Specific phobias set early in life, have a chronic course, and predict development of additional mental health concerns later in life; however, little is currently known about the origins of specific phobias in young children aged 3–6 years. The current study explores the origins of phobic fear among treatment seeking pre-school aged children diagnosed with a Specific Phobia. Specifically, Rachman’s (1977) theory of fear acquisition and differences in children’s specific phobia presentation and parental characteristics across direct and indirect (information and modelling) pathways. Seventy-four children aged 3–6 years with a specific phobia, and their parents completed an assessment battery of child phobic symptoms and related child and parent factors. Parents completed a child diagnostic telephone interview and online questionnaires assessing child factors (phobia type, phobia severity, child anxiety) and parent factors (fears, anxiety symptoms, psychopathology, parental rearing). Children participated in a standardised behavioural approach task (BAT) within the clinic and rated subjective units of distress for their phobic stimuli. All children who experienced a direct aversive event, regardless of other pathways endorsed, demonstrated more behavioural avoidance and subjective distress relative to those who did not. Animal phobias were associated with greater frequency of direct aversive events. Children experiencing the indirect pathways experienced greater generalised anxiety symptoms than all other pathways. The findings of this study suggest unique clusters of clinical presentations across the different pathways to fear among young children with SP. Future research examining whether treatment outcomes differ based on pathways to fear would enhance treatment planning.
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Specific phobias (SP) are among the most commonly occurring disorders across the lifespan and are one of the earliest to onset (Lieb et al., 2000; Steinhausen et al., 2016) with studies indicating emergence among children as young as three years of age (Rifkin et al., 2016). In pre-school aged children, SPs are associated with significant impairments across most domains of life, including, difficulties with education, family, social, and peer relationships (Egger & Angold, 2006; Rifkin et al., 2016; Towe-Goodman et al., 2014). Children with SP are also at greater risk for the development of future mental health conditions, such as substance abuse, depression, panic disorder, eating disorders, and post-traumatic stress disorder (PTSD, Fichter et al., 2009; Lieb et al., 2016; Rifkin et al., 2016). Furthermore, the presence of a childhood SP almost doubles the risk of having an anxiety disorder in adulthood (Fichter et al., 2009). Therefore, understanding the vulnerability factors associated with the onset of SP in early childhood is of priority to improve early detection, intervention, and inform prevention efforts.
The development and maintenance of fears and phobias is multi-determined, arising from a combination of reciprocal biopsychosocial influences including child factors (e.g., temperament, genetics, and cognitive processing of threat), parent factors (e.g., parental psychopathology, parenting practices), and learning experiences (e.g., stress, trauma, fear conditioning) (Kane et al., 2015; Ollendick et al., 2002; Ollendick & Horsch, 2007). Models of the aetiology and maintenance of SPs highlight the bi-directional relationships among these variables and are largely informed by conditioning theories (Watson & Rayner, 1920) and social learning theory (i.e., Bandura, 1971). Conditioning theory proposes that behaviours are learned through the association of either a positive or negative stimulus with a neutral one, to produce a positive or negative response to the neutral stimulus over time. Social learning theory posits that direct learning occurs through reciprocal interactions between behaviours and consequences, via observations and verbal representations.
Informed by fear conditioning theories (Freud, 1909; Watson & Rayner, 1920) and social learning principles, Rachman (1977) proposed a model to explain the origins of fear underlying phobic disorders, including three pathways (1) direct conditioning experiences (e.g., being attacked/bitten/chased by a dog), as well as two indirect social learning pathways, including (2) vicarious modelling (e.g., witnessing a parent behave fearfully and/or be avoidant in the presence of a dog), and (3) informational/instructional pathway (e.g., being told negative information about dogs, suggesting they are dangerous). These different aetiological pathways may result in distinct clusters of phobic symptoms (i.e., greater avoidance versus greater distress), or have stronger associations with specific phobia subtypes (i.e., animal versus natural-environment), or be uniquely associated with other clinical characteristics of the child (e.g., impairment), or family processes (e.g., parental psychopathology, parenting styles). Indeed, Rachman (1978) proposed that fears acquired via direct conditioning experiences might have greater physiological and behavioural responses, whereas indirect (information and modelling) transmission of fear may be associated with more subjective fear responses.
Few studies have examined relationships between the Rachman’s (1977) theory of the origins of fear and the expression of child phobic symptoms. Much of the research (Field & Storksen-Coulson, 2007; Merckelbach et al., 1996; Muris & Field, 2010; Ollendick & King, 1991) that has examined these pathways to fear have primarily relied upon non-clinical samples, providing insight into the nature of the development of normative childhood fears. Less is known however about the pathways to fear associated with the development of children’s clinical phobic symptoms. Additionally, whilst there are well established treatment options available for children with SP across a variety of populations, such as the one session treatment (OST; Davis et al., 2019; Muskett et al., 2020), 20–50% of youth with SPs remain unresponsive to treatment (Ollendick & Muris, 2015). Examination of the relationship between the different pathways to fear, and child phobic symptomatology, could provide valuable information towards earlier detection, greater precision in treatment planning, and the potential for prevention approaches.
