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The Scientific Legacy of Little Hans and Little Albert: Future Directions for
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The Scientific Legacy of Little Hans and Little Albert:

Future Directions for Research on Specific Phobias in
Youth
abc de
Thomas H. Ollendick & Peter Muris
a
Child Study Center, Department of Psychology, Virginia Tech
b
Department of Psychology, Roehampton University
c
School of Applied Psychology, Griffith University
d
Department of Clinical Psychological Science, Maastricht University
e
Department of Psychology, Stellenbosch University
Published online: 11 Apr 2015.
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 Journal of Clinical Child & Adolescent Psychology, 0(0), 1–18, 2015
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ISSN: 1537-4416 print=1537-4424 online
DOI: 10.1080/15374416.2015.1020543

The Scientific Legacy of Little Hans and Little Albert:

Future Directions for Research on Specific Phobias in Youth
Thomas H. Ollendick
Downloaded by [Virginia Tech Libraries], [Mr Thomas H. Ollendick] at 11:40 17 April 2015

Child Study Center, Department of Psychology, Virginia Tech and Department of

Psychology, Roehampton University and School of Applied Psychology, Griffith University

Peter Muris
Department of Clinical Psychological Science, Maastricht University and Department of
Psychology, Stellenbosch University

We review issues associated with the phenomenology, etiology, assessment, and

treatment of specific phobias in children and adolescents and provide suggestions for
future research and clinical practice. In doing so, we highlight the early case studies
of Little Hans and Little Albert and the advances that have been made following the
publication of these seminal cases. In recent years, we have witnessed a deeper under-
standing of the etiology of specific phobias and developed a rich array of evidence-based
assessments and treatments with which to address specific phobias in youth. Although
much has been accomplished in this area of inquiry, we also note that much remains
to be done before we can advance more fully our understanding, assessment, and
treatment of specific phobias in youth. It will be important for future work to build
more firmly on these developments and to better determine the moderators and media-
tors of change with our evidence-based treatments and to more vigorously pursue their
dissemination in real-word settings.

INTRODUCTION Rayner, 1920) was experimental in nature and demon-

During our clinical training, many of us have heard
about Little Hans and Little Albert, two classic case
studies of specific phobias that were published at the
beginning of the 20th century. Both case histories
focused primarily on the etiology of specific phobias
but also advanced our thinking about the treatment of
this anxiety disorder. For example, the case of Little
Hans—a 5-year-old boy who suffered from a phobia of
horses—was used by Freud (1909=1955) to illustrate his
psychodynamic theory of childhood sexuality, the Oedi-
pal complex, and the origins of neurosis and to assert
that such a condition could be alleviated by helping the
individual understand the deeply rooted origins of his
or her fear. The case study of Little Albert (Watson &
Correspondence should be addressed to Thomas H. Ollendick,
Child Study Center, Department of Psychology, Virginia Tech, 460
Turner Street, Blacksburg, VA 24060. E-mail: tho@vt.edu
strated that it is possible to instill a phobia in a healthy
child via classical conditioning: The 11-month-old boy
acquired an intense fear of rats and rabbits by pairing
the presentation of these animals with an aversive loud
noise. The implications of this experiment for treatment
were obvious: By viewing a specific phobia as a learned
fear condition, the idea was born that this condition
could be unlearned by exposing the person to the feared
stimulus under neutral or positive circumstances. These
days, there is little empirical evidence for the psychody-
namic perspective on the etiology and treatment of spe-
cific phobias. In contrast, learning theory dominates
our current thinking: Its basic principles not only play
an important role in contemporary models of the etiol-
ogy of specific phobias but also form the basis for
evidence-based interventions for treating this problem
(Ollendick, Sherman, Muris, & King, 2012).
It is not just happenstance that the early cases of Little
Hans and Little Albert were focused on young children: It
 2 OLLENDICK AND MURIS
is now widely accepted that specific phobias typically have
their origin during the childhood years (Ollendick, 1979).
Yet it is surprising that relatively little research has focused
on specific phobias in children and adolescents over the
years. For example, in an analysis of publication trends,
Muris and Broeren (2009) indicated that specific phobias
are among the least investigated childhood anxiety disor-
ders—with an average number of only 3.3 publications
per year during the past two decades. This does not mean
that we have little or no knowledge about the etiology of
specific phobias or how to assess and treat them in youth.
Still, much of this knowledge comes necessarily from stu-
dies that have been conducted with adults. In this article,
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we summarize what is currently known about the phenom-
enology, etiology, assessment, and treatment of specific
phobias in children and adolescents. We also highlight
future directions for research and clinical practice for
youth with this anxiety disorder.
DEFINITION AND PHENOMENOLOGY
People have had specific phobias for hundreds and
thousands of years: From the time of Hippocrates until
the 18th century, accounts of phobic problems appeared
occasionally in the literature, although they were not
regarded as disorders in their own right. From the
beginning of the 19th century, however, the term phobia
was increasingly used in its current sense to denote an
intense fear that is out of proportion to the apparent
stimulus or situation that provokes it. However, it was
not until 1952 that phobias became a separate diagnostic
category in the psychiatric classification system of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM). In the early editions (DSM-I and DSM-II;
American Psychiatric Association, 1952, 1968), all pho-
bias were grouped together and informed by clinical
speculation, not empirical research. Guided by empirical
research, DSM-III (American Psychiatric Association,
1980) distinguished among agoraphobia, social phobia,
and simple phobia as separate disorders. The latter
category was relabeled as specific phobia in later edi-
tions of the DSM (DSM-IV; American Psychiatric
Association, 1994). In the current version (DSM-5,
American Psychiatric Association, 2013), a specific pho-
bia is defined by the following criteria: (a) marked fear
or anxiety about a specific object or situation; (b) the
phobic object or situation almost always provokes
immediate fear or anxiety; (c) the phobic object or
situation is actively avoided or endured with intense
fear or anxiety; (d) the fear or anxiety is out of pro-
portion to the actual danger posed by the specific object
or situation and to the sociocultural context; (e) the fear,
anxiety, or avoidance is persistent, typically lasting for 6
months or more; (f) the fear, anxiety, or avoidance
causes clinically significant distress or impairment in
social, occupational, academic, or other important areas
of functioning; and (g) the disturbance is not better
explained by the symptoms of another mental disorder.
The diagnostic criteria for specific phobia in children
and adolescents do not differ from those used in adults
with one exception: It is specifically noted that in chil-
dren ‘‘the fear and anxiety may be expressed by crying,
tantrums, freezing, or clinging’’ in DSM-5 (American
Psychiatric Association, 2013, p. 197).
The DSM describes five subtypes of specific phobias,
namely, animal type (e.g., dogs, snakes), blood-
injection-injury type (e.g., sight of blood, dentists), natu-
ral environment type (e.g., heights, storms), situational
type (e.g., enclosed places, elevators), and ‘‘other’’ type
(e.g., loud noises, costumed characters). There is some
albeit limited empirical support for the separate subtyp-
ing of specific phobias. For example, factor analytic
research performed on the fear ratings of children and
adolescents has revealed three primary factors: The first
factor was referred to as animal phobias, the second fac-
tor pertained to blood-injection-injury phobias, and the
third factor combined natural environment and situa-
tional phobias (Muris, Schmidt, & Merckelbach, 1999).
Moreover, in their recent review, LeBeau et al. (2010)
noted that each subtype of specific phobia is somewhat
unique when looking at the prototypic fear response.
The three-systems-model of Lang (1968) provides a
good framework for illustrating this point. According
to this model, fear is reflected in autonomic symptoms
(e.g., tachycardia, increased respiration), subjective feel-
ings of apprehension (e.g., fear of harm and injury, fear
of losing control), and avoidance or escape behavior
(e.g., evading, running away from, or not looking at
the phobic stimulus=situation; staying near another per-
son). Further, not all types of specific phobias display a
comparable profile with regard to the three components.
Although all phobias are accompanied by subjective
reports of distress and although this distress mainly
takes the form of fear, in some animal and blood-
injection-injury phobia types this subjective distress is
characterized by strong feelings of disgust and revulsion.
Similarly, whereas all specific phobias are characterized
by cognitions related to the fear of incurring harm or
injury, there are several phobias, especially situational=
environmental phobias (e.g., enclosed places, claustro-
phobia), that involve additional anxiety expectations
such as fear of going crazy or fear of losing control.
Moreover, although confrontation with the phobic
stimulus usually elicits sympathetic arousal (i.e., tachy-
cardia or increased heart rate) in most phobia subtypes,
a biphasic response pattern (i.e., initial tachycardia
followed by bradycardia or heart rate slowing) is typi-
cally noted in blood-injection-injury phobia (LeBeau
et al., 2010).

