Is intolerance of uncertainty in preschool children a risk factor for later anxiety?

Intolerance of uncertainty (IU) is a cognitive trait characterised by a bias towards perceiving uncertain situations as negative and frightening (Freeston et al., 1994). Research suggests IU is linked to anxiety in both children and adults, with IU even impacting the success of treatment online (Osmanağaoğlu et al., 2018; Marcotte-Beaumier et al., 2021; read Tyler’s Mental Elf blog here). Although IU has been linked to anxiety within childhood, most studies are cross-sectional, limiting our insight into long-term effects. Furthermore, IU is associated with both internalising (e.g., depression) and externalising symptoms (e.g., impulsive and destructive behaviours; Gramszlo et al., 2018; Mcevoy et al., 2019; Sadeh & Bredemeier, 2019) but its developmental course remains unclear.

This study by Ryan and colleagues (2025) aimed to investigate the relationship between IU and generalised anxiety (GA) in preschool children. This study also investigated how IU in preschool children is associated with the trajectory of generalised anxiety (GA) symptoms from early to middle childhood and more broadly, the trajectory of internalising and externalising symptoms.

Individuals with high levels of intolerance of uncertainty have difficulties coping with both everyday uncertainties and big life uncertainties. This causes excessive worry and increases risk for the presentation of anxiety disorders.

Methods

One hundred and eighty families were recruited as part of a larger longitudinal study called ‘Watch Them Grow’. Data was collected at three time points:

• Time-point 1 (TP1): 180 children (aged 3.46 to 4.67 years) in 2017/2018
• Time-point 2 (TP2): 162 children (aged 5.72 to 7.71 years) in Spring 2020
• Time-point 3 (TP3): 148 children (aged 8.27 to 10.36 years) in Autumn 2022

Data was collected using parent-report questionnaires, including:

• The Preschool Anxiety Scale (PAS; Spence et al., 2001) – GA at TP1
• The Spence Children’s Anxiety Scale Parent report (SCAS-P; Nauta et al., 2004) – GA at TP2 & TP3
• The Responses to Uncertainty and Low Environmental Structure questionnaire (RULES; Sanchez et al., 2017) – IU at TP1, TP2 & TP3
• Health Behaviour Questionnaire (HBQ; Armstrong & Goldstein, 2003) – internalising/externalising symptoms at TP1, TP2 & TP3
• Trait scale of Y2 state-trait Anxiety inventory (STAI-Y2; Speilberger et al., 1983) – parent trait anxiety at TP1, TP2 & TP3

Data were analysed using correlations between RULES and other measures across all timepoints. Hierarchical growth curve analyses were then used to explore if IU at TP1 predicted trajectories for GA, internalising symptoms, and externalising symptoms across timepoints.

Results

IU and GA

There were significant moderate to high positive correlations between IU and GA across all timepoints (TP1: r = 0.74, 95% CI [0.67 to 0.80]; TP2: r = 0.68, 95% CI [0.59 to 0.76]; TP3: r = 0.60, 95% CI [0.48 to 0.69]). A moderate positive correlation was also found between IU at TP1 and GA at TP2 (r = 0.46, 95% CI [0.32 to 0.57], p < .001) and TP3 (r = 0.34, 95% CI [0.19 to 0.48], p < 0.001), indicating that higher IU scores at 3-4 years were associated with higher levels of GA at 5-7 years and 8-10 years.

Relatedly, hierarchical growth curve analyses revealed that IU at TP1 was a significant predictor of GA across time (p < .001). Further exploration with plots indicated that for children with higher IU scores, GA decreased between TP1 and TP2, and then slightly increased between TP2 and TP3. In contrast, children with low IU scores showed small increases in GA over time.

IU and internalising/externalising symptoms

Moderate to high positive correlations were also found between IU and externalising and internalising symptoms at every timepoint aside from TP1 IU and TP3 externalising symptoms, which were weakly correlated.

IU was a significant predictor of internalising symptoms (p < 0.001), with a linear effect of time (p <0.001) and a significant effect of parental anxiety (p < 0.001). Exploration through plots identified that internalising symptoms were relatively stable across all three timepoints in children with high IU, whereas children with low IU showed an increase in internalising symptoms over time (although these symptom levels were still lower than those with high IU).

IU at TP1 was also a significant predictor of externalising symptoms (p < 0.001), although there was no effect of time. Unlike other analyses, however, there was a significant effect of parental anxiety (p < 0.001) and marital status (p = 0.033).

Preschool children who had greater difficulty coping with uncertainty were more likely to exhibit higher anxiety and emotional and behavioural problems in later childhood.

Conclusions

The main findings from this longitudinal study by Ryan et al. (2025) indicate that intolerance of uncertainty (IU) is related to generalised anxiety (GA) from preschool into middle childhood, and that IU in preschool can predict trends in GA in early to middle childhood, but it predicts a decrease, not an increase as anticipated.

The authors suggest this may reflect reduced uncertainty during the pandemic, as children were not attending school or taking part in regular activities. As the relationship between high IU and anxiety already seems to be established in preschool children, we cannot conclude that IU precedes the onset of childhood anxiety; however, it appears to be strongly related.