Assessment of SP during childhood is challenging and often overlooked, perhaps because fears are normative and prevalent during childhood and therefore oftentimes not considered serious. SP however are distinctly different from normative fears, and considering the long-term trajectory and highly predictive risk associated with SP, clinicians need to be better equipped to detect early onset phobias. It is therefore recommended that clinicians routinely assess for childhood fears, and in doing so, differentiate from phobias through determining severity, persistence and the nature of avoidance and impact on children/families lives. For instance, childhood fears tend to be transitory in nature and often subside with reassurance, or minor accommodations (e.g., nightlight on for a toddler with fear of the dark). For phobic fears however, severity is marked by extreme distress (i.e., crying, tantrums), with symptoms persisting over several months, accompanied by excessive avoidance and/or family accommodations (e.g., child co-sleeping with parents and unable to walk into a dark room alone in the instance of dark phobia) – as assessed using evidence-based diagnostic modules such as the SP module of the Anxiety Disorders Interview Schedule for Children – Parent/Child versions (ADIS-C/P; Silverman & Albano, 1996). Understanding and assessing aetiological risk factors and learning pathways for SP provides further insight into risk factors for pathological fears and provide a framework for case formulation and treatment planning (for interview questions, see Methods section, and Ollendick & King, 1991). Therefore, research to understand the predictive pathways to pathological fears is important for formulating vulnerability factors associated with SP onset and present targets for personalising treatment.
Pathways to Fear Among Children with SP
Rachman’s (1977) three pathways to fear have been widely validated through adult retrospective accounts (e.g. Murray & Foote, 1979; Rimm et al., 1977), as well as experimental studies with non-clinical children (Field & Storksen-Coulson, 2007; Merckelbach et al., 1996; Muris & Field, 2010; Ollendick & King, 1991). Endorsement of each of Rachman’s (1977) pathways to fear among non-clinical samples vary greatly across studies. Ollendick & King (1991) examined endorsement of Rachman’s (1977) pathways with a subclinical community sample of adolescents (9–14 years, N = 1092) from Australia and America. Participants completed a questionnaire at school and rated their level of fear as ‘none’, ‘some’, or ‘a lot’ in relation to 10 of the most common childhood fears, and comment on the reasons/pathways for their fears. Consistent with findings with retrospective adult samples (e.g., Murray & Foote, 1979), the majority of participants (89%), across the 10 fears, reported experiencing the information/instruction pathway, followed by the vicarious pathway (56%), while 36% reported experiencing a direct conditioning event.
Interestingly, a portion of children who reported ‘a lot’ of fear did not experience a direct conditioning event, or reported ‘no fear’ after experiencing a direct conditioning event. These findings highlight the need for examination of additional mechanisms that may be underlying the development of higher ratings of phobic fear. One explanation may be that those endorsing higher fear ratings are more likely to experience a combination of direct and indirect experiences, or a combination of other biopsychosocial vulnerabilities (e.g., inhibited temperament). Indeed, Ollendick & King (1991) found that those reporting ‘a lot’ of fear were more likely to endorse a combination of pathways than those endorsing no fear.
Merckelbach et al. (1996) examined a clinical sample of girls (9–14 years, N = 22) who met DSM-III criteria for a SP of spiders. They used semi-structured independent child and parent interviews to ascertain the origins of SPs, including Rachman’s (1977) pathways to fear. This study found similar frequencies of reported direct conditioning pathway to Ollendick & King’s (1991) findings, with subclinical adolescents; however, these studies differed in rates of endorsement for the indirect pathways. The frequency of child/parent endorsement for each of the pathways were: 40.9/36.4% for the direct pathway, 17.4/17.4% for the vicarious/modelling pathway, 4.5/0% for the informational/instructional pathway, and 45.5/54.4% whom reported no pathway (“always been afraid”), respectively.
By contrast, another study including clinical children (1–12 years, n = 30) with dog phobia (King et al., 1997), found that half of parents (n = 16, 53.34%) endorsed modelling as the most influential to the development of their child’s fear, followed by a direct conditioning experience (n = 8, 26.7%), and finally the information/instruction pathway (n = 2, 6.7%). There were four (13.34%) participants in which the origins of dog phobia were unknown. Consistent with an earlier adult study of Murray & Foote (1979), King et al. (1997) anecdotally note that many of the parents in their study reported having a fear of dogs themselves since childhood and reported continuing to feel ‘nervous’ around dogs. Taken together, findings from studies to date may suggest that the information/instruction pathway may be more implicated in the development of normative childhood fears than in children with clinical phobias (King et al., 1997).
Indirect Pathways to Fear: The Role of Parents
Given the inherent nature of parental involvement in the indirect learning pathways for children, parenting practices are also implicated in the development of SP. For pre-schoolers, the dominant source of information and modelling that children are exposed to is from parents. Parents of phobic preschoolers may be especially inclined to provide learning contexts associated with fear as many parents experience phobias themselves (King et al., 1998; Murray & Foote, 1979). Parents with fears of their own may model more fear behaviours and provide more threatening information to their children (Remmerswaal & Muris, 2011). Alternatively, parenting a more sensitive and inhibited toddler may influence parenting whereby parents become more over-involved to support their child’s anxious behaviours (Hudson et al., 2009, 2011).
Parental influence is particularly powerful in early childhood. Boseovski & Thurman (2014) compared nonclinical preschool children (3–5 years, n = 30) with a middle childhood group (6–7 years, n = 30) assessing children’s fear following information about a novel animal, provided by two different people, either a person acting as a maternal figure or a zookeeper. Half of the participants received positive information about the novel animal by a maternal figure and negative information by the zookeeper and the other half received the opposite. They found pre-schoolers were more influenced by information given by a maternal figure than the older age group, displaying more avoidance when provided negative information by a maternal figure, compared with the zookeeper. Similar effects have been found with the modelling pathway, in which toddlers have demonstrated increased fear and avoidance when playing with a toy snake, after observing their mother modelling negative interactions with the toy (Gerull & Rapee, 2002). In contrast, positive maternal modelling decreases children’s fear beliefs (Broeren et al., 2011; Egliston & Rapee, 2007; Gerull & Rapee, 2002; Kelly et al., 2010). Taken together, these studies highlight the powerful influence of caregivers on young children on both cognitive and behavioural expressions of fears, versus other sources of information. Thus, further research examining the influence of other parental factors associated with Rachman’s (1977) pathways to fear may elucidate other key variables associated with the origins and persistence of childhood SPs.
