Specific Phobias in Children

This research paper will discuss specific phobias among pediatric population: the major topics this paper will address will include how children develop a specific- phobia as well as the most effective treatment for phobias in children. Specific phobia is defined as an extreme fear of a specific object or situation (Sue, Sue, Sue, & Sue, 2016). Someone with a specific phobia will react to a stimulus in a way of extreme panic and anxiety in a way that is not equally related to the danger of the stimulus. The primary categories of specific phobias are: living creatures, environmental conditions, blood/ injections or injuries, as well as situational factors. The most common fears among children are; spiders, the dark, scary movies and the fear of being teased. The etiology of phobias includes predisposing genetic factors that interact with psychological, social and sociocultural influences. Having history of anxiety within the family and negative relationships during the early ages are major factors into developing a phobia (Sue, Sue, Sue, & Sue, 2016).

In psychology there is a multipath model when talking about mental disorders that directly relates to specific phobias as there are a type of mental disorder. Author Sue, Sue, Sue & Sue (2016) defined this multipath model a model that provides organizational framework for understanding the numerous influences on the development of mental disorders, the complexity of the interacting components, and the need to view disorders from a holistic framework. The biological dimension will look at the etiology of a phobia in the sense that an individual with a specific phobia as an innate tendency to be anxious as well as have strong emotional response to stimuli. Etiology of phobias from the psychological dimension have several different pathways of how a phobia is developed. The four main perspectives of how a phobia develops in the psychological dimension is through; classical conditioning, observational learning, negative information, and the cognitive behavioral. The sociocultural dimension looks at phobias as a level of disgust among different genders, and cultural differences. In the social dimension there is focus on the parental behaviors and these translate to the children. Typically, positive treatment of phobias is through pharmacological treatments by treating anxiety and cognitive behavioral treatments that include Exposure Therapy, Systemic Desensitization, Cognitive Restructuring, and Modeling Therapy.

In psychology there are several different perspectives of the etiologies of all the different mental disorders, this is also true when looking at the etiology of phobias as well as the less severe state known as fear. In general, the perspectives are classified into the four dimensions; biological, psychological, social, and socio-cultural (Sue, Sue, Sue, & Sue, 2016). The etiology of phobias as well as fears over lap since fear is the initial response that initiates a phobia. The perspectives are broken down further into specifics to directly reference phobia etiology; the classical, vicarious, and informative pathways for fear acquisition, the preparedness framework, non-associative theory, fear module theory, and cognitive models. Coelho and Purkins (2009), looked in to each of these different perspectives by looking at different prior research that fell into each perspective.

The classical, vicarious and informative pathways for fear purpose that fear in general is learned from parent and guardian influences. One study showed the levels of fear in a child based on the mother or female guardian in a child's life, how she would display responses of fear. If the mother of child expressed high levels of a fear response in front of a child to a specific stimulus the child would also show a high fear response to a stimulus would also be very high and likely cause he child to develop a phobia. Whereas, if the mother of a child was able to contain their fear response to a stimulus the child would have not have a fear response to the stimulus (Coelho & Purkins 2009). Ultimately, this showed that a child's fear response is highly dependent on the mother's fear response.

The second perspective the Coelho and Purkins looked at was the preparedness framework. This perspective looks at the specifics of how biologic components play a role in the development of a phobia. The preparedness framework looks at the idea that particular stimuli are evolutionarily predisposed to generate a fear response in humans. According to Coelho and Purkins (2009), Charles Darwin noticed that some fears might appear by natural selection. After observing his 2-year-old son being afraid of large animalsDarwin questioned whether fears in children, that seem independent of experiences are effects of hereditariness of real dangers during prehistoric times. A later study that was conducted by Rachman showed a perspective that overtime children will develop the needed abilities to deal with predispositions to fears and actual fears by habituations and experiences. Fears that were not eliminated be resistant to extinction and habituation and were thought to be conditionally learned, resulting in the rare and uncommon fears that lead to phobias and the environment helps in this process (Coelho & Purkins 2009). An example of this theory is that a child that lives in an urban area may be more likely to be afraid of animals such as horses or chickens whereas a child that lives in a country area would be more likely to not be afraid of these farm animals. The reasoning behind this is due to the level of exposure to the stimuli each child experienced, thus leading the comfortability level each child has with the stimulus resulting whether a fear response is activated.