There appears to be only one investigation to date
that has explored the responsivity in each of the three
systems in youth with a specific phobia. In that study
(Ollendick, Allen, Benoit, & Cowart, 2011), clinic-
referred children and adolescents with a specific phobia
(animal, environmental, and situational types) provided
subjective fear ratings, participated in a behavioral
approach test (BAT), and underwent a physiological
assessment of their heart rate. Although the three indices
of fear were significantly related to one another, con-
siderable variation was noted with some children being
concordant and others being discordant across the
response systems. More precisely, based on levels of
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subjective distress and physiological arousal, two con-
cordant groups (i.e., high distress=high arousal and
low distress=low arousal) and one discordant group
(i.e., high distress=low arousal or low distress=high
arousal) were identified. These concordant and discor-
dant groups were then compared on the percentage of
steps completed on the BAT. The low distress=low arou-
sal group completed a significantly greater percentage of
steps (91%) than the high distress=high arousal group
(51%) and a marginally greater percentage of steps than
the discordant group (69%). Thus, concordance across
the three response systems is not always present; more-
over, such discordance might provide valuable infor-
mation on the severity of the disorder and its response
to various treatments as speculated upon by Davis and
Ollendick (2005).
A NOTE ON EPIDEMIOLOGY
Research on the epidemiology of specific phobias in
children and adolescents is scarce. The few studies that
have been conducted indicate that the prevalence rates
of specific phobia in youth vary considerably as a result
of differences in the sample under study (community vs.
clinic referred), the informant assessed (child or parent,
or both), the assessment method used (structured or
unstructured interviews, rating scales), and whether an
impairment criterion is part of the definition of the dis-
order. Nevertheless, with prevalence rates of up to 10%
(Silverman & Moreno, 2005), it is clear that specific pho-
bias are among the most common anxiety disorders in
youth (see also Beesdo, Knappe, & Pine, 2009). Phobias
of animals such as dogs, spiders, and snakes are quite
common, and the same is true for phobias of blood,
injuries, and shots and for environmental phobias of
storms and heights (e.g., Benjet, Borges, Stein, Mendez,
& Medina-Mora, 2012); however, the prevalence of vari-
ous specific phobia types varies from one study to
another. Specific phobias are also more prevalent among
girls than boys (e.g., Kim et al., 2010), although this
gender difference may be more prominent for some
RESEARCH ON SPECIFIC PHOBIAS IN YOUTH 3
types of specific phobia (e.g., animal phobia) than for
others. To what extent prevalence rates vary with age,
socioeconomic status, ethnicity, and culture still remains
to be clarified. More intensive studies of the epidemi-
ology of specific phobias and the various subtypes in
youth are obviously warranted.
ETIOLOGY
The current view is that the etiology of specific phobias
cannot be explained by a single process. Rather there is
accumulating evidence indicating that specific phobias
result from multiple pathogenic factors, including gen-
etic influences, aberrant brain processes, temperament
factors, negative learning experiences, avoidance, and
cognitive distortions (Muris & Merckelbach, 2001;
Ollendick, King, & Muris, 2004).
Genetics
It is well known that specific phobias run in families.
This point is nicely illustrated in an early study of Fyer
et al. (1990), who documented that first-degree relatives
of adults with specific phobias more frequently suffered
from specific phobias (31%) than first-degree relatives of
adults without specific phobias (11%). Moreover, 15% of
the children of the adults with specific phobia were diag-
nosed with specific phobia, compared with 8% of the
children of the control adults. Of additional importance,
results also indicated that the relatives of specific phobia
participants did not have an increased risk for any psy-
chiatric disorder other than specific phobia. On the basis
of these findings, Fyer et al. (1990, p. 255) concluded
that ‘‘specific phobia is a highly familial disorder that
breeds true.’’
Behavioral-genetic studies have also shown that gen-
etic transmission plays a significant role in the familial
aggregation of specific phobias. A recent review and
meta-analysis including 10 twin studies conducted in
adult populations revealed mean heritability estimates
of 32% (range ¼ 22–44%) for animal phobias, 25%
(range ¼ 0–33%) for situational=environmental phobias,
and 33% (range ¼ 28–63%) for blood-injection-injury
phobias (Van Houtem et al., 2013). Unfortunately,
however, few studies have employed a twin design to
examine the genetic liability to specific phobias in chil-
dren and adolescents. One notable exception is the
investigation by Lichtenstein and Annas (2000), who
used parent reports of specific fears and phobias in
1,106 pairs of 8- to 9-year-old Swedish twin pairs. The
overall concordance of specific phobia was higher
among monozygotic than dizygotic twins (52 vs. 25%).
Further analysis revealed that the contribution of this
genetic factor was somewhat different for various
 4 OLLENDICK AND MURIS
specific phobia types, that is, the genetic effect explained
58% of the variation in the liability for animal phobias
and 50% in the case of situational=environmental pho-
bias but only 28% for mutilation phobias (which
included blood-injection-injury phobias). In another
exception, Eley, Rijsdijk, Perrin, O’Connor, and Bolton
(2008) also found a significant contribution of the gen-
etic factor (46%) when explaining specific phobias in
854 six-year-old monozygotic and dizygotic twins from
the United Kingdom. Thus, the limited evidence avail-
able with youth is in line with what has been reported
in the adult literature and indicates that specific phobias
are at least in part heritable.
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Recently, multivariate genetic models with adults
have shown that even at a genetic level, the liability to
specific phobias is multifactorial, involving both specific
and general liabilities (Czajkowski, Kendler, Tambs,
Røysamb, & Reichborn-Kjennerud, 2011). Obviously,
more studies are needed to further investigate the dis-
tinct genetic factors underlying specific phobias and its
subtypes, especially in youth where this approach has
not been adopted thus far.
Neurobiology
During the past 20 years, an increasing number of stu-
dies have used neuroimaging methodology to identify
area-specific alterations in metabolic activity underlying
aberrations in the brain processing of fear in individuals
with a specific phobia. These studies typically use symp-
tom provocation designs (in most cases exposure to pic-
tures of the phobic stimulus) to explore differences in the
neural processing of fear-related stimuli—as assessed
with functional magnetic resonance imaging (fMRI),
single photon emission computerized tomography, or
positron emission tomography—between participants
with a specific phobia and healthy controls. Results of
this research are summarized in a recent review by Del
Casale et al. (2012) who concluded that individuals with
a specific phobia show abnormal activation in brain
areas involved in the perception and early amplification
of fear—including the formation of an autonomic arou-
sal response—such as the amygdala, anterior cingulate
cortex, thalamus, and insula. In addition, it was found
that immediately following exposure, brain areas in
the prefrontal cortex, which are normally activated
in healthy controls to regulate fear, are less activated
in individuals with a specific phobia. With continuing
exposure to the phobic stimulus, however, various corti-
cal and (pre)frontal areas do become more activated in
individuals with specific phobia, probably because of
further conscious threat evaluation, catastrophic think-
ing, and use of cognitive coping strategies. Thus, at a
structural brain level, individuals with a specific phobia
are more easily and more strongly aroused when being
confronted with fear-relevant stimuli while they have
less capability to regulate this hyperactivation (see also
Ipser, Singh, & Stein, 2013).
Of interest, there is some evidence indicating that
successful treatment of specific phobia by means of
exposure leads to a reversal of the brain activation
abnormalities typically seen in these individuals. For
example, Schienle, Schäfer, Hermann, Rohrmann, and
Vaitl (2007) examined brain activation by means of
fMRI in 26 female spider phobic adults and 25 non-
phobic controls during the presentation of spider pic-
tures. The spider phobic individuals were then
randomly assigned to either an exposure therapy group
or a waitlist group. The fMRI assessment was repeated 1
week after the therapy or after the 1-week waiting per-
iod. In keeping with the literature in this research
domain (see earlier), it was found that the phobic indivi-
duals displayed increased activation in the amygdala
and a decreased activation in the prefrontal cortex.
Most important, the exposure treatment produced
increased prefrontal cortex activity in the therapy group
relative to the waiting group. Further, a treatment-
related reduction of physical anxiety symptoms was
documented, which was accompanied by decreases in
the activation of the amygdala and insula. Schienle
et al. (2007) viewed the functional change in the acti-
vation of the prefrontal cortex as the primary process
and conclude that this might be the best indicator of a
successful treatment of this type of phobia (see also
Schienle, Schäfer, Stark, & Vaitl, 2009). Altogether, this
type of neurobiological research has yielded some
intriguing findings on the brain circuits involved in pho-
bic fear; almost all of these studies have been conducted
with animal phobia (in particular spider phobia) in
adults; and, to date, no investigation can be found
examining the fear processing in youth with animal or
other types of specific phobias.
Temperament
Behavioral inhibition refers to the tendency of some
children to interrupt ongoing behavior and to react with
distress and withdrawal when confronted with unfam-
iliar stimuli and situations. This temperament factor is
thought to be an inherited and fairly stable response dis-
position that characterizes approximately 10–15% of
children (e.g., Kagan, Reznick, Clarke, Snidman, &
Garcia-Coll, 1984). Cross-sectional and longitudinal
studies conducted by Biederman and colleagues (Bieder-
man et al., 1993; Biederman et al., 1990) have strongly
suggested that this disposition serves as a risk factor
for anxiety disorders. These studies showed that
behaviorally inhibited preschool children were more
likely to have anxiety disorders including specific pho-
bias compared to control children. This became even

