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.7.Rachman S.J.(1990) Fear and Courage.Freeman, New York.8.Simonoff E., Pickles A., Meyer J., Silberg J.L., Maes H.H., Loeber R., Rutter M.,Hewitt J.K., Eaves L.J., Lindon J.(1997) The Virginia Twin Study of AdolescentBehavioral Development: influences of age, sex, and impairment on rates ofdisorder.Arch.Gen.Psychiatry, 54: 801 808.9.Kessler R.C., Walters E.E.(1998) Epidemiology of DSM-III-R major depressionand minor depression among adolescents and young adults in the nationalcomorbidity survey.Depress.Anxiety, 7: 3 14.10.Eley T.C., Bolton D., O Connor T.G., Perrin S., Smith P., Plomin R.(2003) Atwin study of anxiety-related behaviours in pre-school children.J.ChildPsychol.Psychiatry, 44: 945 960.11.Lichtenstein P., Annas P.(2000) Heritability and prevalence of specific fearsand phobia in childhood.J.Child Psychol.Psychiatry, 41: 927 937.12.Silberg J.L., Neale M.C., Rutter M., Eaves L.(2001) Genetic and environmentalinfluences on the temporal association between earlier anxiety and laterdepression in girls.Biol.Psychiatry, 49: 1040 1049.13.Ohman A., Mineke S.(2001) Fears, phobias and preparedness: toward anevolved model of fear and fear learning.Psychol.Rev., 108: 483 522. PHOBIAS IN CHILDREN AND ADOLESCENTS: COMMENTARIES ________________ 28314.Wood J.J., McLeod B.D., Sigman M., Hwang W.-C., Chu B.C.(2003) Parentingand childhood anxiety: theory, empirical findings, and future directions.J.Child Psychol.Psychiatry, 44: 134 151.15.Klein R.G., Pine D.S.(1990) Anxiety disorders.Child Adolesc.Psychiatry, 4: 486509.16.Weersing V.R., Weisz J.R.(2002) Mechanisms of action in youth psychotherapy.J.Child Psychol.Psychiatry, 43: 3 29.17.Rutter M.(1976) Helping Troubled Children.Plenum Press, New York.5.2Fear, Anxieties and Treatment Efficacy in Children and AdolescentsRachel G.Klein1A key theoretical issue is whether fear in children reflects a unitarypsychological phenomenon that is, whether the result is the samewhether fear is learned or preprogrammed.That the function of normal fear is to alert the organism to danger seems clear.It is viewed as a built-inadaptive signal.Can we assume that other fear-like experiences, such aswatching scary movies, or pathological fear (i.e.phobias) and anxiety (i.e.separation or generalized anxiety disorder) represent similar processes?The answer to these questions has relevance to our approaches in thestudy of anxiety disorders.For one, can studying the neurobiology ofnormal fear inform on the mechanisms underlying distinct anxietydisorders? A body of well-accepted experimental work assumes suchsimilarity [1], but other work suggests that neurobiological pathways ofconditioned fear may be distinct from those of other fearful states [2].Thedistinctions and similarities between normal fear and pathologicalanxiety have implications for our clinical understanding of childhoodanxiety disorders.Our beliefs about the importance of childhood phobias largely come fromretrospective studies of adults with anxiety disorders.The findings fromtwo large epidemiological studies, that adults with anxiety disordersreported onsets in childhood, highlighted the possible importance ofchildhood anxiety disorders [3,4].In addition, the observation that anxietydisorders were the most common mental disorders in adults gave thesedisorders special prominence, especially with regard to specific phobias,since they mostly accounted for the high prevalence of anxiety diagnoses.Inaddition, panic disorder has been found to have greater familial loadingamong patients with specific phobias in childhood than those without such1New York University Child Study Center, 215 Lexington Avenue, New York, NY 10016, USA 284 __________________________________________________________________________________________ PHOBIASa history [5].Finally, among adults with depression, a recalled history ofanxiety disorders is significantly more frequent in women.It has beenproposed that this sex difference in early anxiety accounts for the relativeexcess of depression in women, since early anxiety disorders are predictorsof later depression [6].Findings from these retrospective studies have beeninfluential, but they can only be considered heuristic and suggestive, inview of the well-known limitations of restrospective recall.This isespecially the case for previous anxiety symptoms, since their recall hasbeen found to be particularly unreliable [7].Unfortunately, longitudinal studies of children with anxiety disorders arescarce, but findings consistently show a modicum of stability for anxietydisorder from childhood to adolescence in girls, but not boys [8 10].Aprospective longitudinal follow-up of a general population of children andadolescents is also strongly suggestive that specific phobias and socialphobia are distinct conditions.Specific phobias in either childhood oradolescence were exclusively predictive of specific phobias in adulthood.The course of social phobia was similarly specific, since it presaged onlysocial phobia later on [11].The sex difference in course and the diagnosticspecificity of some childhood anxiety disorders over time argue against thenotion that pathological anxiety and ordinary non-specific fear share similarunderlying mechanisms.It is tempting to assume similarities between specific phobias and socialphobia, since both are treated with behavioural treatment, specificallyexposure.However, this therapeutic commonality can be misleading.Whenextended to psychopharmacology, it would imply (probably erroneously)that selective serotonin reuptake inhibitors (SSRIs) are effective in specificphobias.SSRI studies in children with anxiety disorders have includedspecific phobias, but these co-occurred with other anxiety disorders, andwere not the primary treatment target.To assume efficacy of SSRIs forspecific phobias may not be justified.Commendable efforts have been made to develop systematic treatmentsfor childhood anxiety disorders, but, with a few exceptions, tests oftheir efficacy have fallen short of rigour.The vast majority of studieshave relied on waiting list controls.However, these do not indicatewhether the specific intervention was effective, only whether it is betterthan no treatment.Even this minimal hope of benefit remains dubious,since it is possible that placing anxious children who come for clinicalservices on a waiting list might be deleterious.Credible treatmentcontrols are necessary to estimate the value of interventions.That thistype of control is essential is highlighted by findings from two studies thatfound no difference in efficacy between a special cognitive-behaviouraltreatment package and a control treatment in children with anxietydisorders [12,13]
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