Indeed, overinvolved/controlling parenting and low parental warmth are associated with the development and course of anxiety symptoms and phobias, including greater distress and avoidance behaviours in children (Kane et al., 2015; Murray et al., 2009; Ollendick & Horsch, 2007). A reciprocal relationship exists between parenting and children’s SPs such that parental perceptions of heightened distress symptoms in their child are associated with more accommodating parenting, which relates to greater child avoidance behaviours (O’connor et al., 2020).
One study has examined parenting practices and Rachman’s (1977) pathways to fear in a cohort of nonclinical children (6–10 years, n = 41) (Field et al., 2007). Children were provided with either negative or positive information about two novel animals and they completed the Fear Beliefs Questionnaire (Field & Lawson, 2003) before and after receiving the information, followed by the Parenting Style Questionnaire (Smith, et al., 1993). Punitive parenting (low on warmth and high on negativity) interacted with the informational provision to increase children’s fear beliefs about a novel animal, more than information alone. Parenting practices may contribute to the influence of the indirect pathways to fear and serve to heighten or minimise associated child symptoms, such as avoidance/approach behaviours and cognitive appraisal of fear. These findings identify the need for further exploration of the inter-relationship between parenting practices and origins of fear along with other mechanisms and clinical correlates to help to inform aetiological models of childhood SP and inform advances in prevention and treatment.
The Current Study
The current study explores factors associated with the early onset of SP in young children (aged 3–6 years) in a treatment seeking sample. Specifically, this study aims to (1) ascertain the frequency that parents endorse one or more of three pathways to fear associated with the onset of their child’s phobia, including direct experiences, indirect modelling and information,; (2) to ascertain whether there are differences in children’s age, phobia symptoms (subtype, severity, impairment and approach behaviour) and anxiety, depending on which pathways (i.e. direct, indirect, or a combination of direct and indirect pathways) were endorsed by parents; and (3) to ascertain whether there are differences reported by parents on parenting styles and parent psychopathology across the different pathways to fear endorsed by parents (i.e. no pathway, direct, indirect, or a combination of direct and indirect pathways).
Based on the available literature to date, it is expected that (1) there will be endorsement for at least one of Rachman’s pathways to fear in majority of cases; (2) children who have a direct aversive experience will display greater physical avoidance of their phobic stimulus compared to children who have not (3) parents who endorse the indirect pathways will report having more fears themselves, in comparison to those who do not endorse an indirect pathway and (4) parents who endorse the indirect pathways to fear will report higher rates of anxiety symptoms themselves than those who do not endorse one of the indirect pathways.
Method
Participants
Participants included 74 children, aged 3–6 years (M = 4.65; SD = 0.85), comprised of 41 (55.4%) girls (M age = 4.88, SD = 0.90) and 33 (44.6%) boys (M age = 4.36, SD = 0.70) with a specific phobia (SP). Participants were recruited to a Griffith University clinical trial involving assessment and treatment of pre-school aged children with SPs. Children were recruited through email and mail outs to childcare centres, schools, early childhood health clinics, and social media advertisements. Inclusion criteria for the current trial included; (a) child meets DSM-5 diagnostic criteria for SP diagnosis, (b) aged 3–6 years, (c) willingness to be randomised to a treatment condition (i.e., one-session cognitive-behavioural treatment (OST), psychoeducation support (EST), 6 month waitlist control (WLC); (d) willingness to cease concurrent psychological treatment for phobia or anxiety; and (e) if on a psychotropic medication, the child is on a stable dose of any medications for 12 weeks prior to participation. Exclusion criteria included: (a) primary diagnosis of a non-anxiety disorder, (b) presenting problem was a blood-injection-injury phobia (allowable if not the primary presenting phobia), (c) suicidal risk, and/or (d) co-occurring (suspected) intellectual impairment, presence of Autism Spectrum Disorder (ASD), psychosis, and/or significant language and learning problems.
Measures
Diagnostic and Symptom Severity
The Anxiety Disorders Interview Schedule for DSM-5 for Children – Parent version (ADIS-V-P; Silverman & Albano, unpublished manuscript)
The ADIS-V-P is a semi-structured diagnostic parent interview, designed to diagnose current anxiety and related disorders in children and adolescents, based on the DSM-5 (American Psychiatric Association, 2013) diagnostic criteria. Scores are given based on the number of symptoms endorsed, and the level of interference, or impairment. Within administration of the ADIS-V-P, the disorder severity is quantifiable using the Clinician Severity Rating (CSR). The CSR is interviewer rated on a scale from 0 (absent) to 8 (very severely disturbing/disabling), with a score of 4 indicating clinical significance. The CSR is used to indicate severity of the target SP. The ADIS has good reliability with symptom scale scores for SP, separation anxiety disorder, social phobia, and GAD, as well as comorbid diagnoses (Silverman et al., 2001). ADIS interviews and CSR ratings were conducted by trained independent evaluators and diagnoses were determined during supervision meetings.