more prominent at a 3-year follow-up when the rates of
specific phobias and other anxiety disorders had increased
markedly in the behaviorally inhibited group. In another
study by Muris, Merckelbach, Wessel, and Van de Ven
(1999), children 12 to 14 years of age were provided with
a definition of behavioral inhibition and then asked to
classify themselves as low, middle, or high on this tem-
perament characteristic. In addition, children completed
a standardized scale of anxiety disorders symptoms
that included separate scales for the main types of spe-
cific phobias (i.e., animal, blood-injection-injury, and
situational=environmental). Results indicated that chil-
dren in the high behavioral inhibition group more often
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reported specific phobia symptoms than did children in
the low or middle behavioral inhibition groups.
Thus, although behavioral inhibition is a vulner-
ability factor for a broad range of anxiety disorders,
it appears to be particularly so for social phobia and
specific phobias (for reviews, see Biederman,
Rosenbaum, Chaloff, & Kagan, 1995; Ollendick,
Benoit, & Grills-Taquechel, 2014). It seems plausible
to assume that behavioral inhibition represents the
genetic vulnerability factor contributing to specific
phobias, as well as its associated neurobiological sub-
strate (Fox, Henderson, Marshall, Nichol, & Ghera,
2005), and as such this temperament characteristic
seems to be a derivate of what psychologists have
labeled emotionality or neuroticism (Craske, 2003).
However, it should be noted that not all youth with
behavioral inhibition develop a specific phobia and
not all youth with a specific phobia are behaviorally
inhibited (or highly emotional or neurotic). It would
be interesting to examine whether this temperament
trait is more typical for children and adolescents with
a certain type of specific phobia, multiple phobias,
and a specific phobia with comorbid (anxiety) prob-
lems. Further, given that behavioral inhibition is so
intimately related to avoidance behavior (e.g., Allen,
Myers, & Servatius, 2014), it might be worthwhile to
examine whether this temperament factor has prognos-
tic value for the outcome of treatments addressing
youth with (multiple or complex) specific phobias.
Conditioning
As heritability accounts for a modest albeit important
proportion of the variance in specific phobias, it is
obvious that environmental influences also play a
significant role. In this context, conditioning experiences
with phobic stimuli and situations seem to be
particularly important. In addition to the case of Little
Albert, other clinical case reports suggest that at least
some specific phobias can be explained in terms of
‘‘traditional’’ classical conditioning (King, Hamilton,
& Ollendick, 1988). As but one example, Chatoor,
RESEARCH ON SPECIFIC PHOBIAS IN YOUTH 5
Conley, and Dickson (1988) described five children
(between 8 and 11 years of age) with a choking phobia
who all became fearful of eating after they had gagged
on a food item.
Nonetheless, it is important to note that the theoreti-
cal perspective on fear conditioning has changed over
the past decades. Researchers no longer conceptualize
fear conditioning as simple reflex-like stimulus-response
learning; instead they consider it to be a process during
which individuals learn that one stimulus (the con-
ditioned stimulus [CS]) is likely to predict the occurrence
of another stimulus (the unconditioned stimulus [UCS]),
which, in turn, will elicit a conditioned response under
certain conditions (Davey, 1989; Field, 2006; Mackin-
tosh, 1983). During this process, previous experiences
with the CS, as well as the subjective evaluation of the
UCS, are considered as important determinants of
whether fear conditioning will occur. For example, in
a study by Ten Berge et al. (2002), it was found that
low fearful children had experienced more innocuous
dental visits (i.e., checkups) before their first curative
treatment as compared to high fearful children. This
suggests that previous neutral experiences with the CS
might immunize against the negative impact of an
aversive event, a phenomenon that in the conditioning
literature is labelled as latent inhibition (Lubow, 1973).
Likewise, Ten Berge et al. noted that children’s personal
emotional reactions to the curative treatment enhanced
the aversiveness of the UCS (UCS inflation; Davey,
De Jong, & Tallis, 1993), leading them to the conclusion
that subjective perceptions of threat play a decisive role
during fear conditioning. It is important to note that the
role of latent inhibition and UCS inflation in the acqui-
sition of fears and phobias needs to be further investi-
gated, and that this is especially true for children and
adolescents.
After the initial attempt of Watson and Rayner
(1920), fear conditioning in young children had been
neglected for a long time. However, in recent years, a
number of research groups have begun to develop suit-
able procedures for exploring the phenomenon. For
example, Gao, Raine, Venables, Dawson, and Mednick
(2010) employed a differential conditioning paradigm in
a longitudinal sample of 200 children who were assessed
at ages 3, 4, 5, 6, and 8 years. Children were repeatedly
presented with two types of tones: One tone was paired
with a loud noise UCS (the CSþ), and another tone was
unpaired with this aversive outcome (the CS) while
electrodermal responses to these tones were measured
throughout the experimental procedure. The results
indicated that children displayed larger skin
conductance responses to the CSþ than to the CS,
evidence for a fear conditioning effect. Of interest,
although fear conditioning increased with age, it was
already present in children as young as 3 years old,
 6 OLLENDICK AND MURIS
suggesting that this mechanism might represent a rel-
evant pathway to phobias from early childhood on. In
recent years, there have been a number of other studies
that used variants of this experimental methodology to
study fear conditioning in children and adolescents with
anxiety disorders. For example, Craske et al. (2008)
evaluated aversive conditioning and extinction in chil-
dren with anxiety disorders, children at risk for anxiety
disorders (by virtue of parental diagnostic status), and
control children. All participants underwent 16 trials
of discriminative conditioning of two geometric figures,
with (CSþ) or without (CS) an aversive tone (UCS),
followed by a retest of eight extinction trials, about 2
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weeks later. It was found that both the anxious and
at-risk children displayed heightened conditioned skin
conductance responding as compared to the control
children. Of interest, a similar pattern was found for
CSþ and CStrials, suggesting that the development
of anxiety problems is associated not only with a mech-
anism of elevated excitatory responding to threat cues
but also with a process of impaired inhibition of
responding to safety cues (see also Craske, Treanor,
Conway, Zbozinek, & Vervliet, 2014; Lau et al., 2008;
Waters, Henry, & Neumann, 2009). In spite of this evi-
dence, no research can be found that evaluated the
exclusive role of such fear conditioning in youth with
specific phobias. Besides exploring the precise mech-
anism and boundary conditions of associative (CS–
UCS) learning in childhood phobias, such research
could also make use of neuroimaging techniques to
study the biological underpinnings of fear conditioning
in phobic youths (Pine et al., 2001).
Modeling and Negative Information Transmission
The classical conditioning pathway to phobias assumes
that the person has had direct experience with the CS
and the UCS. However, there are cases in which indivi-
duals develop a specific phobia despite having had no
direct experience with the CS (i.e., the phobic object)
and=or the UCS. In these cases, indirect pathways of
fear acquisition play a pivotal role. For example, fears
and phobias can be learned by observing other people’s
responses to that stimulus or situation (modeling) or by
hearing that a stimulus or situation might be dangerous
or has some other negative connotation (negative
information transmission; Rachman, 1991).
Robust empirical evidence for modeling in phobic
fear has been provided in experiments conducted by
Mineka and colleagues (e.g., Mineka, Davidson, Cook,
& Keir, 1984; see also Askew & Field, 2008), who
demonstrated that rhesus monkeys show clear signs
of distress and behavioral avoidance toward snakes
after watching a model interacting fearfully with these
reptiles. Of interest, follow-up studies revealed that
such modeling of fear occurred only for so-called
fear-relevant stimuli (e.g., snakes, spiders) and not for
fear-irrelevant stimuli (e.g., flowers, rabbits; e.g., Cook
& Mineka, 1989), which is nicely in line with M. E. P.
Seligman’s (1971) preparedness theory of phobic fear.
According to this theory, the stimuli and situations
that phobic individuals fear typically echo the dangers
that our ancestors faced in their Pleistocene savannah
environment. As a result of natural selection, fear of
these evolutionary threats would have become geneti-
cally encoded. Consequently, modern humans would
still possess a preparedness to develop phobias of
snakes, spiders, height, blood, and so on. It has been
assumed that this preparedness can become manifest
not only as a result of modeling experiences but
also as a result of other types of negative learning
(e.g., conditioning; see Öhman & Mineka, 2001). In
the meantime, it is important to note that although
Mineka et al.’s research is still regarded as strong
evidentiary support for fear learning via modeling,
the preparedness account of these findings has received
considerable critique (McNally, 1987).
More recently, researchers have begun to explore
whether modeling is involved in the acquisition of fear
in children. For example, Gerull and Rapee (2002)
observed 15- to 20-month-old toddlers who were
confronted with novel rubber toy spiders and snakes.
During the experiment, children’s mothers were also
present and instructed to display either a positive or a
negative facial expression while their offspring were
exposed to the toy animals. The results showed that tod-
dlers whose mothers displayed a negative facial
expression were more fearful and more hesitant to
approach the toy animals than toddlers whose mother
had exhibited a positive facial expression. Follow-up
experiments by Dubi, Rapee, Emerton, and Schniering
(2008) and Askew, Dunne, Özdil, Reynolds, and Field
(2013) replicated these findings but also indicated that
the observational learning of fear in children of various
ages (i.e., 15–20 months and 6–11 years, respectively)
did not occur exclusively with fear-relevant stimuli but
also with fear-irrelevant stimuli (such as mushrooms
and flowers). Obviously, the latter finding is in contrast
with the results of Cook and Mineka (1989) and the
aforementioned preparedness theory (see Coelho &
Purkis, 2009, for critique). In short, there may be
alternative explanations (which may have to do with
expectancies; Davey, 1995, and stimulus characteristics;
Berger, 2010) for why stimuli that are considered as
‘‘biologically prepared’’ are more easily associated with
aversive outcomes and thus more often develop into a
serious fear or a phobia.
Negative information transmission is assumed to be
another indirect learning mechanism by which fears
and phobias can be acquired. Field, Argyris, and

