Child and Adolescent Mental Health Volume 7, No. 3, 2002, pp.

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Fears and Phobias in Children: Phenomenology, Epidemiology, and Aetiology

Thomas H. Ollendick1, Neville J. King2 & Peter Muris3
Department of Psychology, Child Study Center, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA 2 Faculty of Education, Monash University, Melbourne, Victoria, Australia 3 Department of Medical, Clinical, and Experimental Psychology, Maastricht University, The Netherlands
1

We examine the phenomenology, epidemiology, and aetiology of specic phobias in this brief review. In general terms, a specic phobia exists when fear of a specic object or situation is exaggerated, cannot be reasoned away, results in avoidance of the feared object or situation, persists over time, and is not agespecic. Specic phobias occur in about 5% of children and in approximately 15% of children referred for anxiety-related problems. Most of these children are comorbid with other disorders. We suggest that specic phobias are multiply determined and over-determined. Genetic inuences, temperamental predispositions, parental psychopathology, parenting practices, and individual conditioning histories converge to occasion the development and maintenance of childhood phobias. Inasmuch as any one specic phobia is acquired and maintained through such complex processes, we further conclude that treatment approaches will need to address these multiple dimensions before evidence-based treatments can be fully realised. Keywords: Childhood fears and phobias; phenomenology; epidemiology; aetiology

Description and phenomenology

Just as courage imperils life, fear protects it (Leonardo DaVinci, 1700) According to Marks (1969), Fear is a normal response to active or imagined threat in higher animals, and comprises an outer behavioural expression, an inner feeling, and accompanying physiological changes (p. 1). As we and others have noted elsewhere (Gullone, 2000; King, Hamilton, & Ollendick, 1988; Muris & Merckelbach, 2000; Ollendick, Hagopian, & King, 1997; Ollendick, King, & Yule, 1994), nearly all children experience some degree of fear during their development. Furthermore, although such fears vary in frequency, intensity, and duration, they tend to be mild, age-specic, and transitory. Typically, children evince fear reactions to stimuli such as strangers, separation, loud noises, darkness, water, imaginary creatures, and small animals such as snakes and spiders, as well as other circumscribed or specic events or objects. For the most part, these fears appear to result from day-to-day experiences of growing children and to reect the childrens emerging cognitive and representational abilities. Moreover, most of these fears do not involve intense or persistent reactions, they are short-lived, and, for the most part, they are adaptive. In contrast to normal fears, according to Marks (1969), a phobia: 1) is out of proportion to the demands of the situation; 2) cannot be explained or reasoned away; 3) is beyond voluntary control;

4) leads to avoidance of the feared situation. In an early paper, Miller, Barrett and Hampe (1974) expanded upon Marks denition of a phobia, as it pertains to children. They noted a childhood phobia also: 5) persists over an extended period of time; 6) is unadaptive; 7) is not age- or stage-specic. Miller et al.s (1974) denition of a phobia has been accepted by most mental health professionals working with children. In fact, the two most widely accepted diagnostic classication systems for psychiatric disorders have incorporated major aspects of these criteria into their denitions of specic phobia (American Psychiatric Association, 1994; World Health Organisation, 1991). For example, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) species the following criteria for Specic Phobia (APA, 1994, pp. 410411): 1) marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specic object or situation (e.g., ying, heights, animals, receiving an injection, seeing blood); 2) exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally-bound or situationally-predisposed panic attack; 3) the person recognises that the fear is excessive or unreasonable;

2002 Association for Child Psychology and Psychiatry. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA

Commissioned Review: Fears and Phobias 4) the phobic situation(s) is avoided, or else endured with intense anxiety or distress; 5) the avoidance, anxious anticipation, or distress in the feared situation(s) interferes signicantly with the persons normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia; 6) in individuals under 18 years, the duration is at least 6 months. Of importance to the study of specic phobias in children, the framers of DSM-IV (APA, 1994) recognised that children may not view their fears as excessive or unreasonable; further, DSM-IV allowed that childrens fears may be expressed in childhood ways such as crying, tantrums, freezing or clinging. These are important acknowledgements since these criteria nally recognise the developmental nature of children and the developmental course of their fears (Ollendick & King, 1991a; Ollendick & Vasey, 1999). In addition, DSM-IV (APA, 1994) specied parameters for the duration of specic phobias in children (i.e., 6 months). In previous editions of the DSM, duration was not specied. The designation of fears that persist more than six months and meet DSM-IV or ICD-10 criteria as phobias makes good sense to us.

