Pediatric Anxiety Disorders

Scott N. Compton, Marianne A. Villabo, Hanne Kristensen

• Publisher: Academic Press
• Year: 2019
• ISBN:
  9780128130056
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Pediatric Anxiety Disorders provides a critical, updated and comprehensive overview of anxiety disorders in children and adolescents based on the current state of empirical research. The book provides specific clinical recommendations which integrate new knowledge from neuroscience and innovative delivery formats for interventions. This is the first reference to examine anxiety diagnoses in accordance with the latest edition of the DSM-5, including childhood onset disorders, such as Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphobia and Generalized Anxiety Disorder. The book assists clinicians in critically appraising the certainty of the evidence-base and the strength of clinical recommendations.

• Uses the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5
• Includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach in assessing guideline development
• Focuses on advances in etiology, assessment and treatment
• Presents new advances in our understanding of the brain behind fear and anxiety
• Uses a stepped care approach to treatment

Section II

Disorders

Outline

• Chapter 7 Specific Phobia
• Chapter 8 Separation Anxiety Disorder
• Chapter 9 Panic Disorder and Agoraphobia
• Chapter 10 Social Anxiety Disorder: An Update on Diagnostics, Epidemiology, Etiology, Assessment, Treatment, Unanswered Questions, and Future Directions
• Chapter 11 Selective Mutism
• Chapter 12 Pediatric Generalized Anxiety Disorder
• Chapter 13 Comorbidity in Childhood Anxiety Disorders

Chapter 7

Specific Phobia

Ella L. Oar¹, Lara J. Farrell² and Thomas H. Ollendick³, ¹Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, Australia, ²School of Applied Psychology and Menzies Health Institute QLD, Griffith University, Gold Coast, QLD, Australia, ³Child Study Centre, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States

Abstract

Of the anxiety disorders, specific phobia is one of the most common, affecting up to 20% of young people. Phobias have a complex clinical presentation in youth and are associated with substantial impairment. If untreated they tend to have an unremitting course resulting in lifelong suffering. In this chapter, we discuss the phenomenology and etiology of the phobias and then describe current evidence-based approaches to assessing and treating this disorder in youth. Latest advances in literature are discussed and recommendations given for future basic sciences and applied research in the area.

Keywords

Specific phobia; child; adolescent; assessment; one session treatment

Outline

• DSM-5 Diagnosis 128
• Prevalence 128
• Etiology 129
  • Genetics 129
  • Neurobiology 129
  • Temperament 130
  • Learning 130
  • Parenting 131
  • Cognitive Biases and Avoidance 131
• Development and Course 132
• Comorbidity 133
• Assessment 134
  • Diagnostic Classification and Differential Diagnosis 134
  • Questionnaires 137
  • Behavioral Approach Tasks and Assessment of Phobic Beliefs 138
• Treatment 139
  • Evidence-Based Psychosocial Treatments 139
  • Pharmacological Treatments 141
  • Recent Developments in Treatment 142
• Conclusions and Recommendations 144
• References 144

Over the course of normal development children experience a range of fears (Muris, Merckelbach, Gadet, & Moulaert, 2000). Although usually transient in nature, for some children these fears persist causing significant distress and impairment in functioning. There is a common misconception among parents and health professionals (e.g., doctors and psychologists) that fears and phobias in children are “just a phase” or are a “less serious mental health problem.” This perception likely had its origin in the early depiction of these phobias as “simple” phobias as described in our diagnostic manuals (American Psychiatric Association (APA), 1980; Ollendick, Davis, & Sirbu, 2009). However, a large body of research suggests that childhood phobias are not only highly prevalent, but complex, and if untreated predictive of lifelong suffering. The present chapter will examine the phenomenology, etiology, assessment, and treatment of specific phobia in young people.

DSM-5 Diagnosis

To meet criteria for a DSM-5 diagnosis of a specific phobia children must have a marked fear of a specific object or situation (Criteria A) which is disproportionate to the actual or real danger posed by the stimuli (Criteria D; APA, 2013). Moreover, exposure to the feared object or situation must cause immediate fear and anxiety (Criteria B), and result in avoidance, or sustained distress if avoidance is not possible (Criteria C). The fear, anxiety, and/or avoidance needs to be persistent typically lasting or 6 months or longer (Criteria E) and associated with significant impairment in academic, social, or family functioning (Criteria F). Finally, the fear must not be better explained by another mental health condition (Criteria G) such as a fear of contracting an illness or disease which may be better accounted for by an Obsessive Compulsive Disorder (OCD) diagnosis or a fear of social situations which is characteristic of Social Anxiety Disorder (SAD). DSM-5 classifies phobias into five main types including (1) animals—dogs, spiders, and snakes; (2) natural environment—heights, thunderstorms, the dark, and water; (3) blood–injection–injury (BII)—seeing blood, injections, and blood tests; (4) situational—flying, elevators or lifts, and enclosed spaces; and (5) other—vomiting, choking, costume characters, doctors or dentists, contracting an illness or disease.