Knowles (2001) developed an experimental paradigm
that makes it possible to explore the causal role of this
pathway in the development of childhood fears. The
general outline of this paradigm is simple and straight-
forward: Children are confronted with negative infor-
mation about an unknown stimulus, and before and
after this experimental manipulation their level of fear
to this object is assessed. In a first test, children between
7 and 9 years of age received either negative or positive
information about two unknown monster dolls. Results
showed that fear-related beliefs about the monster dolls
changed significantly as a function of the verbal infor-
mation: Negative information increased children’s self-
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reported fear, whereas positive information decreased
their fear level. In subsequent experiments, the
‘‘monsters’’ in the original paradigm were replaced by
novel but real animals (Australian marsupials such as
the quoll, quokka, and cuscus); moreover, fear was
measured not only by means of self-report but also
with physiological and behavioral indices (e.g., Field &
Lawson, 2003; Field & Schorah, 2007). The initial
findings were confirmed: Negative information is a
powerful way of producing fear of a stimulus for which
children have no prior knowledge, and these fear-
enhancing effects are present in all fear modalities (for
a review, see Muris & Field, 2010).
At least two interesting research lines emerged from
the initial experimental work on the role of negative
information in young children’s fear. First, attempts
were made to explore whether this pathway is involved
in the transmission of fear from parents to children.
For example, Muris, Van Zwol, Huijding, and Mayer
(2010) presented mothers of 8- to 13-year-old children
with ambiguous information about a novel animal
(i.e., the cuscus; ‘‘The cuscus eats about everything’’),
and then asked them to prepare their offspring for a
confrontation with this animal by telling brief stories
with a series of open-ended vignettes. It was found that
trait anxious mothers interpreted the ambiguous infor-
mation about the cuscus in a threatening way and told
rather negative stories about this animal to their chil-
dren. They pointed to the dangerousness of the animal
and prompted their offspring to watch out and to stay
away from it, lest it eat them. Children appeared to pick
up the message of their mothers: The more negative the
stories of their mother, the higher their fear levels
toward the animal. Second, although Field et al.’s
(2001) paradigm has been predominantly employed to
investigate the effects of threat-related information, there
may be other types of negative information that enhance
children’s fear. For instance, based on the notion that the
emotion of disgust also plays a crucial role in some spe-
cific phobia subtypes (Olatunji & McKay, 2009), studies
have examined whether the provision of disgust-related
information also has fear-inducing effects. This research
RESEARCH ON SPECIFIC PHOBIAS IN YOUTH 7
has shown that disgust information about novel animals
has the potential of promoting fear and avoidance in
children (e.g., Muris et al., 2009) and that parents
may function as an important modum in the trans-
mission of this type of negative information (Muris,
Mayer, Borth, & Vos, 2013).
Altogether, there is accumulating evidence suggesting
that the indirect learning pathways of modeling and
negative information transmission are frequently
involved in the acquisition of childhood fear. Of interest,
there is also tentative support showing that these
mechanisms of learning can be exploited therapeutically:
More precisely, some studies have demonstrated that
modeling approach behavior and the provision of
positive information decreases children’s fear of novel
animals (Broeren, Lester, Muris, & Field, 2011; Kelly,
Barker, Field, Wilson, & Reynolds, 2010; Muris,
Huijding, Mayer, Van As, & Van Alem, 2011). How-
ever, so far, research of this type has been exclusively
conducted in nonclinical youth, and thus studies using
the aforementioned paradigms need to be conducted in
children and adolescents with clinical levels of phobic
symptoms.
Avoidance and Cognitive Biases
Mowrer’s (1960) influential two-stage model assumes
that although direct and indirect learning experiences
account for the acquisition of specific phobias, avoid-
ance behavior is responsible for their maintenance. That
is, avoidance serves to minimize direct and prolonged
contact with the phobic object and does not allow the
phobic person to learn that the CS is in fact harmless.
Meanwhile, by evading the phobic stimulus, subjective
feelings of fear and physiological arousal decrease,
thereby negatively reinforcing the avoidance behavior.
As noted by Ollendick, Vasey, and King (2001), there
is considerable evidence that avoidance is the key
mechanism in the conservation of phobic fear. In chil-
dren and adolescents specifically, it is also assumed that
parents play an important role in either the promotion
or elimination of avoidance behavior in their offspring.
Ollendick, Lewis, Cowart, and Davis (2012) recently
found some support for this idea. In their sample of
clinic-referred youth with specific (animal) phobias,
participants completed two BATs: the first one alone
and the second one with a parent present. Overall, it
was found that children were less avoidant during the
parent-present BAT (58% of steps completed) than
during the child-alone BAT (38% of steps completed).
Of interest, performance on the parent-present BAT
was influenced by parent characteristics in addition to
the parents own level of fear: Children performed less
well and thus were more avoidant when their parents
were less warm and less involved in the BAT.
 8 OLLENDICK AND MURIS
However, overall, empirical investigations on the role
of avoidance in childhood specific phobias are scarce,
probably because the lack of convenient measures for
assessing this construct. However, such instruments
are beginning to emerge. For example, Whiteside,
Gryczkowski, Ale, Brown-Jacobsen, and McCarthy
(2013) constructed brief self-report and parent-report
scales for measuring behavioral avoidance in youth with
specific phobias and other anxiety disorders, whereas
Klein, Becker, and Rinck (2011) developed a computer-
ized, reaction-time-based approach-avoidance task
during which children handle a joystick to pull phobia-
relevant stimuli toward themselves or to push them
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away, which provides an index of automatic avoidance
tendency. Clearly, these new measures can be employed
in future research in order to learn more about the role
of avoidance in the development, maintenance, and even
treatment of phobias in children and adolescents.
Further, building on work in cognitive psychology,
an increasing amount of research shows that phobic
individuals display various types of cognitive biases,
reflecting an enhanced processing of threat-related
information. For instance, experimental studies have
demonstrated that individuals with phobias are hypervi-
gilant in their perception of threat cues, a phenomenon
that has been labeled as attentional bias. Vasey,
Daleiden, Williams, and Brown (1995) were among the
first to show that this type of bias is also present among
youth with high levels of anxiety. These researchers
administered a dot probe detection task in a group
of 9- to 14-year-old highly anxious children and a group
of age-matched nonanxious control children. The
results of this study indicated that children high in
anxiety, relative to controls, were faster to react to a
probe if it was preceded by a threatening rather than a
neutral word, in keeping with the hypothesis that
anxious youth allocate significantly more processing
resources toward threat-related material. Although
the Vasey et al. study enlisted youth high in anxiety,
attention bias is also a cognitive distortion that is
highly evident in youth with specific phobias, and there
is evidence that it is already present in children at a
very young age (LoBue, 2010). In recent years, more
sophisticated paradigms have made it possible to study
different components of attention effects that may occur
at different points in time during the processing of
fear-related stimuli (i.e., fast detection of threat,
difficulty to disengage from threat, tendency to shift
attention away from threat; e.g., Koster, Crombez,
Verschuere, & De Houwer, 2004). Researchers have
begun to study these different variants of attentional
bias in youth (e.g., Waters, Bradley, & Mogg, 2014),
but much work remains to be done.
Although attentional bias operates during the early
stages of information processing, there are other
cognitive biases at work during subsequent, more
conceptual stages. A typical example of such a bias in
specific phobias is the covariation bias, which is con-
cerned with a tendency to overestimate the association
between fear- or phobia-related stimuli (CS) and nega-
tive outcomes (UCS; Tomarken, Mineka, & Cook,
1989). In an experiment by Muris, Huijding, Mayer,
Den Breejen, and Makkelie (2007), the first evidence
was obtained for the existence of this type of bias in
youth. Children 8 to 16 years of age played a computer
game during which they were exposed to a series of pic-
tures containing spiders (i.e., negative fear-relevant
stimulus), guns (i.e., negative fear-irrelevant stimulus),
and flowers (i.e., neutral control stimulus). Immediately
after each picture, a face was generated by the computer
signaling the outcome of that trial: A happy face indi-
cated that the child had won three pieces of candy, a
sad face indicated that the child had lost three pieces
of candy, and a neutral face had no positive or negative
consequences. The pictures were shown in a random
order, and the computer game was programmed in such
a way that each picture type was equally often followed
by a happy, sad, or neutral face. After the computer
game, children were asked to provide estimates on the
observed contingencies between the three picture types
and various outcomes. Results indicated that children
displayed an inclination to link the negative outcome
to negatively valenced pictures (i.e., they believed that
they had more often lost candy following pictures of spi-
ders and guns). Most important, the findings also
demonstrated that this covariation bias was modulated
by fear. That is, spider-fearful youths showed a stronger
tendency to associate the spider pictures with a negative
outcome (i.e., losing candy). These results are in line
with what has been reported in the adult literature
(e.g., Tomarken et al., 1989) but still await replication
in clinically referred children and adolescents with
specific phobias.
Although it seems plausible that cognitive biases are
also involved in the preservation of specific phobias in
youths, the empirical support for this idea is limited at
this time. Attempts have been made to explore whether
attentional bias is a predictor of treatment success. For
example, Legerstee et al. (2009) conducted a study in
which 131 children and adolescents (8–16 years of age)
with anxiety disorders (about one third of whom had
a specific phobia) performed a pictorial dot probe task
before they received a standardized cognitive-behavioral
treatment. Results indicated that selective attention for
threatening pictures was predictive of treatment out-
come. Further inspection of the specific components of
attentional bias revealed that treatment nonresponders
were characterized by difficulties to disengage their
attention away from threat, whereas treatment
responders showed an initial tendency not to engage