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Epidemiology of specific phobias in children

In recent years, several epidemiological studies have estimated that the prevalence of anxiety disorders (including specic phobia) in non-selected community samples of children ranges from 5.7 to 17.7% (see Costello & Angold, 1995, for a review). In general, anxiety disorders tend to be more prevalent in girls than boys and in older than younger children. For specic phobias, several studies report relatively low prevalence rates: Anderson, Williams, McGee and Silva (1987) reported a 2.4% rate for 11-year-old children from New Zealand, whereas McGee et al. (1990) reported a rate of 3.6% for 15-year-old adolescents from that same birth cohort of New Zealand children; Bird et al. (1988) reported an overall rate of 2.6% in children and adolescents between 4 and 16 years of age from Puerto Rico; Steinhausen et al. (1998) reported a 2.6% rate in children and adolescents between 7 and 16 years of age in Switzerland; Costello, Stouthamer-Loeber and DeRosier (1993) reported a 3.6% rate in 1218 yearolds from the United States; Essau, Conradt and Petermann (2000) indicated a 3.5% rate in 1217 year old adolescents in Germany; Verhulst et al. (1997) indicated a 4.5% rate in Dutch adolescents between 13 and 18 years of age; nally, Wittchen, Nelson and Lachner (1998) reported a 2.3% rate in a sample of 1424 year old community respondents. In two other studies, both conducted in the United States, prevalence rates were somewhat higher and were found to be 9.1% in both communities and in two different age groups: 711-year-old children in a study by Costello et al. (1988) and 1416-year-old adolescents in a study by Kashani et al. (1987). Differences in prevalence rates appear to be due to differences in ascertainment practices, criterion denitions of diagnosis, and func-

tional impairment associated with the phobias. These differences notwithstanding, it is evident that specic phobias range in prevalence from 2.6 to 9.1% of children and adolescents, and that they average about 5% across studies. In their review of epidemiological studies, Costello and Angold (1995) concluded that OAD/GAD (overanxious disorder/generalised anxiety disorder), separation anxiety, and simple (i.e., specic) phobia are nearly always the most commonly diagnosed anxiety disorders, occurring in around 5% of children, while social phobia, agoraphobia, panic disorder, avoidant disorder, and obsessive-compulsive disorder are rare, with prevalence rates generally well below 2% (p. 115). Thus, although specic phobias are not highly prevalent in children and adolescents, they do occur with considerable frequency and may result in considerable distress (Essau et al., 2000; Silverman et al., 1999; Wittchen et al., 1998). Two other epidemiological ndings are of considerable interest. First, although ndings are not conclusive, it appears that comorbidity within the anxiety disorders is less frequent for phobic disorders than it is for other anxiety disorders in community samples of children and adolescents (Costello & Angold, 1995). That is, phobic disorders tend to be relatively pure in these samples, whereas other anxiety disorders tend to overlap and to co-exist with one another. Furthermore, these other anxiety disorders tend to co-occur with other internalising (e.g., especially depression) and externalising (e.g., conduct disorder, attention decit hyperactivity disorder) disorders, whereas phobic disorders in community samples do not. Second, there appears to be a modest level of continuity for the anxiety disorders in general, as well as the specic phobias in particular across intervals varying from 2 to 5 years (between 20 to 40%). That is, about 30% of children with a phobic disorder at a later point in time also had one at an earlier point in time. This conclusion is based on studies conducted in New Zealand, Germany, Canada, and the United States (see Costello & Angold, 1995; Ollendick & King, 1994, and Nottelmann & Jensen, 1995, for reviews). These ndings indicate that childhood phobias are moderately stable and relatively pure in community samples. Different conclusions can be drawn from clinical samples, however. In a review of comorbidity in clinical samples, Brady and Kendall (1992) reported that comorbidity between anxiety disorders and other internalising disorders and externalising disorders was as high as 61.9%. This very high rate was found in a group of children and adolescents referred to an outpatient clinic for school refusing children, followed by rates of 55.2% in a sample of psychiatric inpatient children (mixed diagnoses), 36.4% in a sample of children with primary affective disorders, and 31.5% in a sample of 8 13-year-old mental health outpatients (mixed diagnoses). Unfortunately, the studies reviewed by Brady and Kendall (1992) did not isolate comorbidity effects for specic phobias versus other anxiety disorders. Fortunately, one early study (Last, Strauss, & Francis, 1987) and one recently published study have done so (Silverman et al, 1999). Last et al. (1987), in a sample of children and adolescents between the ages of 5 and 18 referred to an anxiety disorder outpatient clinic, found that 15% of the children met criteria for a primary