The Behavioural Approach Test (BAT)
Children completed a BAT, in which they were asked to approach their phobic stimuli inside a room, under experimental conditions and following standardised instructions. An example for dog phobia would be: “Now, I want to see how you feel being around a dog. So, if you want to do so, open the door, walk to the end of the room, and pat the dog with one hand until I say stop. Remember you don’t need to do this if you don’t want to, and just go as far as you can.” The researcher obtains a score of approach behaviour based on the child’s proximity to the stimuli on a scale from 0 (no approach) to 10 (completed task), for instance; opening a door (1), walking into a room with a dog and dog handler (2), stands within arm’s reach of the dog (5) then patting the dog for 20 s (10). Additionally, a 5-point (0 = not scared to 4 = really scared), visual subjective units of distress scale (SUDS) was used to measure the child’s level of distress immediately before administration of the BAT, following the instructions.
Origins of Fear
The Pathways to Fear Survey (PFS)
This is a structured parent interview designed to ascertain parental report of the origin of their children’s SP based on the three pathways identified by Rachman (1977). Pathways to fear surveys have been modified and used in many previous studies examining Rachman’s (1977) pathways to fear (Doogan & Thomas, 1992; King et al., 1997; Muris et al., 1997; Ollendick & King, 1991). The PFS included questions related to (1) whether the participant had a direct experience with the phobic stimuli (e.g. has your child had a bad or frightening experience with their phobic stimuli?); (2) whether the child witnessed modelling of fear towards the phobic stimuli and from whom (e.g. has your child ever witnessed you showing fear of their phobic stimuli?), and (3) whether the child received negative information about the phobic stimuli, for instance warning them about the dangers of the phobic stimuli and from whom (e.g. have you ever warned your child about the dangers of their phobic stimuli?). Each item was coded yes or no, based on whether the described experience was deemed as negative and potentially threatening. For example, the information pathway was coded yes, as endorsed for a dog phobia if the child had been told “stay away from dogs because they are dangerous and may bite or scratch you” and coded no if they had been told information such as “ask the owner first before you pat a strange dog”.
Additionally, the PFS asked whether parents experienced similar fears or phobias, and whether they themselves had their own threatening experience with the child’s phobic stimuli. Parent responses regarding endorsement of each pathway to fear were coded as yes or no, based on the strict definitions for each pathway. Parent self-reported fear was coded as yes or no and categorised into DSM-5 phobia subtype.
Child Anxiety Symptoms
The Preschool Anxiety Scale (PAS, Spence et al., 2001)
Adapted from the Spence Children’s Anxiety Scale (Spence, 1997), the PAS includes a measure of overall anxiety symptoms for children aged 3–6 years, as well as five subscales including generalised anxiety, social anxiety, obsessive-compulsive, physical injury fears, and separation anxiety. The questionnaire consists of 28 items scored on a 5-point Likert scale, ranging from 0 ‘not at all’ to 4 ‘very often true’ yielding a total score range 0–112. The PAS subscales showed good internal consistency with Cronbach’s alphas of 0.82 for obsessive compulsive disorder, 0.83 for social anxiety, 0.83 for separation anxiety, 0.50 for physical injury fears, 0.84 for generalised anxiety and 0.92 for the total.
Parenting Styles
The Egna Minnen Betraffande Uppfostran, Parent version (EMBU-P, Castro et al., 1997)
Is a parent-report measure designed to obtain parent ratings of their own style of rearing behaviours with their children. The 40 items are rated on a 1 (no, never) to 4 (yes, most of the time) rated Likert-scale. The EMBU-P provides four subscale scores (parental emotional warmth, rejection, overcontrol, and anxiety) and a total score. The EMBU-P showed adequate internal consistency across most subscales with Cronbach’s alpha of 0.76 for emotional warmth, 0.79 for rejection and 0.72 for anxious rearing. Internal consistency was low for the over-control subscale, with Cronbach’s alpha of 0.52.
Parental Psychopathology
The Brief Symptom Inventory (BSI; Derogatis, 1993)
The BSI is a commonly used self-report scale used to assess psychological symptoms in the last seven days. The 53-item BSI comprises of nine primary symptom dimensions, (somatisation, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism). This study utilised the total BSI score. subscales of anxiety and phobic anxiety to test the hypotheses regarding parental anxiety. Items are scored on a five- point Likert scale ranging from 0 “not at all” to 4 “extremely”. The subscales for this measure showed adequate internal consistency with Cronbach’s alpha ranging from 0.72–0.90. The total score showed a high level of internal consistency with Cronbach’s alpha of 0.96, for the current sample.
Procedure
Ethics approval was obtained prior to the conduct of the research study (GU Ref No: 2018/145). Parents of potential participants self-referred to the clinical trial and were initially screened via telephone for SP symptomatology and exclusion criteria. Upon completion of the screening, the study aims and procedures were explained to participants and initial verbal consent obtained to proceed to telephone assessment interview including the ADIS-5-P diagnostic interview and the Pathways to Fear Survey. Following the ADIS assessments, children were randomised to one of the three treatment conditions. Parents completed the self-report questionnaires online via LimeSurvey and an in-person assessment session in which they provided written informed consent and their child completed the BAT, independently of their parent. Both the ADIS telephone interview and the in-person assessment sessions (i.e. BAT) were administered by graduate level research assistants trained in administration of the ADIS and BAT.
Overview of Analyses
Data was screened to identify missing values in the dataset. There were 5 (7%) children who did not complete the BAT and pre-BAT SUDS ratings, and 6 (8%) parents who did not complete the online questionnaires. Data was identified as missing at random. Missing cases were excluded analysis by analysis. Online questionnaires were completed by one parent only, with 95% being mothers (M age = 36, SD = 4.07) and 5% fathers (M age = 39, SD = 6.19).