their attention to threat. These findings indicate that
various types of attentional biases exist in anxious and
phobic youths, which may have differential implications
for the continuation of the anxiety pathology (see also
Waters, Mogg, & Bradley, 2012).
Multifactorial Origin
As noted earlier, specific phobias—like other types of
child psychopathology—are thought to have multi-
factorial origins. So far, studies have mainly focused
on isolated factors, but it would be extremely valuable
if future research would make attempts to study how
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various factors interact with each other in the develop-
ment of specific phobias. As it seems impossible to
design studies including all factors involved, we provide
a few examples of what such research might look like.
First, classic longitudinal studies could be conducted
to explore the role of more distal factors such as familial
(genetic) vulnerability, temperament, cognitive biases,
and avoidance tendencies of children and parents in
the development of specific phobias. Second, experi-
mental work could focus on the additive and interactive
effects of direct (conditioning) and indirect (modeling,
negative information transmission) learning experiences
on the acquisition of fear for novel stimuli (i.e., the for-
mation of strong CS–UCS associations) while also
studying individual difference variables that increase
children’s proneness to such learning events (e.g.,
behavioral inhibition; e.g., Field & Price-Evans, 2009).
Third, a number of the etiological factors (i.e., learning
experiences and cognitive biases) are also preeminently
suitable for being studied by means of neuroimaging
techniques, and such research could provide valuable
insight in the biological underpinnings of the pathogen-
esis of childhood specific phobias.
ASSESSMENT
Given the complex clinical presentation (e.g., phenom-
enology, comorbidity, etiology) of specific phobia, a
thorough assessment is critical to the provision of
evidence-based treatments (Ollendick et al., 2004). A
comprehensive assessment should ideally be multi-
method (e.g., clinical diagnostic interview, question-
naires, behavioral observation, cognitive tasks) and
multi-informant (e.g., child, parent, teacher, and per-
haps peers) to gain an accurate picture of the child
across contexts and settings (Silverman & Ollendick,
2005, 2008). To develop a complete picture of the child’s
specific phobia, it is also desirable to investigate all
aspects of the phobic response (cognition, psychophys-
iology, behavior, and subjective distress; Davis &
Ollendick, 2005). In addition, in as much as specific
RESEARCH ON SPECIFIC PHOBIAS IN YOUTH 9
phobias are frequently comorbid with other disorders,
it is desirable to undertake a broad assessment of
psychopathology to identify these comorbid conditions
and to assist in differential diagnosis (e.g., specific pho-
bia of the dark vs. separation anxiety; specific phobia of
choking vs. panic disorder). Quite obviously, to address
all of these aims is a formidable undertaking and it is not
always possible to achieve all of them; rather, selective
assessment that targets the specific phobia of an individ-
ual child and the context in which it occurs is paramount
(see McLeod, Jensen-Doss, & Ollendick, 2013). In the
pursuit of these goals, several different tools are avail-
able, including reliable and valid diagnostic interviews
(e.g., Anxiety Disorders Interview Schedule for DSM-IV:
Child and Parent Versions; Silverman & Albano, 1996)
and self-report (e.g., the Fear Survey Schedule for
Children–Revised, Ollendick, 1983; the Spence Chil-
dren’s Anxiety Scale, Spence, 1998) and parent-report
questionnaires (e.g., the Achenbach System of Empiri-
cally Based Assessment, Achenbach, 2009). In addition,
Muris, Simon, Bos, and Hale (2014) recently con-
structed the Youth Anxiety Measure for DSM-5, which
measures the frequency of children’s and adolescents’
anxiety disorders symptoms in terms of the latest
version of this psychiatric classification system. This
self- and parent-report questionnaire includes 18 items
covering the five types of specific phobias (i.e., animal,
natural environment, blood-injection-injury, situational,
and other). Obviously, this new scale now needs to be
subjected to rigorous psychometric evaluation.
In addition to these more traditional diagnostic and
self- and parent-report measures, a BAT is an integral
part of any specific phobia assessment, as it allows one
to directly observe the youth’s phobic behaviors. The
BAT is a controlled and standardized test in which the
child is asked to approach a phobic object or situation
so that avoidance behavior can be observed directly.
Performance on the test is scored as the number of steps
successfully completed during the test, which provides
an objective assessment of the phobic behavior. Further,
the child can be asked about the experienced level of fear
at each step and his or her expectancies and catastrophic
beliefs in relation to phobic object or situation
(Ollendick, Raisevich, Davis, Sirbu, & Öst, 2010).
Finally, physiological data, such as heart rate and skin
conductance responses, may also be collected. Thus,
BATs enable the clinician to assess all three systems of
the child’s phobic response (subjective=cognitive,
physiological, and behavioral; see earlier).
Although BATs allow the clinician to directly observe
the child’s behavior in the presence of the phobic object
or situation and hence can be used to confirm or extend
the information obtained from diagnostic interviews and
questionnaires, their implementation in clinical practice
is limited. The main reason for this probably is that
 10 OLLENDICK AND MURIS
BATs are sometimes challenging to arrange (e.g.,
retrieving, storing, and caring for stimuli or scheduling
offsite visits). Still, the incorporation of BATs into the
assessment process is strongly recommended, not only
because this type of assessment provides important
diagnostic information but also because it gives an indi-
cation of a possible starting point for treatment and
what the child is currently able to manage in terms of
interacting with the phobic object or situation (Davis
& Ollendick, 2011). The use of BATs in research is also
sparse, which is unfortunate because the simultaneous
assessment of all three systems of the phobic response
provides unique venues for scientific research. For
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example, as noted earlier, concordance=discordance
across fear systems may be related to severity of the pho-
bia and thus potentially has prognostic value for therapy
outcome (Ollendick et al., 2011). In addition, examin-
ation of treatment responsivity in all three systems could
provide a better picture of the extent to which therapy
was actually successful in eliminating the specific phobia
in the child or adolescent (Davis, May, & Whiting,
2011). Finally, the three-systems assessment as provided
by BATs could resolve important theoretical issues on
gender differences in phobias (e.g., Are girls really more
fearful than boys? Ginsburg & Silverman, 2000) and
children’s courageous behavior (i.e., taking action in
the face of, and despite, fear; Muris, 2009; Muris,
Mayer, & Schubert, 2010).
Similar to BATs, recent years have witnessed an
emergence of studies using other assessment tools,
including performance-based measures, particularly
those emanating from experimental cognitive psychol-
ogy (e.g., the aforementioned dot probe test and the
approach-avoidance task), to assess cognitive processes
and behavioral tendencies in youth with specific phobias
and other anxiety disorders (for an overview, see Muris
& Field, 2008). Although this research has yielded
important information on the way that phobic and
anxiety-disordered children process fear-relevant
information, thereby providing further insight in the
persistence of these problems, most of these performance-
based measures are limited from a psychometric point of
view (Hadwin & Field, 2010). In the upcoming years, it
will be a challenge for researchers to demonstrate that
these cognitive tasks are reliable and valid; in addition,
normative data need to be collected before these
measures can be transported to and applied in clinical
practice.
Finally, the finding in the adult literature that specific
phobias are associated with increased amygdala and
decreased prefrontal cortex activation (Schienle et al.,
2007; Schienle et al., 2009) calls for replication in
children and adolescents with this anxiety disorder.
However, the cost and specialized training of the
equipment needed to assess these biological indices
reduce the likelihood of their adoption in clinical
practice settings.
TREATMENT
Freud did not actually conduct therapy with Little Hans
(he only had a couple of informal contacts with the
young boy’s father), but the phobic complaints
disappeared, and this was taken as support for the
effectiveness of child psychoanalysis in the treatment
of specific phobias (King et al., 1988; Wolpe &
Rachman, 1960). However, more than a century later,
there is no empirical evidence for the use of psychody-
namic therapy in treating specific phobias in children
and adolescents. The scientific legacy of Little Albert
fares considerably better in this respect. Inspired by
Watson and Rayner’s (1920) experiment, Cover Jones
(1924) developed the procedure of desensitization, which
refers to the unlearning of fear via repeated confron-
tations with the phobic stimulus or situation. This
technique is now labeled as exposure and is an essential
part of behavioral and cognitive-behavioral interven-
tions. Indeed, a meta-analytic study performed on 33
randomized controlled trials examining the efficacy
of psychological treatments for specific phobias in
adults indicated that exposure-based interventions
were superior over alternative treatment approaches
(Wolitzky-Taylor, Horowitz, Powers, & Telch, 2008).
The treatment outcome research on childhood
specific phobias is clearly less substantial, but there is
support for a number of interventions and in all of them
exposure plays an important role (Grills-Taquechel &
Ollendick, 2012; L. D. Seligman & Ollendick, 2011).
Traditional behavioral therapies such as systematic
desensitization, reinforced practice (or contingency
management), and participant modeling all require
children to progress through a graduated exposure
hierarchy and combine this with another therapeutic
component (respectively relaxation, reinforcement, and
vicarious learning; Essau & Ollendick, 2013; Ollendick
& Cerny, 1981). Cognitive-behavioral therapy (CBT)
for phobic and anxious youth developed during the
early 1990s (see Kendall, 1994) includes exposure to
feared stimuli and situations as a key element but also
incorporates many of the aforementioned behavioral
techniques, as well as cognitive restructuring to correct
children’s negative thinking in relation to the feared
stimuli. This intervention has been repeatedly shown
to be more effective than a waitlist control condition
or a psychological placebo treatment (Silverman, Pina,
& Viswesvaran, 2008), and at least one study has now
demonstrated that it is equivalent to pharmacotherapy in
efficacy (Walkup et al., 2008). As such, CBT—according
to criteria for evidence-based treatments specified by