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Thomas H. Ollendick, Neville J. King & Peter Muris instruction). In addition, parents were allowed to indicate that they did not know how the phobia developed or that their child had always been afraid of water (i.e., fearful upon their very rst contact with water). Although 2% of parents attributed their childs phobia to a direct conditioning episode and another 26% reported vicarious conditioning episodes, a majority of the parents (56%) believed that their childs fear had been present from their childs very rst contact with water. The remaining 16% of the parents were not able to offer any explanation of onset, recalling no traumatic experience but reporting nonetheless that their child had not always displayed a fear of water. Finally, none of the parents believed that information associated with adverse consequences was the most inuential factor in the development of their childs phobia (however, 14% of the parents believed that such information had been somewhat inuential). These ndings from parents of water-phobic children are similar to those reported by McNally and Steketee (1985) for 22 adults (mean age of 40.0) who evidenced severe animal phobias (e.g., snake, cat, bird, dog, and spider). In this study, a structured interview was conducted to obtain information regarding the mode of onset, course of development, and frequency of natural exposure to the phobic animal. Information was also obtained regarding the feared consequences that the phobic adults expected to occur following unavoidable encounters with the feared animal, as well as the specic stimulus characteristics of the feared animal that they found particularly distressing. As with Menzies and Clark (1993a), a majority of the adults (68%) could not recall the onset of their phobia, reporting that they had the fear as long as they could remember. Of the remaining adults, 23% attributed their fear to a frightening encounter with the animal and thus were classied as conditioning cases. The remaining 9% of phobic adults were classied as vicarious and instructional cases. In one instance, the patient reportedly acquired a bird phobia after her father teasingly told her that a bird might swoop down and get her (instructional onset), whereas in another instance a patient attributed her snake phobia to watching frightening movies that depicted snakes as dangerous (vicarious conditioning). Interestingly, of those who could recall the origin of their phobia, all indicated that it began before the age of 10 and that the intensity of the phobia remained constant over the ensuing years (on average for 24 years). Moreover, nearly all patients (91%) reported that they expected to panic or at least experience very high levels of fear if an unavoidable encounter with the feared animal were to occur, while about half (46%) also expected that the animal would harm them or attack them. Finally, regarding stimulus characteristics of the feared animal, most patients (77%) reported that the most upsetting aspect of the feared stimulus was the way the animal moved. Independent of movement, 64% of the patients cited the physical appearance of the animal as the second most distressing characteristic, followed by sounds made by the animal (27%) and specic tactile properties of the animal (23%). Collectively, ndings by Menzies and Clarke (1993a) for young children and McNally and Steketee (1985) for adults stand in sharp contrast to those obtained by Ost