This next perspective of how phobias come to be is counter to preparedness, is the non-associative theory. The non-associative theory originates from the observation that each species have fears that are part of their development. But the hypothesizes these may occur without the direct or indirect experiences with the stimulus (Coelho & Purkins 2009). Classical condition does not need to occur for a phobia to happen but there has to have been a stimulus or situation that occurred for fear responses to be activated. The studies conducted show that fear is not innate, so a child will not express fear upon the first interaction with the phobic stimulus.

The following perspective is the Fear Module Theory, this theory was formed to account for the uneven distribution of fear while discounting non-associative fear acquisition. The fear module theory looks at four characteristics; relative selectivity to stimuli, automaticity, encapsulation and specific neuronal circuit (Coelho & Purkins 2009). Selectiveness looks at the extent to which a certain stimulus activates the fear module. Automatism is fast reflex activation of defense to a stimulus. Encapsulation is the relative independence and resistance of the fear response, from conscious cognitive control. The neuronal aspect of the fear module looks at the idea that the fear module is controlled by a specific circuit (Coelho & Purkins 2009).

The final etiology perspective of phobias is cognitive models. Cognitive models look at the idea that conditioning can be conceptualized as a cognitive process. A participant will learn to that a determined stimulus precedes adverse outcomes. Fear is not only related to a biological preparation, but also to attributions regarding safety and danger to a stimulus. In general, this perspective looks at the ability that I child has to cope with the stimulus. This is directly related to the whether a child maybe anxious or not. Their level of cognitive ability to process the stimulus will play a role in the way that they respond.

Understanding the etiology of phobias is crucial determining the treatment approach. It is clear that cognitive behavioral treatments are the basis when treating a child that has phobias. While there are many forms of cognitive behavioral treatments, intensive exposure treatments seem to be common. In an original study Davis et al. (2009), focused on one session treatment and the exposes process needed. The process of the authors' experiment is summarized as followed.

Before the main set of treatment, clinicians used diagnostic and functional assessment to find the exact type of stimulus that caused the fear reaction in each child. Diagnostic assessment is crucial in establishing the phobia and the fear response but also in the planning the treatment session, the functional assessment allows for the transition between assessment and treatment During this point the clinician would try to get the child to want to be involved with the process rather than just agreed to go along. During this point in time the parent and child motivation was determined to understand the purpose of the treatment. (Davis et al. 2009).

The purpose of the treatment was to use mechanisms to elect fear, so cognitions could be activated and addressed, permits fear to habituate and avoidances to extinguish, as well as prevented behavioral and cognitive avoidance in safe environments. Treatment consisted of one three-hour session with breaks only to combat fatigue of the child but did not reinforce any avoidance behaviors. During treatment the child was exposed to age appropriate cognitive challenges, this would include asking the child what they think would happen during exposure and then asking the child to discuss what happened during this step of exposure. It is important to highlight the positives of the situation with the child, making sure the child understands that what they thought would happen is not what actually happened. The clinician may also use participant modeling. This can include the clinician modeling the step of exposure with the stimulus as well as modeling the proper coping techniques to go along with the size of the stimulus. This part of the treatment starts with the clinician showing how to deal with the stimulus, to including the child, to the clinician removing self from modeling the situation. During each exposure step the child is continuously exposed to the stimulus until fear is reduced by 50 percent, this will ensure routine to the child to reduce the fear the stimulus causes. Reinforcement is used to give the kids a sense of accomplishment. Verbal praise and physical contact of such as a pat on the back. During the reinforcement do not allow a chance for avoidance. Praise should be given for a positive improvement, praise should never be given to a child that expresses avoidance behaviors. (Davis et al. 2009)

After the treatment session parents were brought in to have the children show their parents their new-found skills and ability to interact with stimulus as a positive reinforcement of the behaviors. A this point parents are informed about the positive coping mechanisms that the child learned during the treatment session. They also received information to help the child with self-exposure experiences. Self-exposures should occur for constantly for one month after session to solidify and maximize the treatment gain (Davis et al. 2009). The experimenters had concluded that this type of a treatment would be highly effective in children and to be the most cost and time effective form of treatment. Being able to have the length of exposures be longer made it easier for the habituation of the phobia. One longer treatment of 180 minutes had higher effects that 300 minutes of spaced out treatment.