Chambless and Ollendick (2001)—can be regarded as a
well-established treatment for youth with phobias and
anxiety disorders. However, although children and ado-
lescents with specific phobia have participated in the
controlled trials evaluating the efficacy of CBT, this
research has primarily been undertaken with other anxi-
ety problems (i.e., generalized anxiety disorder, separ-
ation anxiety disorder, and social phobia). So far, no
study can be found that has investigated the effect of
this generic, transdiagnostic CBT treatment with chil-
dren and adolescents with specific phobias, and so the
relative efficacy of this approach remains unclear.
A variant of CBT called One-Session-Treatment
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(OST) has been specifically developed for treating spe-
cific phobias; initially the intervention was designed
for adults (Öst, 2012), but later the protocol was
adapted for use with children and adolescents (see
Davis, Ollendick, Reuther, & Munson, 2012; Ollendick
& Davis, 2013). OST consists of a single, 3-hr session
of graduated hierarchical exposure in combination with
elements of psychoeducation, participant modeling,
reinforced practice, skills training, and cognitive
restructuring. The therapist first provides a rationale
for treatment and identifies the child and therapist as a
‘‘team’’ who are working together to overcome the
child’s fear. Treatment comprises a series of behavioral
‘‘experiments’’ during which the child is encouraged
to approach the feared stimulus while thinking of him-
or herself as a ‘‘scientist’’ or ‘‘detective’’ testing out
phobic cognitions. The therapist acts as a model
demonstrating how to handle the fearful situation,
encouraging the child to participate in the exercises,
and providing reinforcement following successful
approach behavior.
There is strong empirical support for OST as an effec-
tive intervention for youth with specific phobias. For
example, in the largest controlled trial conducted at
two sites in Sweden and the United States, Ollendick
et al. (2009) randomly allocated 196 children and
adolescents with a diverse range of phobias to OST,
educational support (i.e., a psychological placebo inter-
vention that did not include exposure or cognitive
restructuring as active treatment ingredients), or a
waitlist control condition. Treatment outcome was
evaluated by means of semistructured diagnostic inter-
views, self- and parent-report questionnaires, and BATs,
which were all administered at pretreatment, posttreat-
ment, and 6-month follow-up. Results showed that
OST and educational support were superior to the wait-
list control condition. Moreover, OST yielded better
outcome than educational support on clinician ratings
of phobia severity, percentage of participants being
diagnosis free at posttreatment (i.e., 55% following
OST vs. 23% following educational support), child
ratings of anxiety during the BAT, and treatment
RESEARCH ON SPECIFIC PHOBIAS IN YOUTH 11
satisfaction. Treatment gains in both active treatment
conditions were maintained at the 6-month follow-up.
Other randomized controlled studies have also pro-
vided empirical support for the efficacy of OST in youth
with specific phobias. More precisely, research has shown
that OST produces better results compared to a waitlist
control condition (Flatt & King, 2010; Leutgeb, Schäfer,
Köchel, & Schienle, 2012; Leutgeb & Schienle, 2012; Öst,
Svensson, Hellstrom, & Lindwall, 2001) and that it is
superior to an alternative psychological approach for
treating specific phobias (i.e., eye-movement desensitiza-
tion and reprocessing; Muris, Merckelbach, Holdrinet,
& Sijsenaar, 1998; Muris, Merckelbach, Van Haaften,
& Mayer, 1997). Given that these positive effects have
been documented by multiple research groups from vari-
ous parts of the world (i.e., Australia, Austria, Sweden,
the Netherlands, and the United States), with youth
who have a diverse range of specific phobias, OST can
be viewed as a well-established treatment for children
and adolescents with specific phobia.
Although CBT—and OST in particular—has been
shown to be effective for youth with specific phobias,
there still remains a significant proportion of youth
(i.e., 20–50%) who only partially respond or do not
respond at all to these treatments. Thus, attempts
should be made to further improve the outcomes for
these youth. One possibility could be to combine CBT
or OST with pharmacotherapy. There is some evidence
indicating that children and adolescents with other
anxiety disorders show greater improvement following
a combination treatment of CBT with a selective
serotonin reuptake inhibitor (as compared to the mono-
therapies of CBT and medication alone; see Walkup
et al., 2008). Although the current consensus is that an
exposure-based intervention is the treatment-of-choice
for specific phobias and that medication has little addi-
tive value (Muris, 2012; Ollendick & March, 2004),
research on this topic is largely lacking, and thus it
remains possible that a combination of CBT=OST and
pharmacotherapy may be indicated for youth with mul-
tiple specific phobias and comorbid psychopathology.
Another possibility to enhance the effectiveness of
OST was recently explored by Ollendick et al. (2015),
who investigated whether the involvement of parents
might serve in this regard. Ninety-seven phobic youth
6 to 15 years of age were randomly assigned to either
regular OST or a parent-augmented OST, during which
parents received psychoeducation about the etiology
and maintenance of specific phobias, were provided
with the rationale for this type of treatment, directly
observed the treatment of their child, practiced what
they had observed with their child, and received
instructions on how to help their child conduct the
exposure exercises in their homes following treatment.
Surprisingly, treatment outcome assessments conducted