diagnosis of simple (i.e., specic) phobia. Furthermore, they reported that 64% of children and adolescents with a primary diagnosis of simple (i.e., specic) phobia presented with one or more additional diagnoses, including overanxious disorder, social phobia, obsessive-compulsive disorder, panic disorder, major depressive disorder, dysthymia, and oppositional deant disorder. Similar results were reported recently by Silverman et al. (1999) in their study of 104 children between 6 and 16 years of age referred to a phobia outpatient treatment program. A majority (72%) of the children had at least one comorbid diagnosis: 19% had an additional specic phobia, 16% had separation anxiety disorder, 14% had overanxious disorder, and 6% were diagnosed with attention decit hyperactivity disorder. The remaining 17% of the 72% who had a comorbid diagnosis were distributed over eight additional diagnostic categories with a rate of less than 5% each. Collectively, these ndings indicate that clinically signicant phobias are present in approximately 5% of children and adolescents in community samples and in about 15% of outpatient, clinic-referred samples. Furthermore, these ndings suggest that clinic-referred children and adolescents who present with specic phobias to specialty clinics are more likely to be comorbid with other disorders than are community samples. These ndings undoubtedly have important implications for the assessment and treatment of these phobic youth (Brady & Kendall, 1992; King, Ollendick, & Gullone, 1991; Nottelmann & Jensen, 1995; Seligman & Ollendick, 1998).

Aetiology of fears and specific phobias in children

The aetiology of childhood phobias is not fully understood at this time (King, Gullone, & Ollendick, 1998; Muris & Merckelbach, 2000; Ollendick et al., 1997). While childhood phobias may result from terrifying or frightening experiences, they may also be due to less direct inuences such as observing a phobic reaction in another child or through reading about or hearing about fears and phobias in others. Still, other childhood phobias apparently have no obvious environmental cause, direct or indirect, and reportedly have always been present in the child. In this latter instance, the child, according to parental report, has always been afraid of the phobic object, apparently in the absence of direct or indirect conditioning experiences. For example, an intense fear and avoidance of snakes or spiders may develop in a child who has never been traumatised directly or indirectly. Yet the child is terried of snakes or spiders and actively avoids going on excursions into the countryside due to fear of some frightening event occurring. To the parents knowledge and the childs recollection, no terrifying events that might have served to condition the child have ever occurred. Menzies and Clarke (1993a) illustrated this etiological conundrum in a study with 50 water-phobic children (mean age 5 years). Parents of these children were administered a questionnaire that consisted of a list of commonly reported origins of phobias including all three of Rachmans (1976, 1977) now classic pathways to fear acquisition (i.e., direct classical conditioning, vicarious conditioning, and information/

Commissioned Review: Fears and Phobias and his colleagues for adult phobic patients (see Ost & Hugdahl, 1981, 1985). For example, in a study of 110 patients undergoing behavioural treatment of phobias (41 with small animal phobias [snakes, spiders, rats], 34 with social phobias, and 35 with claustrophobia), Ost and Hugdahl (1981) reported that only 15.1% could not recall experiences of any kind regarding the onset of their phobias. In contrast, more than half (57.5%) ascribed their phobias to direct experiences of the conditioning type, with 17% attributing their phobias to vicarious conditioning experiences and 10.4% to informational or instructional experiences. Thus, in this sample, very few patients could not recall the origins of their phobias and twice as many patients recalled acquiring their phobias through direct conditioning experiences as through indirect experiences (vicarious or instructional). As in the McNally and Steketee study (1985), however, duration of the phobias was extended (average of 24 years), with most patients reporting childhood onset and unrelenting intensity over the intervening years. Inconsistencies in origins of phobias in these studies are difcult to reconcile but may be due, at least in part, to differences in questionnaires used, operational denitions of conditioning events, and severity of the phobias (see King et al., 1998; Menzies & Clarke, 1995, and Ollendick et al., 1997, for additional commentary). In addition, these studies have not included a comparison group of non-fearful participants. In order to establish the aetiological signicance of conditioning events or negative expected consequences in the development of specic phobias such a contrast group is imperative. If painful or frightening experiences with the stimulus are equally prevalent among non-fearful controls, or if expectations of panic or harm are equally high among controls, then such experiences or expectations alone cannot be a sufcient explanation for development of the phobia. Fortunately, at least two adult studies and one child study have included nonfearful groups and have made such comparisons. In the rst study, DiNardo et al. (1988) examined these issues in 16 dog-phobic young adults and 21 non-fearful matched controls. Similar to the Ost and Hugdahl (1981) ndings, 56% of the phobic adults reported direct conditioning events associated with the origin of their phobia; unexpectedly, however, 66% of the nonfearful subjects also reported direct conditioning events. Obviously, reliable differences between the two groups were not observed. In fact, direct conditioning experiences were reported by more of the non-fearful controls than the phobic group! Furthermore, the majority of encounters for both phobic and non-fearful adults were similar and consisted of painful events involving bites or scratches. Although the two groups had similar experiences with dogs, they had very different expectations about the consequences of an encounter with a dog. Not surprisingly, and consistent with the ndings of McNally and Steketee (1985), 100% of phobic subjects expected to experience fear and harm upon an encounter with a dog, whereas only a small minority (14%) of non-fearful subjects expected similar outcomes. DiNardo and colleagues (1988) concluded that high expectancies of fear and harm served to maintain phobic avoidance in the phobic group. In a second study with adults, Menzies and Clarke (1993b)