Intolerance of uncertainty appears to be strongly related to childhood generalised anxiety. However, further research is needed to understand whether it precedes the onset of childhood anxiety or if there are other factors that are more important.

Strengths and limitations

Strengths

A key strength of this study is the control for marital status and parental anxiety, both of which were found to have a significant effect in relation to IU and externalising symptoms. Changes in parental marital status or family (e.g., parental separation, divorce) can be uncertain and destabilising events in themselves that cause significant anxiety (Coe et al., 2017). Equally, anxiety is known to have a strong environmental transmission (Eley et al., 2015), so it was important for the authors to account for parental anxiety and anxiety within the home environment to ensure this did not confound and impact the reliability of the results.

Another strength is the longitudinal design. This is the first study to examine IU and GA from early to middle childhood, which allows researchers to track the trajectories of anxiety over time within a cohort. Attrition across timepoints was relatively low, strengthening the validity and reliability of findings as it increased statistical power, which allowed for more precise modelling of developmental patterns.

Limitations

A key limitation is the reliance on parent report measures of IU, particularly as it has been suggested that parent and child report measures of IU do not always align (Osmanağaoğlu et al., 2021). The lack of child self-report or behavioural measures is also a limitation of the wider literature of IU within early childhood. While attempts to create task-based IU measures for children have been unsuccessful (Osmanağaoğlu et al., 2021), validated questionnaires for older children do exist (Cromer et al., 2009) and could have been adapted to compliment parent reports.

Furthermore, although marital status and parental anxiety were controlled for, a vast number of potential confounds were not considered. For example, peer relationships and bullying have both been shown to impact the presentation of emotional disorders such as anxiety (Gladstone et al., 2006). Therefore, there is a possibility that such confounds may have interacted with IU to increase the levels of anxiety observed within this sample.

Finally, the authors did not report whether any participants were receiving therapy throughout study data collection, which could have impacted the levels of anxiety observed. Specifically, this could account for the sudden decrease in anxiety between TP1 and TP2 in those who had high levels of IU at TP1. However, anxiety did then increase again between TP2 and TP3, suggesting that any potential therapeutic effects were not long-lasting.

Although this longitudinal study controlled for confounders such as marital status and parental anxiety, additional relevant variables could have been considered, like peer relationships and bullying.

Implications for practice

The current study suggests a nuanced relationship between intolerance of uncertainty (IU) and generalised anxiety (GA). IU was associated with greater GA at baseline yet also predicted a decrease in anxiety over time; this suggests a complex developmental trajectory of anxiety that needs to be better understood across the short- and long-term, with more research into the role IU plays. It is particularly important that this research is done outside of the COVID context, which the authors recognise could have impacted their findings.

The authors suggest that a follow-up into adolescence would further our understanding of the role IU has in later anxiety development. Adolescence is a key risk period for the emergence of emotional disorders due to the significant developmental changes, which are often characterised by uncertainty (Casey et al., 2010; Copeland et al., 2014; Rapee et al., 2019). Previous cross-sectional research has found that IU is correlated with anxiety disorders within adolescence (Ye et al., 2023), but without a longitudinal design, there are limits to the conclusions that can be drawn.

Furthermore, as IU was found to be strongly related to GA in early childhood, it indicates a potential avenue for future interventions targeting IU in preschool children. In recent years, interventions have been developed that target potential risk factors for anxiety, such as behavioural inhibition (Chronis-Tuscano et al., 2022). Behavioural inhibition is a temperamental characteristic that refers to a tendency to be cautious, shy, or restrained in new situations (Kagan et al., 1984). Not only is it a risk factor for anxiety, but it is also suggested that IU and behavioural inhibition overlap in definition and are related (Zedbik et al., 2018). Evidence suggests that behavioural inhibition programs are effective at reducing anxiety within childhood (Chronis-Tusano et al., 2022; Ooi et al., 2022), and it would be interesting to see if an intervention targeting IU would have a similar effect. However, it is still important to recognise that these findings and suggestions come from one study, with limits to determining causality; much more research is needed prior to intervention development.

Finally, from a practice perspective, it is important for clinicians to recognise the consistent association between IU and GA across childhood, as well as the relationship between IU and internalising and externalising symptoms. IU is likely involved in a range of psychopathologies and subsequently may be present across cases, with varying impact. Depending on the service user, IU may be something that needs to be addressed during treatment, even though the potential impact of IU on treatment in children is still unclear.

Although intolerance of uncertainty is strongly associated with childhood anxiety in preschool children, how it impacts levels of anxiety over time appears complicated and should be examined outside of the COVID-19 context.

Statement of interests

None.

Links

Primary paper 

Ryan, Z. J., Rayson, H., Morriss, J., & Dodd, H. F. (2025). Does intolerance of uncertainty predict child generalised anxiety? A longitudinal study. Journal of Anxiety Disorders, 112, 103004. https://doi.org/10.1016/j.janxdis.2025.103004

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