The next treatment method ties into the previous treatment, this treatment is the combination of pharmacological and cognitive behavioral. Farrell, (2018) looked at the effect of D-cycloserine we paired with one session treatments. The main focus of the experiment was to see if D-cycloserine enhanced exposure therapy outcomes. The effects of D-cycloserine in children were compared to those that received a placebo. Opposing the hypothesis that D-cycloserine would have enhancing effects, there were no major differences of the effects of the children that received D-cycloserine versus the children that had had the placebo. This experiment was a small sample size resulting in a limitation of not having enough information to fully rule out the effectiveness of augmenting one session treatments with D-cycloserine.

The next part of the paper will outline limitations of treating children with phobias that also have ADHD. A large part of the child population has ADHD or express behaviors that are typical of ADHD, a major question in the study of child phobias is how effective treatment would be in these children. In an experiment conducted Halldorsdottir et al. (2016), looked at the effectiveness of both one session treatments and educational support treatment in treating phobias in children with ADHD. Symptoms continued to be significantly associated with poor long term out comes of both one session treatment and educational support treatment. For one session treatments, ADHD interfered with sustained anxious arousal that is necessary for habituations to occur and to solidify the effects of a one session treatment. This is due to the distractibility of ADHD, decreasing the effectiveness of exposures. But conduct problems related to ADHD do not affect cognitive behavioral treatment of anxiety. Educational support treatments were not effective because psychoeducation interferes with the cognitive behavioral therapy. The more one knows about the treatment and the phobias the less effective treatment will be (Halldorsdottir et al. 2016).

In conclusion, it is clear that there are many different perspectives to the etiology of phobias in children. Understanding each of these perspectives and how they all interact with one another will ultimately be the deciding factor for treatment options. Observations concerning distinct models of fear acquisition are best understood as part of a continuum. Looking at and understanding each of the extreme ends allows for the better understanding of the middle of the continuum. In an extreme case of fear response being purely innate, these are so prepared that they show as instinctual defensive reactions. The opposite side of this continuum are the situations should be due to aversions being related to a large quantity of aversive experiences. (Coelho & Purkins 2009). Behaviors cannot be plainly separated into cognitive and emotional categories, the areas of the brain work in connection to one another rather than in isolation. Fear relevant stimuli are more infrequent to non-fear-related stimuli, fear of a stimulus comes from the idea that familiarity and experiences. The most common form of treatment is cognitive behavioral, one session exposure therapy treatments and the use of pharmacological treatment has not been proven to be as effective (Coelho & Purkins 2009; Farrell 2018). While this appears the most effective way to treat phobias in children there remain limitations regarding the populations the treatment will work on as it was not effective in children with ADHD (Halldorsdottir et al. 2016).

References

Coelho, C. M., & Purkins, H. (2009). The origins of specific phobias: Influential theories and current perspectives. Review of General Psychology, 13(4), 335“348. https://doi-org.ursus-proxy-1.ursus.maine.edu/10.1037/a0017759

Davis, T. E., Ollendick, T. H., ?–st, L. (2009). Intensive treatment of specific phobias in children and adolescents. Cognitive and Behavioral Practice, 16(3), 294-303. doi:10.1016/j.cbpra.2008.12.008

Farrell, L. (2018). D?cycloserine?augmented one?session treatment of specific phobias in children and adolescents. Brain and Behavior, 8(6): 10.1002/brb3.984

Halldorsdottir, T., & Ollendick, T. H. (2016). Long-term outcomes of brief, intensive CBT for specific phobias: The negative impact of ADHD symptoms. Journal of Consulting and Clinical Psychology, 84(5), 465“471. https://doi-org.ursus-proxy-1.ursus.maine.edu/ 10.1037/ccp000008

Sue, D., Sue, D. W., Sue, D. M., & Sue, S. (2016). Understanding abnormal behavior. Stamford, CT: Cengage Learning.

Waters, A. M., Bradley, B. P., & Mogg, K. (2014). Biased attention to threat in pediatric anxiety disorders (generalized anxiety disorder, social phobia, specific phobia, separation anxiety disorder) as a function of 'distress' versus 'fear' diagnostic categorization. Psychological Medicine, 44(3), 607-16. doi:https://dx.doi.org.ursusproxy1.ursus.maine.edu/10.1017/S0033291713000779

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