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reported similar ndings in a study of 50 height phobic young adults and 50 non-fearful matched controls: there were no differences between the phobic and nonfearful groups in acquisition pathways. However, the groups did differ on expected consequences upon encounter with heights, as they did in the DiNardo et al. (1988) study on fear of dogs. A majority of the height-phobic young adults reported extreme fear and panic associated with heights. Interestingly, even though many specic phobias are acquired in childhood and adolescence (Marks, 1987; Ost & Hugdahl, 1981, 1985), efforts to explore pathways of acquisition have relied largely on retrospective reports of adults, frequently 20 or more years after onset of their phobias. As noted above, many adults report that they are simply unable to recall the onset of their phobias with sufcient specicity or, due to time and associated life experiences, recall events that help them make sense of their fears or phobias. To date, only one study has addressed these issues directly in a child and adolescent sample. In this study, Ollendick and King (1991b) explored Rachmans (1977) three pathways of fear acquisition in 1092 Australian and American children between 9 and 14 years of age. In response to 10 commonly reported fears in children, the youths were asked to indicate their own level of fear and then whether 1) they remembered having a bad or frightening experience with the feared object (direct conditioning experience), 2) their parents, friends or other acquaintances showed fear or avoidance of the feared object (vicarious conditioning), and 3) they had been told, or heard stories about, frightening things regarding the feared object (instruction or information pathway). Responses to acquisition routes were highly idiosyncratic and dependent on specic fear stimuli. For example, 36% of the sample indicated a bad or frightening experience with snakes, whereas 70% indicated a similarly frightening experience with not being able to breathe (i.e., choking, gasping, not able to catch breath). Moreover, 65% indicated someone they knew showed extreme fear of snakes, whereas 46% indicated someone they knew showed extreme fear of not being able to breathe. Finally, 89% of the youth indicated they had heard or been told frightening stories about snakes, whereas 76% indicated similar instruction/ information about not being able to breathe. (Percents do not add up to 100% since youth could endorse more than one pathway.) These ndings suggest that pathways may be phobia-specic and that the causes may be multiply-determined, if not over-determined (Ollendick, 1979). Unfortunately, we did not include a category of always present or cannot recall as in the Menzies and Clark studies (1993a,b). In this study, we also formed groups of high-fearful and low-fearful children based on endorsements to the fear stimuli. The primary difference between high- and low snake-fearful children was that the high-fearful children were more likely to endorse a combination of modelling plus information/instruction (30%) and direct conditioning plus modelling plus information/ instruction (29.4%) than their non-fearful counterparts (17.8% and 6.9%, respectively). The two groups, however, did not differ on direct conditioning, modelling, or information/instruction as sole sources of inuence. In a similar vein, the primary difference between high and

