for example availability of health care and social security systems,
may be more of subject to differences between countries.
Single Factors are Generally Weak but Some Risk And Protective Factors Seem
Stronger and More Important Than Others
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The single risk and protective factors in preschool children, identified in research and
shown in Table 1 are significantly (i.e., are not due to chance), but generally quite weakly
associated with a higher (risk factors) or lower (protective factors) risk for externalizing or
internalizing problems in adolescence and/or adulthood. It was not possible to calculate the
actual effect sizes for the protective factors. However, for risk factors, it is clear that the effect
sizes (when presented in the reviews or meta-analyses) are small for the majority of the single
factors (i.e., that most children exhibiting only one of these individual risk factors will have a
very good chance of not developing externalizing or internalizing problems in the future).
Very few studies have investigated the differential and unique effects of risk and
protective factors in preschool children. However, a British large-scale longitudinal study –
The 1970 British Cohort Study – did just this and followed about 16.000 preschool children
(assessment of risk factors at age 5) into early adolescence (age 10) and adulthood (age 30-34)
(Murray et al., 2010). Among the factors identified as risks (see Table 1) and assessed at age
5, conduct problems/externalizing problems was clearly the single most important risk factor
for conduct problems at age 10. Conduct problems at age 5 increased the risk about four times
for conduct problems at age 10. The other risk factors at age 5 increased the risk about 1.5-2.0
times for conduct problems at age 10. This was true among both boys and girls. In terms of
the risk for adult criminality, conduct problems did not stand out as much and all risk factors
including conduct problems increased the risk for adult criminality about equally much (1.52.0 times each) (Murray et al., 2010). Thus, in preschool age, conduct problems of the child
may be the single most important risk factor for adolescent problem behavior. Other risk
factors tend to be quite similar in their unique predictive power of long-lasting behavior
problems.
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The More Risk Factors the Higher the Risk and the More Protective Factors the Better
the Protection – The Cumulative/Additive Effects of Risk and Protective Factors
Both risk and protective factors tend to have cumulative effects according to research,
i.e., the more risk factors the higher the risk and the more protective factors the stronger the
protection (Appleyard et al., 2005; Eriksson et al., 2010; for a review of cumulative effects).
For example, in the 1970 British Cohort Study, with an increasing number of risk factors at
age 5, the more the children developed conduct problems in adolescence. Prevalences
increased from 2% and 5% (with 0 risk factors) to 38% and 54% (with 5 or more risk factors)
for girls and boys, respectively. In terms of predicting adult criminality, the tendency was the
same with the number of children developing adult criminality increasing from 3% and 17%
(with 0 risk factors) to 11% and 44% (with 3 or more risk factors) for girls and boys,
respectively (Murray et al., 2010). Similarly, average scores on the Child Behavior Checklist
(CBCL) externalizing and internalizing indices at ages 7 and 16 were found to increase with
accumulation of risk factors assessed at 4.5 years among the participants in a longitudinal
study of at-risk urban children (Appleyard et al., 2005).
Protective Factors Not Always the Opposite Sides of Risk Factors
A protective factor is, according to the definition used here, something that decreases the
probability for a certain outcome in the presence of risk. Thus, the presence of one or several
protective factors can make the child more resilient against risk factors, i.e., can make it
possible for the individual to develop well despite the presence of risks. When we define
protective factors in this way it is clear that the opposite sides of risk factors not always are
protective. This is clearly shown in the list of factors identified in the present review – see
Table 1. This is in fact an important conclusion because to our experience, a common opinion
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among professionals working with children is that the opposite side of risk always is
protective.
The Complexity and Heterogeneity of Risk and Protective factors
Research provides us with a rather extensive list of risk and protective factors as shown in
Table 1. A complexity and limitation of this research is that we based on research, as of yet,
do not know which of these factors that have causal relations to externalizing or internalizing
problems. We know that the identified risk and protective factors co-vary with higher and
lower risk respectively for future externalizing or internalizing problems. Co-variation
between a potential cause and the effect is necessary but not sufficient to conclude causality.
Furthermore, different risk and protective factors will apply in different ways to different
children, and the same factor can vary in importance between individual children. Two
processes, equifinality and multifinality, are of special importance to mention in this context.