Frequency data was calculated to determine the number of parents endorsing each of the pathways to fear. Chi-square tests were used to determine whether there were differences in frequencies across the different pathways to fear and phobia subtype and to examine whether there were differences in frequencies of phobia subtype between direct aversive experiences and all other pathways. One-Way ANOVAs were used to determine whether there were between group differences across the different pathways (4 levels: no pathway, combined direct and indirect, direct only, indirect only; i.e., due to low cell numbers, indirect only includes parental endorsement of either modelling, information, or both modelling and information) based on child symptoms of phobic severity (CSR), steps completed in the BAT, and pre-BAT SUDS (i.e., not scared, a little scared, really scared). A Chi-Square was used to examine whether there were differences across the pathways based on the level of attempt at the BAT (i.e., did not attempt, partially completed, or completed). One-Way ANOVAs were used to examine whether there were differences between the different pathways on parent report measures related to child anxiety symptoms, child impairment, parenting styles, and parental psychopathology. Clinical presentation of phobias might be different in relation to direct, aversive experiences. Therefore, for child variables, a comparison was also made for children with a direct aversive experience (43%) relative to children with no direct experience (57%), providing a more powered comparison of the effects of direct experiences on outcome variables. Given the exploratory nature of this study and the small sample size, correction to alpha was not applied for multiple comparisons, given that doing so increases the risk of Type II errors (Jaccard & Guilamo-Ramos, 2002).
Results
Phobic Severity
Phobic severity, as measured by the ADIS-5-P CSR, ranged from 4–8 with the mean rating of severity in the moderate range (M = 6.05, SD = 1.03), as shown in Table 1. The distribution of phobia severity by child age deviated from the normal curve, with age 3–4 years (W = 0.90, p = 0.008) negatively skewed with lower overall CSR ratings (M = 5.88, SD = 0.98), and the 5–6 year age group (W = 0.91, p = 0.003) positively skewed with higher overall CSR ratings (M = 6.19, SD = 1.07). An independent groups t-test examined differences in CSR ratings between these age groups showed no significant difference: t(72) = −1.31, p = 0.195. See Table 1 for means and standard deviations for all other child measures, including the pre-BAT SUDS and steps achieved during the BAT.
Table 1
Means (and standard deviations) of the child measures in total and across the pathways to fear (n = 74)
Measure
No Pathway M (SD)
Direct Only M (SD)
Indirect Only M (SD)
Combined Direct and Indirect M (SD)
Total Score M (SD)
Significance level (F or X2)
Clinician Severity Rating
6.07 (1.05)
6.26 (0.93)
6.00 (1.11)
5.77 (1.09)
6.05 (1.03)
0.620
SUDS Pre-BAT
2.19 (1.63)b
3.53 (0.96)a
2.31 (1.65)
1.91 (1.45) b
2.54 (1.55)
0.008**
BAT Steps Completed
3.62 (3.20)
1.79 (3.36)
4.08 (4.63)
2.64 (3.83)
3.04 (3.67)
0.034*
Total Anxiety (PAS)
29.81 (16.58)
31.39 (15.78)
41.08 (22.19)
28.54 (17.92)
31.94 (17.85)
0.263
PAS Obsessive-Compulsive
1.81 (2.90)
1.61 (1.85)
2.58 (4.54)
1.85 (3.00)
1.90 (3.00)
0.851
PAS Social Anxiety
6.38 (4.82)
8.33 (5.74)
8.00 (5.92)
5.85 (3.93)
7.07 (5.12)
0.448
PAS Separation Anxiety
4.92 (4.59)
4.94 (4.61)
7.58 (5.07)
5.38 (4.39)
5.48 (5.65)
0.386
PAS Generalised Anxiety
5.58 (3.91)
5.56 (4.27)
9.42 (4.89)
4.92 (4.35)
6.12 (4.45)
0.038c
SUDS subjective distress units, BAT behavioural avoidance task, PAS preschool anxiety scale, BIQ behavioural inhibition questionnaire
Difference between conditions denoted by a,b
*sig. < 0.05
**sig. < 0.01
The majority of children presented with a primary SP of animal type (n = 43, 58%), followed by Natural Environment Type (n = 19, 26%), and then Other type (n = 12, 16%). There were no other phobia subtypes endorsed. The most frequent presenting phobias were dogs (n = 38, 51%), the dark (n = 13, 18%), spiders (n = 3, 4%), loud noises (n = 3, 4%), heights (n = 2, 3%), hospitals, and water (n = 2, 3%).
Pathways to Fear – Frequencies, age and gender effects
Majority of parents endorsed at least one pathway to fear (n = 46, 62%). The frequency (i.e., number) of endorsement of the pathways are shown in Fig. 1. A Chi-square analysis revealed no gender differences in the types of pathways endorsed, χ2 (3, n = 74) = 1.47, p = 0.713.
Fig. 1
Frequency (number) of each pathway to fear endorsed by parents (n = 74)
×
Age Differences
A Chi-Square examined whether there were differences in the type of pathways (no pathway, direct only, indirect only, combined direct and indirect) endorsed across younger (age 3–4 years) versus older (5–6 years) age group. A significant difference was found χ2 (2, n = 74) = 7.90, p = 0.048, with a large effect size V = 0.33. An indirect pathway alone was endorsed more often with the older age group (86%) than the younger age group (14%).
Pathways to Fear and Child Symptoms
SP Subtypes
A Chi-square analysis examined whether there were differences in the frequency of pathways endorsed by mothers across the major phobia subtypes of animal, natural environment and other. There were no significant differences found, χ2 (6, n = 74) = 9.77, p = 0.134. A Chi-square analysis found significant differences in frequencies of those who experienced a direct aversive experience compared with all other pathways, based on phobia subtype, χ2 (2, n = 74) = 8.62, p = 0.013, two-sided, with a moderate effect size, V = 0.34 (see Table 2). Within this analysis, majority (56%) of children within the animal phobia subtype experienced a direct aversive event.