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Thomas H. Ollendick, Neville J. King & Peter Muris 1992; Marks, 1987; McNally, 1987; Menzies & Clarke, 1995; and Muris et al., 2002, for discussion of issues related to these theories). Nonetheless, the pursuit of heritability estimates has continued to fuel this debate. Although no known studies of heritability exist for children with specic phobias, studies with adults suggest that specic phobias may be largely due to non-genetic factors (Carey, 1990; Kendler et al., 1992). In discussing the role of genetics in specic phobias, social phobia, and agoraphobia, Kendler et al. (1992) propose that these subtypes of phobias can be placed along an etiologic continuum: at the one end of the continuum lies agoraphobia which has the latest age of onset, the highest heritability estimate, and the least specic environmental inuences. At the other end of the continuum lie the specic phobias, which have the earliest age of onset, the lowest heritability estimates, and the highest specic environmental inuences. They conclude The estimated heritability of liability of phobias. . . indicates that genetic factors play a signicant but by no means overwhelming role in the aetiology of phobias. Individual-specic environment appears to account for approximately twice as much variance in liability to phobias as do genetic factors (p. 279). Overall, genetic factors appear to be associated with a general state or propensity toward fearfulness (although Stevenson, Batten & Cherner, 1992, question this conclusion with high fearful albeit not phobic children), whereas the environment plays a stronger role in making an individual afraid of, say, snakes rather than heights or enclosed places. Specicity is afforded by the environment (Ollendick et al., 1997). Along with genetic factors, constitutional (i.e., temperament) characteristics of the child may play a role in the onset and maintenance of specic phobias in children. Temperament refers to stable response dispositions that are evident early in life, observable in a variety of settings, and relatively persistent across time (Chess & Thomas, 1977, 1984). Two of the most important temperamental categories are based on responses or initial reactions to unfamiliar people and novel situations, frequently referred to as shyness vs sociability, introversion vs extroversion, or withdrawal vs approach. In unfamiliar situations or upon meeting new people, shy or inhibited children typically withhold responding or interrupt ongoing behaviour, show vocal restraint, and withdraw. In contrast, sociable and uninhibited children typically seek out novelty, engage in conversation, smile, and explore the environment around them. Data from Chess and Thomas New York Longitudinal Study (1977) show that these tendencies to approach or withdraw are relatively enduring dimensions of behaviour. In recent years, Kagan and his colleagues (Kagan, 1989; Kagan, Reznick, & Gibbons, 1989; Kagan, Reznick, & Snidman, 1988) have demonstrated that approximately 10% to 15% of American Caucasian children are predisposed to be fussy and irritable as infants, shy and fearful as toddlers, and cautious, quiet, and introverted when they reach school age; in contrast, about 15% of the population show the opposite prole, with the remainder of the population intermediate on these dimensions. Kagan hypothesised that inhibited children, compared with uninhibited children,

low not able to breathe fearful children was that the high-fearful children were more likely to ascribe their fear to a combination of direct conditioning plus information/instruction (24.7%) and direct conditioning plus modelling plus instruction/information (28.9%) than their low-fearful counterparts (9.3% and 4.1%, respectively). As with snake fears, the two groups did not differ on direct conditioning, modelling, or instruction/information as sole sources of inuence. Thus, although direct conditioning sources were endorsed more frequently for children fearful of not being able to breathe and indirect effects (modelling and information/instruction) were ascribed to more frequently for children fearful of snakes, high- and low-fearful children did not differ on these inuences when viewed as the sole source of their level of fear. Rather, only when one of these sources was combined with another source (or multiple sources) were meaningful differences obtained. Direct conditioning alone or modelling alone or information/instruction alone did not result in fear acquisition for most of the youths. Finally, a signicantly greater percentage of non-fearful youths indicated that they had not been exposed to any of the three primary pathways of fear acquisition than the fearful youths (32.8% of those non-fearful of snakes and 34.0% of those non-fearful of not being able to breathe). Of course, it should be noted that these ndings and those of others are based on retrospective reports and are therefore subject to limitations attendant to selfreport studies. Although the children and adolescents in our study were closer in time to the onset of their fears than adults whose fears had a developmental onset and prolonged course, they still had to rely on their recollections to identify the likely sources of onset. As such, these ndings really speak to the causal attributions of children and adolescents to account for the onset of their fears. These attributions may or may not reect actual causes and, accordingly, may or may not reect the real sources of acquisition. In future research, these self-reports should be supplemented with intensive structured interviews, behavioural observations, and use of other informants (e.g., parents, teachers) to determine their validity (Ollendick et al., 1997). Overall, these ndings suggest that not all phobias are acquired through individual-specic learning histories and other causal factors may need to be considered. Among these other factors are those related to the heritability of phobias, biological-constitutional factors of the child, and parenting inuences on the growing child. Early on, Darwin (1877, cited in Marks, 1987, p. 112) asked, May we not suspect that. . .fears of children, which are quite independent of experience, are the inherited effects of real dangers. . .during savage times. Basically, Darwin suggested that aversive experiences with certain stimuli were not necessary for the acquisition of fear; rather, some fears were independent of experience and were largely innate. Advancing this notion, Seligman (1971) hypothesised that associations between certain stimuli and fear responses were more likely to be formed than others (i.e., prepared and constituting non-cognitive forms of associative learning). The status of this notion of inherited phobia proneness is certainly controversial and well beyond the scope of this review (see Davey,