Equifinality (Cicchetti & Rogosch, 1996) refers to the fact that a certain outcome can develop
through several different developmental pathways and have different causal backgrounds for
different children. Behaviors can have many different roots, and the patterns of the most
salient and important risk factors will vary between individuals. Thus, individuals developing
externalizing or internalizing problems will often do so with different risk factors.
Multifinality (Cicchetti & Rogosch, 1996) refers to the process through which the same risk
factors are associated with different outcomes. Hence, the same kinds of risk factors can lead
to different things.
More Similarities Than Differences Between Boys and Girls Concerning Risk and
Protective Factors
Even though boys are clearly overrepresented when it comes to externalizing problems, and
girls are overrepresented with internalizing problems, the same risk factors seem relevant
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
regardless of gender (see Moffitt et al., 2001. Neither are there any clear or strong indications
of that protective factors would be crucially different between boys and girls (Eriksson et al.,
2010). There are, however, indications that boys are often exposed to a higher number and
greater level of risk for externalizing problems than girls, even though the risks in and of
themselves are basically the same (see Moffitt et al., 2001). The practical implication of this is
that an assessment of risk and protective factors does not need to be different for boys and
girls.
Heritability and Upbringing and Risk and Protective factors
Several studies show that genetic as well as environmental factors are important for the
development of externalizing and internalizing problems (see e.g., Arseneault et al., 2003;
Eley et al., 2003; Kendler et al., 2006). One way of understanding this is that the genetic
makeup of the individual affects the early development of the nervous system of that
individual which makes up the disposition, vulnerability or sensitivity of the individual for
developing various genetically underbuilt risk factors. Several of the risk factors listed in
present article such as for example; hyperactivity, attention problems, restlessness, are at least
partly genetically underbuilt (e.g., Larsson et al., 2004). Important to note here is that these
partially genetically underbuilt risk factors can of course be intervened with effectively
although they are in part genetically underbuilt.
Discussion
The first purpose of this paper was to identify risk and protective factors in preschool age for
externalizing and internalizing problems. Our review of previous reviews and meta-analyses
of preschool risk and protective factors showed that quite many potentially changeable and
thus practically useful risk and protective factors have been identified via empirical research.
Because most reviews identified in the present review have focused on risk factors for
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
externalizing problems in adolescence or adulthood it is important reiterate that several,
perhaps many, of the identified risk factors also are risk factors for other problems as well,
such as substance use problems and other mental health problems (see e.g., Moffitt et al.,
2001; Wångby et al., 1999). A purpose of the present paper was also to discuss how this
knowledge of risk and protective factors can be used in social work practice with children and
their families. Therefore, we now move on to discuss some of the complexities and nuances of
risk and protective factors and then move on to discuss how this knowledge can be used in
practice.
Using Knowledge about Risk and Protective Factors in Practice – A Concrete Way of
Working Evidence Based
Evidence based practice concerns from which sources professionals gather information to
handle their roles as professional decision makers and important people in interventions. In
order to work in an evidence based manner, the professional must use the best available
evidence gathered from research when making decisions about how to approach and intervene
with the problems of children and their families. The professional must also integrate his or
her professional expertise and the perspective of the individual child and the family into their
decision making process (see Sackett et al., 1996). This integration of sources of knowledge
can be illustrated by the Evidence Based Practice triad presented in Figure 1.
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RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
Best
evidence
from
research
Professionals’
expertise
EBP
Childrens’ and
families’ expectations
and values
Figure 2. The Evidence Based Practice (EBP) -triad.
This review can be seen as a source of available evidence concerning risk and protective
factors in preschool age for externalizing and internalizing problems. This evidence, gained
through longitudinal empirical research concerning risk and protective factors, is however
based on groups of children. A risk factor is thus a factor that generally means a bit higher
risk for externalizing or internalizing problems. This means that many children exhibiting this
risk factor will never develop externalizing or internalizing problems. Here is where the
professional and his or her expertise and capability to analyze the risk and protective factors
in adequate ways comes in and becomes essential for the plan for interventions. The essential
analyses that the professional need to learn to master to carry out adequately are the ones that
deals with the extent a particular risk factor present in a specific case really is a crucial and
causal risk factors for that specific individual and whether the weak protective factor observed
has the potential to make the individual more resilient to risks.
