the prevalence of specific phobia and associated comorbid features in children and adolescents

8/10/2019 The Prevalence of Specific Phobia and Associated Comorbid Features in Children and Adolescents

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Journal of Anxiety Disorders 24 (2010) 629634

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

The prevalence of specific phobia and associated co-morbid

features in children and adolescents

Soo-Jin Kim, Bung-Nyun Kim , Soo-Churl Cho, Jae-Won Kim,Min-Sup Shin, Hee-Jung Yoo, Hyo Won Kim

Division of Child and Adolescent Psychiatry, Department of Neuropsychiatry, College of Medicine, Seoul National University, 101 Daehakro, Chongno-Gu, Seoul, Korea

a r t i c l e i n f o

Article history:Received 9 October 2009

Received in revised form 9 April 2010

Accepted 9 April 2010

Keywords:

Specific phobia

Subtype

Co-morbidity

DISC-IV

CBCL

a b s t r a c t

Objective:The aims of this study were to investigate the prevalence, associated co-morbid psychiatricdisorders and behavioral/emotional problems associated with the subtypes of specific phobia in children

and adolescents.

Methods:A total of 2673 randomly selected children and adolescents from Seoul, Korea were assessed

usingthe parent version of theDiagnostic InterviewSchedule for Children(DISC-IV) andChildrens Behav-

ior Checklist (CBCL). We analyzed differences in psychiatric co-morbidities and CBCL profiles among the

subtypes of specific phobia.

Results:The 1-year prevalence of specific phobia was 7.9% (95% CI 7.638.17). Animal phobia was asso-

ciated with anxiety disorder (OR 8.68, 95% CI 1.9139.51) and oppositional defiant disorder (OR 2.55,

95% CI 1.275.12). Natureenvironment phobia was associated with anxiety disorder (OR 25.70, 95% CI

6.16107.10). Bloodinjectioninjury phobia showed associations with attention-deficit/hyperactivity

disorder (ADHD: OR 6.74, 95% CI 2.8116.15). Subjects with natureenvironment phobia scored higher

than did controls on the anxious/depressed, social problems, attention problems, and total behavioral

problem profiles of the CBCL. Subjects with bloodinjectioninjury phobia scored significantly higher

than did controls on the attention problems, aggressive behaviors, and externalizing problem profiles.

Conclusions:Contrary to animal phobias, natureenvironment and bloodinjectioninjury phobias were

associated with various behavioral and emotional problems and approximately correlated to their co-morbid psychiatric disorders. Among these subtypes, significant differences were found in demographic

characteristics,co-morbidpsychiatric disorders,and emotional/behavioral problems.These findings sug-

gest that distinctive clinical characteristics might be related with different subtypes of specific phobia

andclinicianmust considerpsychiatric co-morbiditieswhen treating children& adolescents withspecific

phobia.

2010 Elsevier Ltd. All rights reserved.

1. Introduction

Only a small body of literature examines the epidemiology and

clinical features of childhood specific phobia based on DSM-IV or

ICD-10 defined criteria. Moreover, few studies have specifically

examined thesubtypesof specific phobia. Accordingto DSM-IV, theprevalence rates of specific phobias vary across cultures and eth-

nicities. Previous studies of children have found prevalence rates

of between 2.4% and 3.6% in New Zealand (Anderson, Williams,

McGee, & Silva, 1987; McGee, Feehan, Williams, & Anderson,

1990),2.6% in Puerto Rico (Bird et al., 1988), 2.6% in Switzerland

(Steinhausen, Metzke, Meier, & Kannenberg,1998), and3.5%in Ger-

many (Essau, Conradt, & Petermann, 2000). Using a sample of 3021

Corresponding author. Tel.: +822 2072 3647; fax: +822 747 5774.

E-mail addresses:[email protected], [email protected](B.-N. Kim).

individuals aged 1424 years in Munich, Wittchen, Nelson, and

Lachner (1998)reported a lifetime prevalence of specific phobia

of 2.3% and a 12-month prevalence of 1.8%.