Table 2
Frequency of child phobia subtype for each pathway to fear endorsed (n = 74)
Phobia Subtype
Pathway to Fear
Animal Type % (n)
Natural Environment Type % (n)
Other Type % (n)
No Pathway
28 (12)a
63 (10)a
33 (4)
Direct Pathway Only
33 (14)a
11 (2)a
25 (3)
Indirect Pathway Only
16 (7)
21 (4)
25 (3)
Combined Direct and Indirect Pathways
23 (10)
5 (1)
17 (2)
Total
100 (43)
100 (19)
100 (12)
asignificant at α < 0.05
Phobia Severity, Approach Behaviour, and Subjective Distress
A One-way ANOVA was conducted to examine whether there were differences in phobia severity between the 4 pathways endorsed (i.e., no pathway, direct, indirect, combined pathways). Results indicated no statistically significant differences in CSR across groups, F(3, 70) = 0.60, p = 0.620.
A One-Way ANOVA revealed a significant difference in pre-BAT SUDS ratings across pathways, F(3, 65) = 4.24, p = 0.008, with a large effect size, η2 = 0.16. Children whose parents endorsed the direct pathway only expressed significantly higher SUDS ratings than those who did not endorse a pathway at all, and those who endorsed combined direct and indirect pathways. There were no other significant differences between the pathways and pre-BAT SUDS ratings (Table 1).
A Chi-square revealed a significant difference across pathways to fear groups, and whether or not the child attempted to approach their fear stimuli (BAT) χ2 (3, n = 68) = 8.58, p = 0.034, with a large effect size, V = 0.36. See Table 3 for frequencies of attempts at completing the BAT. Pairwise comparison illustrated that there were significantly more children within the direct pathway who did not attempt the BAT (63%), relative to children with no pathway (19%), p < 0.05. Further, within the direct pathway alone, 37% of children attempted to complete the BAT (partial and complete attempts), whilst 80% of those who did not endorse a pathway attempted or fully completed the BAT (p < 0.05).
Table 3
Frequency of child approach/avoidance behaviour for each pathway to fear endorsed (n = 69)
Attempt BAT
Pathway to Fear
Did Not Attempt % (n)
Partial Attempt % (n)
Completed All Steps % (n)
No Pathway
19 (5)a
73 (19)b
8 (2)
Direct Only
63 (12)a
26 (5)b
11 (2)
Indirect Only
39 (5)
39 (5)
23 (3)c
Combined (Direct and Indirect)
46 (5)
36 (4)
18 (2)
Total
39 (27)
48 (33)
13 (9)
BAT behavioural approach test
asignificant differences at α < 0.05
bsignificant differences at α < 0.05
csignificant differences at α < 0.05
Child Anxiety Symptoms
A One-Way ANOVA was conducted to ascertain whether there were differences in child anxiety symptoms (PAS total scores and sub-scales) across the different pathways to fear (i.e., no pathway, direct pathway alone, indirect pathway alone, combined direct and indirect pathway). For the total score there was no significant difference on child anxiety across pathways to fear group, F(3, 65) = 1.36, p = 0.263. A significant difference was found on the generalised anxiety subscale, F(3, 65) = 2.98, p = 0.038, with a large effect size, η2 = 0.12, whereby children experiencing indirect pathways were higher on generalised anxiety than all other pathways. There were no significant differences regarding parent reported pathways to fear and the other PAS subscales.
Child Pathways to Fear and Parent Factors
Parent Self-Reported Fear
There were 48 participants (65%) where at least one parent reported having a fear of their own. A Chi-Square was conducted to examine whether there were differences in the frequency of parent reported fears across the types of child pathway endorsed (i.e., no pathway, direct only, indirect only, combined pathways). There were no significant differences found χ2 (3, N = 74) = 3.44, p = 0.343, two-sided.
Of those parents that reported having a fear of their own, 27 (54%) reported a fear of Animal Type, 17 (35%) reported a Natural Environment fear type, 3 (6%) reported Other type, and 1 (2%) reported Blood Injection Injury fear. There were 26 parents (54%) who reported having the same fear type as their child, and 22 parents (46%) who reported having a different fear to their child. See Table 4 for means and ranges for all parental measures examined.
Table 4
Means (and standard deviations) of the parental measures in total and across the pathways to fear (n = 74)
Measure
No Pathway M (SD)
Direct Only M (SD)
Indirect Only M (SD)
Combined Direct and Indirect M (SD)
Total Score M (SD)
Significance level (F or X2)
EMBU-P Anxious Rearing
21.44 (4.40)
20.39 (3.43)
20.08 (3.40)
23.23 (4.51)
21.26 (4.08)
0.180
EMBU-P Emotional Warmth
34.60 (3.80)
33.89 (3.92)
35.25 (2.90)
36.69 (2.21)
34.93 (3.50)
0.157
EMBU-P Overcontrol
26.68 (3.42)
26.00 (3.09)
25.42 (3.80)
28.31 (4.72)
26.59 (3.73)
0.222
EMBU-P Rejection
16.28 (3.13)
17.00 (4.89)
15.50 (3.00)
15.38 (2.10)
16.16 (3.50)
0.554
BSI Total
3.00 (3.50)
5.26 (6.00)
4.91 (2.59)
4.10 (3.31)
4.15 (4.18)
0.316
BSI Phobic Anxiety
0.15 (0.37
0.38 (0.69)
0.42 (0.41)
0.29 (0.46)
0.15 (0.37
0.360
BSI Anxiety
0.27 (0.41)
0.48 (0.51)
0.50 (0.29)
0.31 (0.33)
0.27 (0.41)
0.247
EMBU-P the egna minnen betraffande uppfostran, parent version, BSI brief symptom inventory
Parental Rearing Style
One-Way ANOVAs examined whether there were differences across the type of pathway endorsed (i.e., no pathway, direct only, indirect only, combined pathways) and parenting styles (EMBU-P subscales). There were no significant differences found for Anxious Rearing F(3, 64) = 1.68, p = 0.180, Emotional Warmth F(3, 64) = 1.80, p = 0.157, Overcontrol F(3, 64) = 1.51, p = 0.222, and or Rejection F(3, 64) = 0.70, p = 0.554 across groups with different pathways to fear.