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Risk-Focused Prevention and Treatment
A very concrete way of integrating the best available evidence into practice is to make
use of existing research on risk and protective factors in tailoring interventions. This can be
done within the framework of risk-focused prevention and treatment. A risk-focused approach
in prevention and treatment is based on the idea that modification of key risk factors for a
certain problem will decrease the problem. Similarly, strengthening key protective factors for
a certain problem will buffer against or modify the effects of risk for the problem (Farrington
& Welsh, 2007). The risk focused approach then basically builds on two steps: 1) Identify
children with risk factors and perhaps also with weak protective factors. Assess risk and
protective factors of the child and family in detail if possible. 2) Aim interventions to reduce
the risk factors and to strengthen the protective factors. Adhering to this approach is a very
hands-on way to link research, practice and policy making (Farrington et al., in press) that has
been considered by several governments as both plausible and practical (Farrington & Welsh,
2007).
Three Useful Guiding Principles in Risk Focused Prevention and Treatment – The Risk,
Need, and Responsivity Principles
When applying risk-focused prevention or treatment in practice, there are three guiding
principles that are very useful: the principles of Risk, Need, and Responsivity (e.g., Andrews
et al., 1990; Andrews & Bonta, 2006; Dowden & Andrews, 1999, 2002, 2003). Actually,
several meta-analyses have shown that the use of these principles will increase the possibility
for implementing effective interventions among children as well as adults (Andrews et al.,
1990; Dowden & Andrews, 1999, 2002, 2003; Lipsey, 2009).
The Risk principle implies that an intervention will be more effective if the most
intensive efforts are focused on children at high risk. Hence, the most ambitious and intensive
20
RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
interventions should be directed to children at high risk for future problems. As described
above, children with several risk factors are generally at higher risk than children with fewer
risk factors. The Need principle implies that interventions are more effective if they are
tailored to focus on the specific child’s most relevant needs, that is, the factors that explain or
cause the problems of the particular child at hand. The Responsivity principle says that
interventions need to be tailored, in terms of both content and delivery, to suit the abilities,
inclination, and motivations of the specific child and family. This principle says that the
professional must think about how the interventions should be planned and implemented so
that the child and the family respond to the intervention. Clearly, a reliable and valid
assessment of risk and protective factors is essential for professionals to conduct to be able to
work in accordance with these three important principles because one needs to know things
about risk and protective factors to be able to do a risk assessment (the Risk principle) and to
identify the needs of the child and the family (and follow the Need principle).
Structure is Important in Assessments
Thus, when working practically and concretely according to risk-focused prevention and
treatment and according to the Risk, Need, and Responsivity principles, it is essential to
assess risk and protective factors of the child and in his/her surroundings. This can be done in
at least two main ways: With or without structure/instrument. Structure is here referred to as
clear definitions of the risk and protective factors to be assessed, as well as clear and welldefined rating scales of the risk and protective factors – which are typical characteristics of
structured assessment instruments. Examples of structured instruments that involve risk and
protective factors identified in this review are the Early Assessment Risk List for Boys under
age 12 (EARL-20B; Augimeri, Webster, Koegl, & Levene, 1998), the Early Assessment Risk
List for Girls under age 12 (EARL-21G; Levene et al., 2001), and the Evidence-based
21
RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
STructured assEssment instrument of Risk and protective factors (ESTER-assessment;
Andershed & Andershed, 2010). A structured method or instrument will provide clear
definitions and a set way of conducting the assessment and the assessment will also be
documented in a systematic, structured and standardized manner. Achieving high so called
inter-rater agreement is a basic feature of legal security in assessments. This means that two
independent raters agree to a high extent in the assessment of for example a child and his or
her family. This is easier to achieve when using a structured assessment instrument (see e.g.,
Andershed et al., 2010; Enebrink, Långström, Hultén, & Gumpert, 2006). In terms identifying
risk and protective factors, the use of a structured instrument is also a good thing. A recent
study showed that professionals trained in and using a structured instrument (ESTERassessment) identified significantly more risk and protective factors in a case, as compared to
professionals not trained in nor using a structured instrument (Andershed & Andershed, in
prep.). Thus, if correctly used, there are many advantages of using structured instruments to
assess risk and protective factors. Thus, we would argue based on research that professionals
should use structured instruments when assessing risk and protective factors in children and
their families.