 12 OLLENDICK AND MURIS
at posttreatment and follow-up revealed that parental
involvement did not enhance OST treatment outcome,
with no significant differences being observed between
the two groups. Ollendick and colleagues speculated that
parents in the augmented condition who had seen their
children do well in treatment and felt empowered to help
them following treatment developed inordinately high
expectations for their children and perhaps became less
tolerant of their children’s semiavoidant behaviors fol-
lowing treatment. Indeed, following treatment, several
parents commented on how frustrated they became with
their children when they could not or would not engage
the phobic stimulus as they had during treatment, despite
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their best efforts to help them to do so. This possibility
awaits further examination, and we are mindful of the
admonition of Barmish and Kendall (2005), who
asserted that ‘‘as alluring as it might be to include parents
as co-clients for multiple theoretical reasons, this belief
cannot be mistaken as evidence’’ (p. 578). We concur.
Yet another possibility to enhance the effectiveness of
OST and other CBT approaches in the treatment of spe-
cific phobias in youth is the use of attention bias modi-
fication training (ABMT). ABMT aims at the correction
of the initial hypervigilance in the perception of threat
cues that is so typical for individuals with phobias and
other anxiety disorders. ABMT is conducted by means
of a dot probe task, which requires participants to detect
the location of a dot that appears on the location of
either a threat-related or neutral stimulus that are briefly
presented on a computer screen. By presenting the dot
always on the location of the neutral stimulus, an indi-
vidual can be trained to move attention away from
threat. Following the pioneering work by MacLeod,
Rutherford, Campbell, Ebsworthy, and Holker (2002),
a host of studies have demonstrated that this procedure
is effective in reducing fear and anxiety in adults (for a
review, see Hakamata et al., 2010). Recently, attempts
exploring the effects of ABMT in youth with anxiety dis-
orders have yielded similar positive results (e.g., Bechor
et al., 2014; Eldar et al., 2012; Shechner et al., 2014;
Waters, Pittaway, Mogg, Bradley, & Pine, 2013).
Although these studies included some children and ado-
lescents with specific phobias, only one study can be
found that specifically focused on this anxiety disorder.
In that study, Waters et al. (2014) examined whether
ABMT augmented the efficacy of OST in the treatment
of childhood phobias. Thirty-seven youth 6 to 17 years
of age were randomly assigned to OST plus ABMT or
OST plus control training. The results showed that
OST plus ABMT produced somewhat better treatment
results than OST plus control training, but on most out-
come measures no differences between the conditions
were observed. Waters et al. (2014) suggested that a
stronger dose of AMBT might be necessary to
demonstrate the extra effect over and above an already
powerful intervention such as OST. Moreover, it would
be interesting to study the efficacy of ABMT as a
stand-alone intervention for children and adolescents
with specific phobias.
Other new developments have used diverse techno-
logical applications in the treatment of specific phobias.
For instance, there is a body of evidence on the efficacy
of Internet-delivered cognitive-behavioral interventions
for anxiety disorders in adults (Andrews, Cuijpers,
Craske, McEvoy, & Titov, 2010). Recently, an open trial
by Vigerland et al. (2013) has shown that the delivery of
CBT via the Internet may also have potential to reduce
symptom severity in 8- to 12-year-old children with spe-
cific phobias, but clearly randomized controlled trials are
needed to further evaluate this treatment format.
Another technological application is computer-aided
vicarious exposure (CAVE), which asks the phobic per-
son to guide an avatar through a hierarchy of exposure
exercises that are simulated on a computer screen (e.g.,
Smith, Kirkby, Montgomery, & Daniels, 1997). A first
evaluation of the efficacy of CAVE in youth with spider
phobia has demonstrated that this intervention resulted
in significant reductions of phobic symptomatology,
although exposure in vivo was clearly superior on subjec-
tive as well as behavioral outcome measures (Dewis et al.,
2001). Given these promising results, further exploration
of the efficacy of CAVE seems warranted: Such research
should establish the issue of clinical improvement (i.e.,
the proportion of children and adolescents who are diag-
nosis free) and the applicability to other types of specific
phobias. As a final example, virtual reality (VR) makes
use of computer-generated environments that can simu-
late a physical presence in the real or imagined world
by presenting a person not only with visual images but
also with other sensory information (e.g., sound, move-
ment, tactile experiences). With this technology, nonlive
exposures to phobic stimuli or situations become fairly
realistic, which might give this technology considerable
therapeutic potential. In fact, controlled treatment out-
come research conducted with adults with specific pho-
bias (in particular of spiders, heights, and flying) has
shown that VR treatment is effective and equipotent to
exposure treatment with regard to fear reduction on
the subjective=cognitive, physiological, and behavioral
level (Parsons & Rizzo, 2008; Powers & Emmelkamp,
2008). However, the utility of this approach is largely
unknown in youth with specific phobias (Bouchard,
2011), and studies evaluating this innovative procedure
in this population are desperately needed.
Moderators and Mediators of Change
Unfortunately, there is still a dearth of research on
moderators and mediators of effective interventions
for childhood specific phobias. Moreover, the available