Prevalence

Specific phobia affect up to 10% of young people in the community and 20% in clinical settings (Bener, Ghuloum, & Dafeeah, 2011; Kessler, Chiu, Demler, & Walters, 2005; Kim et al., 2010; Ollendick, Hagopian, & King, 1997). Thus, they are one of the most common anxiety disorders in children and adolescents. Prevalence rates have been found to vary by gender with phobias more commonly observed in girls than boys (Burstein et al., 2012; Essau, Conradt, & Petermann, 2000; Kim et al., 2010). Only a small number of epidemiological studies have explored the prevalence of the different phobia subtypes in youth. These studies have found animal and natural environment phobia types to be the most prevalent, followed by BII and then situational phobias (Burstein et al., 2012; Essau et al., 2000; Kim et al., 2010). A similar pattern has been observed in clinical samples with animal and natural environment phobias comprising the largest proportion of children and adolescents participating in randomized controlled trials (RCTs; Ollendick et al., 2015; Ollendick, Öst, et al., 2009; Öst, Svensson, Hellstrom, & Lindwall, 2001; Silverman et al., 1999).

Etiology

Evidence suggests that specific phobias are multifactorial in origin (Ollendick & Muris, 2015). Genetic influences, neurobiology, temperament, learning experiences, parenting, cognitive biases, and avoidance have all been hypothesized to be involved in the development and maintenance of phobias (Oar, Farrell, & Ollendick, 2015; Ollendick & Muris, 2015).

Genetics

Evidence from family aggregation and twin studies suggest a genetic contribution to specific phobia development. For example, the first degree relatives of adults with specific phobia are at significantly increased risk of developing a phobia (31%) in comparison to the first degree relatives of nonclinical controls (11%; Fyer et al., 1990). Additionally, the children of parents who have a phobia have been found to be at greater risk of developing the same type of phobia as their parent (Fredrikson, Annas, & Wik, 1997; Fyer, Mannuzza, Chapman, Martin, Klein, 1995). Recently, Van Houtem et al. (2013) and colleagues conducted a systematic review and meta-analysis of the genetic basis of fears and phobias. The review identified 10 adult twin studies which estimated heritability for specific phobias. The authors concluded that specific phobias were moderately heritable with mean estimates of 32% for animal phobias (range 22%–44%), 25% for situational phobia (range 0%–33%), and 33% for BII phobia (range 28%–63%). To date only a small number of twin studies have explored the genetic heritability of phobias in samples of children and adolescents (Eley, Rijsdijk, Perrin, O’Connor, & Bolton, 2008; Lichtenstein & Annas, 2000), with studies finding that between 46% and 65% of the variation in specific phobias can be accounted for by genetics. Interestingly, one study found that the contribution of genetic factors differs between the phobia subtypes with genetic effects explaining 58% of the variance in animal phobia, 50% in situational/environmental phobia, and 28% in mutilation (including BII) phobias in youth (Lichtenstein & Annas, 2000). Thus, there is evidence across both child and adult studies to suggest that phobias are in part genetically determined.

Neurobiology

Given advances in neuroimaging over the past 20 years, an increasing number of studies have explored altered metabolic activity in specific areas of the brains of individuals diagnosed with phobia. Recent systematic reviews (Del Casale et al., 2012; Ipser, Singh, & Stein, 2013) have found evidence for abnormal brain activation in phobic adults specifically, within the parts of the brain that are involved in the perception and early amplification of fear such as the amygdala, anterior cingulate cortex, thalamus, and insula. Following exposure to a feared stimuli, adults with a specific phobia appear to show reduced activation in brain regions which regulate fear (Del Casale et al., 2012). Thus, neuroimaging results indicate that adult phobia sufferers appear to be more easily aroused in the presence of their phobic stimuli and have a reduced capability to regulate this arousal. To date neuroimaging studies in anxious children and adolescents have predominantly been conducted in samples of youth with Generalized Anxiety Disorder (GAD), SAD, and Separation Anxiety Disorder (SepAD; Blackford & Pine, 2012). Hence, it is currently unknown whether brain aberrations associated with abnormal threat processing in phobic adults are similarly present in phobic children and adolescents, an area in need of further research.

Temperament

There has been considerable research into the role of temperament in the development of child anxiety disorders. Temperament refers to a child’s pattern of behavioral tendencies and their efforts to regulate these tendencies in response to the environment (Goldsmith et al., 1987). Several temperament styles have been explored in the literature. In relation to childhood anxiety disorders, behavioral inhibition has been the most widely researched and is characterized by a propensity to experience distress, fear, and avoidance in unfamiliar situations or in the presence of unfamiliar people or objects (Kagan, Reznick, Clarke, Snidman, & Garcia-Coll, 1984). Both cross-sectional and longitudinal studies have found that behaviorally inhibited preschoolers are significantly more likely than control children to meet crit...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Preface
• Acknowledgment
• Section I: Foundations
• Section II: Disorders
• Section III: Interventions
• Section IV: Special Issues
• Index