Risk Focused Prevention Needs to be Carried Out With Care by Well Trained
Professionals
Professionals working the approach and principles described here need appropriate
training/education to do so. Such training need to include basic schooling in risk and
protective factors, the research underlying these factors and its strengths and limitations. It
also need to include training in how to communicate this information to the family and, not
the least, how to use the information about risk and protective factors in making effective
plans of interventions.
22
RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
Using research, based on groups of children, such as the research presented here, as a
means for identifying individual children at risk will always be a difficult act of balance. For
example. some high risk children and families will not develop long lasting problems, while
others will. Unfortunately, they will not necessarily appear to be very different at the time of
assessment. Hence, there is no definite way for a professional to determine who the children
and families are that will fare well in spite of risk. Professional will likely identify and
intervene with a larger number of children than what is necessary. In the same fashion
however, we will also fail to detect some children and families who need professional help.
These limitations of risk-focused prevention and treatment need to be known by the involved
professionals. A very important aspect of applying general risk and protective factors on
individual children and families has to do with the professional’s communication with the
care givers. Professionals have to be able to communicate risk – why certain factors are being
assessed, what high risk means, etc – in a very nuanced way, to avoid potential negative
effects in terms labeling of the child or in terms of poor relations between the family and the
professional.
What Professions Should Work with Risk Focused Prevention and Treatment?
All professionals working with preschool children, given the adequate training and
supervision can apply the concrete thinking of risk focused prevention and treatment. It is a
very concrete way of working in an evidence based way. It is however likely that the concrete
assessments and interventions will be carried out in different ways depending on where we
are (e.g., primary child and family health care, psychiatry, preschool, social work, etc)
because of differences in amount of time for assessments and interventions and because of
differences in the purpose of work of the specific profession, but with the same focus and on
the same risk and protective factors.
23
RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
A Process of Assessment, Intervention, and Follow-Up Involving Risk and Protective
Factors
In Figure 3 below we propose a process of assessment, intervention, and follow-up which
involves the practical use of risk and protective factors. First, a structured assessment is
carried out, preferably using a structured checklist, instrument, or questionnaire. This is done
by a trained professional or professionals. This results in a list of risk factors that are present
and that needs to be reduced or ultimately eliminated and protective factors that are weak and
that needs to be strengthened in the specific child and his/her family. Now, the professional or
professionals carries out an analysis of these risk and protective factors using the Risk, Need,
and Responsivity principles. The Risk principle: How high is the risk for future problems and
of high priority is this child and family for the most intensive interventions? The Need
principle: Which are the needs of the child and the family, e.g: which of the risk factors
present are the most important to intervene with for this particular child and family? Which of
the risk factors are causing the problem behavior/s of the child? The Responsivity Principle:
Which interventions can be effective to reduce the most important risk factors and strengthen
the most important protective factors and how should they be delivered to the child and the
family to be effective? Then, interventions are carried out and after some time, as follow-up
assessment is conducted and a new analysis starts, that can result in that the interventions can
stop because they have been very successful or that the same interventions that have been
carried out need to continue, or that some or all interventions need to be changed in order to
gain positive changes in the child. We would argue that this kind of circular process should be
structurally undertaken in practice until the final goals of the interventions have been reached.
24
RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
Structured
assessment by
trained
professional/s of
risk- and protective
factors
Observed factors
Pronounced Risk
factors: E.g:
Aggression
Hyperactivity
Poor parenting
Rejection
Weak Protective
Factors: E.g:
Warmth
Safety
Analysis by
trained
professional/s
concerning
Risk? Need?
Responsivity?
Available interventions
Analyses to tailor
a plan for
intervention/s
Intervention D
Intervention A
Intervention B
Intervention C
Intervention E
Figure 3. A Process of Assessment, Intervention, and Follow-Up Involving Risk and
Protective Factors.
Final Comments and Conclusions
There is an extensive amount of research on risk and protective factors in preschool age for
future problems. This knowledge is not complete or perfect. There are many things we need to
know more about concerning risk and protective factors. However, this extensive amount of
research make up the best available evidence for the time being and it should be used by well
trained professionals so that they can work in an evidence based way to help more children to
a better life.
25
RISK AND PROTECTIVE FACTORS IN PRESCHOOL AGE
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