Parent Psychopathology
One-Way ANOVAs examined whether there were differences across the pathway types and parental psychopathology (BSI Total score). There were no significant differences found, F(3, 64) = 1.20, p = 0.316.
Discussion
This is the first study to examine the frequency and associations of parent endorsed origins of fears and their associations with SP in pre-schoolers. Specifically, this study examined differences in the clinical expression of child phobias and comorbid symptoms across different sub-groups associated with children’s pathways to fear (i.e., direct experiences, modelling, informational pathways), and explored parental variables that might differ across sub-groups. The factors considered in this study (i.e. parental psychopathology and parenting styles) have long been endorsed in the development of anxiety disorders generally, with older children with normative fears, and with adults using retrospective data. This study provides a valuable extension of these studies to consider specific clinical characteristics and presentations that are related to the different pathways and the development of SP in young children.
Pathways to Fear and Child Clinical Characteristics
Within this young sample, 62% of children with SP endorsed at least one of the pathways described in Rachman’s (1977) theory of the origins of fear. Of those that endorsed a pathway, the most common pathway was a direct experience only (42%), followed by a combination of a direct and indirect pathways (28%), modelling alone (15%), information alone (11%), and then both indirect pathways (4%). Examples of the direct aversive events reported within the animal phobia subtype include experiences such as dogs jumping into the child’s pram, pawing at them, and dogs running into the family home barking, and/or cornering them within an enclosed space. It should be noted that the direct aversive situations reported by parents were, whilst unusual, not markedly dangerous situations. The indirect pathways were more frequently endorsed among older children (5–6 years) compared with those in the younger age group (3–4 years). One explanation for this may be that there is a cumulative effect of the indirect pathways, resulting in increasing parental exertion of verbal information and modelling in relation to their child’s fears over time.
Within this study, there were no significant differences in child SP severity (CSR) across the pathways. The animal phobia subtype was associated with significantly higher rates of children experiencing a direct aversive event, supporting the hypothesis that there may be unique mechanisms underlying development of each of the phobia subtypes. As hypothesised, children whose parents endorsed the direct pathway displayed greater behavioural avoidance of their phobic stimulus, when completing the BAT, than those who did not endorse a pathway and those who endorsed a combination of direct and indirect pathways. Of those children who experienced a direct aversive event, a significant majority (63%) did not attempt the BAT task at all and endorsed significantly higher pre-BAT SUDS ratings than those who did not endorse a direct conditioning experience. Given that this was a very young sample, it may be that closer proximity in time and/or younger age of occurrence of the aversive event is associated with higher levels of subjective distress.
By contrast, the indirect pathways were associated with less behavioural avoidance (given that majority (62%) of children, within this pathway, completed the BAT) and higher ratings of parent-reported child generalised anxiety symptoms, in comparison to the other pathways. These increased child anxiety symptoms may indicate a more general vulnerability towards development of comorbid anxiety disorders, specifically worry and generalised anxiety disorder, within this subsample of children. Generalised worry is differentiated from fear-specific worry, as generalised worry is based on the future potential for threat, whereas fear-specific worry is primarily based on actual occurrences of threat (Aktar et al., 2017). Children who experience the indirect pathways to fear, may therefore, be more susceptible to anticipatory worry more generally, rather than only in response to an immediately present threat. For example, children who experience the indirect pathways and are afraid of thunderstorms may express worry more profusely, asking their parents what the weather forecast is as soon as they wake up, and repeatedly throughout the day, as well as noticing subtle changes in clouds, or wind. They may also be more concerned about extreme weather events and worried about going to the park in case the weather may change. Children who do not experience the indirect pathways and demonstrate less generalised worry, by contrast, may respond with distress in the presence of a thunderstorm only, with the absence of anticipatory worry.
Furthermore, worry is seen as a cognitive avoidance coping strategy that is central to generalised anxiety (Aktar et al., 2017). The findings of the current study show that children who experienced the indirect pathways to fear, demonstrated significantly less behavioural avoidance than those experiencing a direct aversive event. The increased frequency of generalised anxiety symptoms within the indirect pathway subsample, suggests that these children are engaging in more cognitive related avoidance strategies through increased worry, and less behavioural avoidance. The social learning mechanisms underlying the indirect pathways to fear suggest that these children may learn worry as a more generalised coping strategy, through parental verbal communication and modelling of avoidant behaviours, resulting in more profuse and generalised sensitivity for anxiety and threat vigilance and more generalised worry across contexts. Consequently, these children may be more prone to the development of future anxiety disorders later in life. As such, there may be a stronger familial transmission of parent to child vulnerability within this subsample, whereby anxious parents are communicating more threat related information and modelling more avoidance, as is seen in the familial transmission of anxiety more generally (Murray et al., 2009).
