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Section 29
Diagnosing Phobias in Children

Question 29 | Test | Table of Contents

Diagnostic evaluation
Of the many structured diagnostic interview schedules that have been developed for children, we recommend the Child Version of the Anxiety Disorders Interview Schedule for DSM-IV (ADIS for DSM-IV-C; Silverman & Albano, 1996) because of its specialist nature and developmental considerations. A broad range of diagnostic categories are included in the examination, thus allowing for the diagnosis of specific phobia and any comorbid disorders. The ADIS for DSM-IV-C involves separate child and parent interviews, with the interview process usually beginning with the child (time frame for examination being past year). In the section on specific phobia, questions are organised around animal type, natural environment type, blood-injection/injury type, situational type, and other type. In each interview, the child or parent provides ratings on a 0–8-point scale in relation to fear intensity and interference in the child’s life. A visual analogue scale, the Feelings Thermometer, helps in the anchoring of these ratings. High kappa coefficients for specific phobia (1.00 and 0.84) were found respectively in two studies (Silverman & Nelles, 1988; Silverman & Eisen, 1992) that evaluated the psychometric properties of the child version of the ADIS. Examples of other diagnostic instruments include the Diagnostic Interview for Children and Adolescents (DICA; Weiner et al., 1987) and the Kiddie- Schedule for Affective Disorders and Schizophrenia (K-SADS; Fisher et al., 1997).

Self-report measures
Standardised self-report measures also aid in the determination of the scope and type of phobia. In particular, the Fear Survey Schedule for Children- Revised (FSSC-R; Ollendick, 1983) provides a window into a variety of phobias, including specific phobia and social phobia. Ollendick (1983) reported a 5-factor solution for this 80- item instrument:
Factor 1: Fear of failure and criticism
Factor 2: Fear of the unknown
Factor 3: Fear of injury and small animals
Factor 4: Fear of danger and death
Factor 5: Medical fears.
The FSSC-R has been researched extensively in terms of its psychometric properties and shown to have good reliability, concurrent validity, and dicriminant validity (King & Ollendick, 1992; Ollendick, 1983). More recently, Gullone and King (1992) developed the Fear Survey Schedule for Children and Adolescents (FSSC-II). The FSSC-II comprises 78-items, including socially significant items, such as AIDS and nuclear war, frequently excluded from fear survey schedules (factor structure similar to the FSSC-R).

Additional self-reports of a more specialist nature or specific focus, such as the Spider Phobia Questionnaire for Children (Kindt, Brosschot, & Muris, 1996) also exist. Further, more general measures of anxiety and functioning may prove useful in assessment. Greenhill et al. (1998) argue that many of the established anxiety scales, such as the Revised-Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978) and the State-Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973), were developed from adult versions and have failed to reliably distinguish anxious children from children with other disorders (e.g. Perrin & Last, 1992). Newer instruments for the assessment of anxiety, developed de novo for use with children, and with good psychometric properties include, the Multidimensional Anxiety Scale for Children (MASC; March et al., 1997), the Screen for Child Anxiety Related Emotional Disorders (SCARED: Birmaher et al., 1997), and the Spence Children’s Anxiety Scale (SCAS; Spence, 1997).

Behavioural tasks
There are two types of behavioural tasks: Behavioural Avoidance Tasks (BATs) and Direct Observation of Anxiety (DOA) tasks. For example, BATs are a commonly used means of phobia assessment (King, Ollendick, & Murphy, 1997). Typically, this assessment procedure involves having the phobic child enter a room or laboratory and approach the feared stimulus. In the assessment of a child with a dog phobia, for example, the child is requested to perform a graduated series of stimulus-related tasks (Bandura, Grusec, & Menlove, 1967). These range from taking a few steps closer to the dog to actual physical contact with the dog. Despite reassurances about the safety of the situation, children with severe phobias invariably freeze and refuse to approach the dog. One strength of the BAT, as noted by Kazdin (1973), is that it provides highly reliable behavioural measures of avoidance, such as amount of time spent in the presence of the anxiety-provoking animal, distance from the animal, and number and latency of approach responses.

Hamilton and King (1991) demonstrated the temporal stability of a BAT in the assessment of 14 dog-phobic children (aged 2 to 11 years). Two test administrations were conducted 7 days apart prior to treatment, and high test-retest reliability was obtained (r ¼ .97). Ten children obtained identical total approach scores, with the other four displaying slightly less avoidant behaviour from Time 1 to Time 2.

Another important question that awaits further research inquiry is the extent to which the child’s performance on a BAT actually corresponds with phobic behaviour in natural settings. Avoidance tests are often restricted to fairly safe exercises with the clinician/researcher and perhaps another caregiver in close proximity to the child. This, of course, constitutes a situation quite different from the exposures that occur in the natural setting. For example, in an avoidance test the dog phobic child is required to approach a dog that is secured in some way. But in the community, the dog may be unrestrained and approach the child, thus representing a different set of antecedent conditions. To date, it must be acknowledged that the validity claims of such tests used with animal phobic children have not been comprehensively researched (King et al., 1997; Morris & Kratochwill, 1983).
- King, Neville J., Muris, Peter, Olledick, Thomas H.; Childhood fears and phobias: Assessment and Treatment; Child & Adolescent Mental Healt; May 2005; Vol. 10, Issue 2.

Personal Reflection Exercise #12
The preceding section contained information regarding how to diagnose phobias in children.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
One Session Treatment (OST) is Equivalent
to Multi-session Cognitive Behavioral Therapy (CBT)
in Children with Specific Phobias (ASPECT):
Results from A National Non-Inferiority
Randomized Controlled Trial

- Wright, B., Tindall, L., Scott, A. J., Lee, E., Cooper, C., Biggs, K., Bee, P., Wang, H. I., Gega, L., Hayward, E., Solaiman, K., Teare, M. D., Davis, T., Wilson, J., Lovell, K., McMillan, D., Barr, A., Edwards, H., Lomas, J., Turtle, C., … Marshall, D. (2023). One session treatment (OST) is equivalent to multi-session cognitive behavioral therapy (CBT) in children with specific phobias (ASPECT): results from a national non-inferiority randomized controlled trial. Journal of child psychology and psychiatry, and allied disciplines, 64(1), 39–49.

Peer-Reviewed Journal Article References:
Eterović, M. (2020). Recognizing the role of defensive processes in empirical assessment of shame. Psychoanalytic Psychology. Advance online publication.

Garcia-Lopez, L.-J., Beidel, D., Muela-Martinez, J.-A., & Espinosa-Fernandez, L. (2018). Optimal cut-off score of Social Phobia and Anxiety Inventory-Brief Form: Detecting DSM-5 social anxiety disorder and performance-only specifier. European Journal of Psychological Assessment, 34(4), 278–282.

Glazier, B. L., & Alden, L. E. (2019). Social anxiety disorder and memory for positive feedback. Journal of Abnormal Psychology, 128(3), 228–233.

QUESTION 29
What are two behavioral measures for determining if a child has a specific phobia? To select and enter your answer go to Test.

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