Just a few epidemiological studies have assessed the psychi-

atric co-morbidities of specific phobia, and even less information

is available on co-morbidity with regard to its specific subtypes.Lewinsohn, Zinbarg, Seeley, Lewinsohn, and Sack (1997) exam-

ined lifetime co-morbidities of anxiety disorders in a community

sample of high school adolescents aged 1419 years. Specific pho-

bia was found to be highly co-morbid with separation anxiety

disorder (odds ratio (OR): 4.7) and social phobia (OR: 7.2). In an

epidemiologic study of 36 adolescents aged 1217 years with spe-

cific phobias, Essau et al. (2000)reported that 47.2% of subjects

had co-morbid anxiety disorders, 36.1% had co-morbid depres-

sive disorders, 33.3% had co-morbid somatoform disorders, and

8.3% had co-morbid substance use disorders. Becker et al. (2007)

reported the lifetime prevalence of co-morbidity among the sub-

0887-6185/$ see front matter 2010 Elsevier Ltd. All rights reserved.

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630 S.-J. Kim et al. / Journal of Anxiety Disorders24 (2010) 629634

types of specific phobia in a community sample of young women

aged 1824. In their study, animal phobias were significantly asso-

ciated with other anxiety disorder (OR 2.36), affective disorder (OR

3.07), somatoform disorder (OR 3.99), and substance disorder (OR

4.00) but not with eating disorders. Height phobia was only associ-

ated with anxiety disorders (OR 2.72). The bloodinjectioninjury

subtype of specific phobiawas also related to anxiety disorders (OR

5.24).

As mentioned above, co-morbid psychiatric disorders among

the specific phobia subtypes in samples of young adults or adoles-

cents have been examined in several studies. However, no studies

have evaluated those co-morbidfeatures in samples including chil-

dren. In addition, very few studies have examined differences in

behavioral or emotional characteristics among the subtypes of spe-

cific phobia. Moreover, to the best of our knowledge, no previous

study has used an Asian community sample. Thus, the aim of the

current study was to investigate the prevalence of specific pho-

bias and to explore whether different co-morbidities and different

behavioral/emotionalcharacteristics was associatedwith eachsub-

type of specific phobia in a community sample of Korean children

and adolescents.

2. Methods

2.1. Subjects and procedures

This study formed a part of the Seoul Mental Health Epidemi-

ologic Study for Children and Adolescents (Cho et al., 2006a,b),

which is a cross-sectional study that was conducted in Seoul,

Korea, between September 2005 and February 2006. The sub-

jects were 617 year old children and adolescents attending

schools in Seoul, Korea. Subjects for the study were recruited

using a multi-stage stratified random selection method. For the

present study, Seoul was divided into six school districts based

on the socioeconomic status of residents. Seven elementary, six

middle, and six high schools were randomly selected to pro-

vide a representative sample. Ten classes were randomly selected

from each elementary school, and three classes were randomlyselected from each middle and high school. The interviewers

were educated lay volunteers, all of whom were educated to at

least to the bachelors degree level. All had previously been edu-

cated in the practice of the Diagnostic Interview Schedule for

Children version IV, parent version (DISC-IV) by skilled psychia-

trists, and they received constant quality control monitoring by

psychiatrists from the Department of Child and Adolescent Psy-

chiatry at Seoul National University Hospital. The interviewers

scheduled interviews with subjects parents by phone and then

conducted the interviews at the relevant schools. They gave full

explanations of the study procedures to the subjects parents and

obtained informed consent for their childrens participation in the

study. Parents of 2673 students completed the Diagnostic Inter-

view Schedule for Children, 4th edition (DISC-IV). The studentsconsisted of 1645 children and 1028 adolescents. The children

and adolescents completed the Korean version of the Childrens

Depression Inventory (CDI);thus, the assessment of depressive dis-

order was made not by parents, but by the children themselves.

The subtypes of specific phobia were determined according to

DSM-IV criteria based on questions in DISC-IV about what makes

their child fearful. Specific phobias included (1) animal type; (2)

natureenvironment type, including height, thunder, lightning,

darkness and water; (3) bloodinjectioninjury typeincludingnee-

dles, blood, seeing laceration wounds, and injection; (4) situational

type, including bridges, tunnels, highways, elevators, and escala-

tors. The parents of the subjects also filled out the parents version

of the Korean edition of the Children Behavior Checklist (K-CBCL).