evidence on moderators is mixed. For example, some
studies do not show that age has an impact on the treat-
ment outcome of OST (e.g., Ollendick et al., 2009; Öst
et al., 2001), but the parent augmentation study by
Ollendick et al. (2015) revealed that age of the child pre-
dicted treatment outcome across both OST interven-
tions. More specifically, older children were rated by
the parents as showing greater improvement in dealing
with their phobia and by masked clinicians as having
lower clinical severity associated with their phobia at
posttreatment and at follow-up in both the standard
and parent-augmented conditions. Thus, for younger
children OST was somewhat less successful, which seems
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puzzling in light of the fact that specific phobias have
such an early age of onset and the duration of the pho-
bia would be potentially less than it would be for older
children. This might suggest a need to adjust and deliver
the intervention as a function of development, which
could be achieved by using techniques such as play,
emotive imagery, drawings, and cartoons when treating
younger children. Promising work in this direction has
been conducted (e.g., Minde, Roy, Bezonsky, &
Hashemi, 2010; Monga, Young, & Owens, 2009) but
needs further replication and elaboration.
With regard to mediators, precious little is known
about the mechanisms at work during effective interven-
tions for childhood specific phobias. Most clinicians
agree on the notion that exposure is an important
element of any effective treatment for specific phobias,
and this has been confirmed by research (Wolitzky-
Taylor et al., 2008). According to modern learning
theory and cognitive psychology, exposure is thought
to have its positive results because either the CS–UCS
association is broken down so that fear extinction
occurs (Hofmann, 2008) or the threat-laden beliefs and
faulty cognitive assumptions are disconfirmed through
the repeated exposure exercises (Foa & Kozak, 1986;
Foa & McNally, 1996). Yet, to date, no study can be
found that has investigated whether a decrease in the
strength of the CS–UCS relationship or the changes in
faulty cognitions is the mechanism underlying successful
exposure therapy for specific phobias in youth. More-
over, interventions such as CBT and OST consist of
treatment packages that include many therapeutic com-
ponents in addition to exposure. It may be very useful to
conduct dismantling studies to explore the relative effi-
cacy of these components in the treatment of children
and adolescents with specific phobias, so that these
interventions can be fine-tuned and further optimized.
CONCLUSION
Based on our review, it is clear that we have learned
much about specific phobias since the seminal case
RESEARCH ON SPECIFIC PHOBIAS IN YOUTH 13
studies of Little Hans and Little Albert. Yet, as we have
noted, much of this knowledge is based on findings from
adults and=or nonclinical samples of children. Although
much research awaits us in the ensuing years, the foun-
dation for additional inquiry is firmly in place. We need
to build upon this foundation, enlist what we already
know, and explore new and creative ways to implement
and disseminate what we learn in this process. In a
recent review, Young, Ollendick, and Whiteside (2014)
examined barriers to the implementation and dissemi-
nation of exposure strategies in routine clinical practice.
Although the barriers are considerable (and beyond the
scope of this article), Young et al. concluded that they
are addressable and that the implementation of
exposure-based strategies is critical for the advance of
evidence based practice (see also Ollendick, 2014). We
conclude our discourse with 16 specific, bulleted topics
for future research that we hope will guide the next
generation of research and address the shortcomings
we have identified in this review.
. The epidemiology of DSM-5-defined specific
phobias in youth, with special attention for varia-
tions in prevalence rates with regard to phobia
subtype, age, gender, socioeconomic status, and
culture=ethnicity
. Distinct specific and general genetic liability fac-
tors underlying specific phobias and its subtypes
in children and adolescents
. Neurobiological research into the underlying
aberrations in the brain processing of fear in
children and adolescents with diverse specific
phobias
. Temperamental vulnerability of children and
adolescents with a certain type of specific phobia,
multiple phobias, and a specific phobia with
comorbid anxiety and depression, as well as other
problems such as attention deficit hyperactivity
disorder
. Experimental studies exploring the mechanism and
boundary conditions of fear conditioning, as well
as it biological underpinnings in youth with differ-
ent types of specific phobias
. The role of the indirect learning pathways of
modeling and negative information transmission
in youth with clinical levels of phobic symptoms
. The precise role of avoidance and cognitive biases,
as well as parenting practices and parental psycho-
pathology, in the onset, course, and maintenance
of childhood specific phobias
. Research exploring the multifactorial origin of
specific phobias in youth, which should focus on
additive and interactive effects of various risk
and vulnerability factors as well as associated,
underlying brain processes
 14 OLLENDICK AND MURIS
. Psychometric evaluation of new DSM-5-based
self- and parent-report scale for measuring symp-
toms of specific phobias in youth and cognitive
performance-based measures assessing the proces-
sing of fear-relevant information
. More frequent employment of the BAT and
assessment of concordance=discordance among
the three response systems and the implications
for treatment outcomes
. Evaluation of the efficacy of generic, transdiagnos-
tic CBT for children and adolescents with specific
phobias, and compare them with the efficacy of
OST
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. Research on moderators and mediators of effec-
tive interventions for specific phobias in youth
. Dismantling studies exploring the relative efficacy
of various therapeutic components included in
interventions such as CBT and OST
. Development of age-sensitive variants of effective
interventions for childhood phobias such as OST
. Evaluation of pharmacotherapy and new treat-
ment techniques (AMBT, CAVE, and VR) as
add-on and=or stand-alone interventions for youth
with specific phobias
. Examination of specific barriers to the implemen-
tation and dissemination of effective exposure-
based techniques in routine clinical practice
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