Commissioned Review: Fears and Phobias have a low threshold for arousal in the amygdala and hypothalamic circuits, especially to unfamiliar events and that they react under such conditions with sympathetic arousal (Kagan, Reznick, & Snidman, 1987). In general, sympathetic activation is indicated by high heart rate, low heart-rate variability, and acceleration of heart rate under stressful conditions. Indeed, inhibited children have been shown to have higher and more stable heart rates and to show greater heart-rate acceleration under stressful and novel conditions than uninhibited children. Further, inhibited children have been shown to have a greater increase in diastolic blood pressure when changing their posture from a sitting to a standing position than uninhibited children, suggesting noradrenergic tone (Biederman et al., 1995). Collectively, these ndings indicate a more reactive sympathetic inuence on cardiovascular functioning in inhibited children. The behavioural response of withdrawal and avoidance shown by children with behavioural inhibition, along with the considerable evidence of increased arousal in the limbic-sympathetic axes, ts well with current hypotheses of the neuropsychological underpinnings of anxiety disorders (see Gray, 1982; Gray & NcNaughton, 2000, and Davis, 1992 for discussions). The sample of inhibited and uninhibited children studied by Kagan and colleagues has been described in detail elsewhere (see Kagan et al., 1987, 1988). Briey, children were identied at 21 months of age for a study on the preservation of temperamental differences in normal children. The children were selected from a larger group of 305 Caucasian children whose mothers described them as displaying inhibited or uninhibited behaviour across different situations. On the basis of the interviews, 117 children were invited to the Harvard Infant Study Laboratory and were studied more extensively. Initially, 28 children were identied as the most extremely inhibited and 30 as the most extremely uninhibited. Subsequent to identication, 22 inhibited and 19 uninhibited children were available for followup at 4, 5, and 7 years of age. Biederman and colleagues (1990) reasoned that the inhibited children identied by Kagan and colleagues would be at risk for the development of anxiety disorders. Their hypothesis was based on earlier work they had conducted with the offspring of parents with panic disorder and agoraphobia (PDAG). In this study, they reported a high prevalence of behavioural inhibition in children born to adults with PDAG compared with control children of parents without anxiety disorder (Rosenbaum et al., 1988). They then examined the Kagan et al. longitudinal sample of normal children when the children were 7 to 8 years of age. Mothers of the 22 inhibited and 19 uninhibited children were systematically interviewed using a structured diagnostic interview. Although a variety of measures were obtained in this study, only the results of diagnosis for common childhood anxiety disorders will be presented here. Findings revealed that the rates of all anxiety disorders were higher in inhibited than uninhibited children: overanxious disorder (13.6% vs 10.5%), separation anxiety disorder (9.1% vs 5.3%), avoidant disorder (9.1% vs 0%), and phobic disorders (31.8% vs 5.3%). Only differences for phobic disorders were statistically signicant. Clearly, the inhibited group was found to be at risk for anxiety