Pathways to Fear and Parent Factors
Overall, more than half of the parents in this study also reported having a fear of their own, with the same pattern of phobia subtypes as the children, reporting animal type, natural environment type and other type, in order of frequency. These findings extend on previous research, noting specific links between parent and child fears. Unexpectedly, however, there were no significant differences found between frequency of parent reported fears and the pathway types. It was expected that parents who endorsed the indirect pathways to fear for their child would report higher rates of fear themselves. These findings suggest that the mechanisms underlying intergenerational transmission of fear require more than the presence of parent fear alone. Furthermore, our hypothesis that parents endorsing the indirect pathways would report higher rates of anxiety symptoms themselves, was not supported.
When examining parenting styles, there were no differences found across types of pathways, suggesting little variation in parenting styles across the different pathways to fear within this very young clinical sample. These findings may contribute to wider research contemplating the direction of effects between parenting styles and childhood anxiety, whether parenting practices arise from parents’ own anxieties, child symptoms, or the interaction of both (Murray et al., 2009). Taken together with wider previous research linking parental overcontrol/overinvolvement with anxious children (Murray et al., 2009), these findings indicate that parenting styles specifically may be less implicated in the development of phobias in very young children, and more implicated in their maintenance. Further studies examining parenting styles with very young clinical samples would assist in clarifying the question regarding the direction of effects and potential uniqueness of SP presentations in relation to associations with parental rearing practices.
Taken together, the findings of this study suggest that the animal phobia subtype in very young children is more frequently associated with a direct aversive experience. Having a direct aversive experience was associated with greater child avoidance behaviours and greater child reported subjective units of distress, when confronted with their phobic stimulus, relative to the other pathways and no pathway. The indirect pathways, however, were associated with greater parent-reported child generalised anxiety (PAS).
Future Research
Considering these unique presentations, future research examining whether these factors influence treatment outcomes would be highly beneficial and a deeper understanding of the influence of these pathways may assist in more targeted treatment planning. For instance, the increased rates of generalised anxiety symptoms among children who experience an indirect pathway to fear may confound treatment efficacy, and require an adjunct of more general anxiety treatment, involving both the child and parent. Furthermore, increasing evidence suggests that the Pathways to Fear Survey (Doogan & Thomas, 1992; King et al., 1997; Muris et al., 1997; Ollendick & King, 1991) is a valuable tool in examining the origins of children’s fears that could guide case formulation alongside other measures of child-clinical variables (e.g., interference – the Child Anxiety and Life Interference Scale, Lyneham et al., 2013; anxiety severity – Spence Children’s Anxiety Scale, Spence, 1997; Fear Survey Schedule for Children- Revised, Ollendick, 1983) and parent related variables (i.e., parenting stress – Parenting Stress Index, Abidin, 2012; parental rearing styles – EMBU, Castro et al., 1997) that are implicated in the presentation and maintenance of childhood phobias. A theoretically based formulation of phobic fears in childhood allows for tailoring a child’s treatment plan, resulting in enhanced outcomes. Future research examining the inclusion of parents in treatment, targeting the specific learning pathways implicated in theory (Rachman, 1977) and addressing parent’s own fears and potential fear-inducing life experiences, would provide insight into the possibility of more personalised child phobia treatment and enhanced treatment outcomes. Considering the efficacy of the indirect pathways as therapeutic procedures (Askew et al., 2008; Broeren et al., 2011; Rifkin et al., 2016; Ollendick & King, 1991), the findings of this study could be beneficial in collaborative approaches to treatment including parents, potentially leading to better treatment outcomes for children at this age and thwarting the pathway to development of future mental health conditions. Furthermore, larger scale prospective longitudinal studies examining whether these findings are replicated and consistent with a larger sample would be highly valuable.
Strengths and Limitations
This study extends upon the current literature by considering and comparing the combinations of pathways, including direct and indirect combined and both indirect pathways combined, which are hypothesised to occur naturally during daily interactions (King et al., 1998; Murray et al., 2009); including all reported phobia subtypes; and addressing some of the methodological limitations of previous research in this area (i.e. reducing memory bias, including diagnostic assessment, strictly defining pathways). Limitations included the small sample size across subgroups, limiting power to detect differences, leading to the increased likelihood of type II errors in these calculations. Further, the Pathways to Fear Survey is not a validated measure, despite similar measures being used in several other related research studies (e.g., Doogan & Thomas, 1992; King et al., 1997; Muris et al., 1997; Ollendick & King, 1991).
Conclusions
In summary, the findings of the current study suggest that there are indeed unique clusters of clinical presentations across the different pathways to fear among young children with SP, as hypothesised in Rachman’s (1978) theory. There were significant differences found between the type of pathway endorsed and clinical symptoms seen in the child, such as behavioural avoidance, subjective distress when encountering their feared stimuli, and anxiety symptoms.
Author Contributions
All authors contributed to the study conception and design, and the key contributors were Lisa Trimarchi (first author) and Lara J. Farrell (primary supervisor). Material preparation and data collection were completed by Lisa Trimarchi and project staff associated with the ongoing research at Griffith University. Data management and analyses were undertaken by Lisa Trimarchi. The first draft of the manuscript was written by Lisa Trimarchi. All authors commented on previous versions of the manuscript and read and approved the final manuscript.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
Ethics Approval
Ethics approval was gained through the Griffith University Human Research Ethics Committee (GU Ref No: 2018/145). Participation in the study was voluntary and participants provided informed consent. Participants who were identified as ineligible to participate were referred to appropriate services.
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