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disorder, particularly phobic disorders. It should be recalled that designation of group status as inhibited vs uninhibited occurred at 21 months of age and that assessment for psychopathology in the present study occurred when the children were approximately 7 years of age. In a subsequent study, Hirshfeld and colleagues (1992) re-examined these ndings by contrasting children who remained inhibited or uninhibited throughout childhood with those who were less stable across the four assessment periods (21 months, 4 years, 5 years, and 7 years). Four groups of children were formed: stable inhibited (n 12), unstable inhibited (n 10), stable uninhibited (n 9), and unstable uninhibited (n 10). As is evident, 54.5% of the inhibited children and 47.4% of the uninhibited children maintained stable group status across the assessment periods. Again, while a multitude of measures were obtained, ndings related to the rate of phobic disorders only will be highlighted here. The researchers showed the following rates of phobic disorders at age 7 years: stable inhibited 50%, unstable inhibited 10%, stable uninhibited 11.1%, and unstable uninhibited 0%. (Rates for the other anxiety disorders were also higher for the stable inhibited group compared to the other groups.) Thus, children who remained consistently inhibited from 21 months through 4, 5, and 7 years of age accounted for the high rates of phobic disorders found to be associated with behavioural inhibition in the earlier study (Biederman et al., 1990). In this stability study, Hirshfeld et al. also obtained diagnostic interviews on the parents themselves. Comparison between parents of the stable inhibited group and the other three groups indicated that the parents of the stable inhibited group themselves were also characterised by a greater prevalence of phobic disorders and related anxiety disorders. Again, it should be noted that the children and parents in the Kagan et al. (1987, 1988) longitudinal cohort were selected for a study on the preservation of temperamental differences in normal children. They were not selected because they were thought to be at risk or because they presented with anxious symptomatology. The increased rates of anxiety disorders and phobic disorders in parents of stable inhibited children (as well as heightened levels of behavioural inhibition in children born from anxiety disorder parents) raise the possibility that the association between stable behavioural inhibition and anxiety disorder is familial, perhaps genetic. If genetic, it is probable that the link is one that predisposes the child to a heightened level of general fearfulness or anxiety sensitivity, as suggested by Kendler et al. (1992). As noted by Hirshfeld et al. (1992, p. 108), Whether behavioural inhibition is under genetic inuence remains unresolved and can be elucidated ultimately only by carefully controlled twin or adoption studies and by genetic linkage studies. Alternatively, stable behavioural inhibition in the child might be related to having a parent with an anxiety disorder. Continued exposure to a parents anxious symptomatology might lead a child to remain cautious, uncertain, and fearful in novel or unfamiliar situations. Further, phobic parents might model phobic avoidance on a regular basis and may have difculty encouraging their youngsters to explore their

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surroundings and take risks (Hirshfeld et al., 1992). Parents of anxious children have long been described as overprotective and shielding their children from potential misfortunes. Recent studies by Barrett, Dadds, and their colleagues, as well as others, using direct behavioural observations of parent-child interactions in ambiguous and stressful situations, conrm such protective and insulating patterns (Barrett et al., 1996; Dadds et al., 1996; Siqueland, Kendall, & Steinberg, 1996; Whaley, Pinto, & Sigman, 1999). Finally, it is interesting to note that Kagan suggested early on that children who stopped being inhibited seemed to come from families in which children were encouraged to be more sociable and outgoing (Kagan et al., 1987). In the absence of such encouragement and modelling of avoidance, behavioural inhibition might be expected to persist and be refractory to change. In all probability, stability of behavioural inhibition may be related to a combination of genetic inuences, parental psychopathology, and environmental factors that transact in a reciprocal manner. In the nal analysis, a host of factors converge to occasion the onset and maintenance of specic phobias in children. Genetic inuences and temperamental tendencies may predispose the child to general fearfulness, behavioural inhibition, and phobic disorder; however, particular forms of parental psychopathology and specic conditioning histories are seemingly necessary to set the stage for the development of a specic phobia such as fear of heights or fear of dogs.

Summary
Although childhood fears are a part of normal development, a subset of children evidence fears that interfere with their daily functioning. A specic phobia is said to exist when fear of a specic object or situation is exaggerated, cannot be reasoned away, results in avoidance of the feared object or situation, persists over time, and is not age-specic. Specic phobias occur in about 5% of children and in approximately 15% of children referred for anxiety-related problems. Most of these children are comorbid with other disorders. Specic phobias are multiply determined and overdetermined. In the nal analysis genetic inuences, temperamental predispositions, parental psychopathology, parenting practices, and individual conditioning histories converge to occasion the development and maintenance of childhood phobias. Inasmuch as any one specic phobia is acquired and maintained through such complex processes, treatment approaches will likely need to address these dimensions before evidence-based treatments can be fully realised (Ollendick & King, 1998, 2000).

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