Control subjects were randomly selected from an age- and gender-

matched group of those without a specific phobia. The control

group was used as the reference group when CBCL mean T-scores

for specific phobia subtypes were compared. The study protocol

was approved by Seoul National University Institutional Review

Board.

2.2. Assessment measures

(1) Diagnostic Interview Schedule for Children, 4th edition (DISC-

IV): psychiatric disorders, as defined by the DSM-IV, were

assessed using the Korean version of the DISC-IV. Interviews

were organized into six diagnostic sections: anxiety disorders,

mood disorders, disruptive behavior disorders, substance use

disorders, Schizophrenia, and miscellaneous disorders (eating,

elimination, and tic disorders,pica and trichotillomania). In this

study,the DISC-IV scoring algorithms for ascertaining the pres-

ence of a diagnosis were derived based on data from parents.

Good testretest reliability of the DISC-IV has been reported

(Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). The reli-

ability and validity of the Korean version of the DISC-IV have

been previously determined and reported (Cho et al., 2006a,b).

(2) Child Behavior Checklist (CBCL): the empirically derived CBCL

(Achenbach, 1991)is one of the most-studied instruments for

the evaluation of child andadolescent psychopathology. It con-tains 112 behavioral items, which are scored by a parent. The

social competence scale can be subdivided into three areas;

activities, social, and school scales, and the sum of the scores

on these subscales yields a total competence score. The behav-

ioral/emotional problem scores are divided into three broad

dimensions: internalizing, externalizing and mixed categories,

which form a total behavior problem score (excluding items 2

and4). Theinternalizing scale consists of three subscales; with-

drawn, somatic complaints and anxious/depressed syndromes;

the externalizing scale consists of the delinquency and aggres-

sion scores, and the mixed category includes thought, social,

and attention problems. Parents were asked to rate childrens

behavior problems on a 02scale (0= not true;1 = somewhat

or sometimes true; 2 = very true or often true) for the previ-ous6 months. Numerous studies have confirmed thestabilityof

the instruments psychometric properties, showing good valid-

ity in both clinical and non-clinical populations (Biederman et

al., 1993, 2001).The Korean version of the CBCL was standard-

ized in 1997 (Oh & Lee, 1997).

(3) The Childrens Depression Inventory (CDI): the Childrens

Depression Inventory (CDI; Kovacs, 1985), which was com-

pleted by the 717 year old children and adolescents, is the

self-rating scale measuring the severity of depressive symp-

toms, scored from 0 to 2. Subjects are asked to refer to their

feelings, cognitions, and behavior during the past 2 weeks

through 27 items. The Korean version of the CDI was standard-

ized in 1990 (Cho & Lee, 1990)and its validity and reliability in

Korea has been previously been well established and reported(Cronbachs = 0.88). A total score of 22 was considered to be

a cutoff point for screening depression in the Korean version.

2.3. Data analysis

The ratio of children to adolescents, gender differences, and

socioeconomic status (SES) of each specific phobia group was com-

pared with those of the control group using a chi-squared test. We

divided age into four groups to assess prevalence according to age:

68, 911, 1214, and 1517 years. A one-way ANOVA was per-

formed to assess differences in mean age between each subtype

group and the control group. Co-morbidpsychiatric disorders were

also assessed by DISC-IV. Logistic regressions were performed to

analyze the odds ratio of co-morbidities of each subtype compared


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S.-J. Kim et al. / Journal of Anxiety Disorders24 (2010) 629634 631

Table 1

Demographic characteristics among the subjects with the three subtypes of specific phobia and the control.

Animal Naturalenvironmental Bloodinjection injury SP No SP

Subjects number (%)a 91 (49.2) 60 (32.4) 34 (18.4) 185 (100) 1952(100%)

Children (


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Table 2

The prevalence and odds ratio of psychiatric co-morbidities in the three subtypes of specific phobia according to DISC-IV.

Anxiety disorder ADHD ODD Elimination disorder Tic disorder

Animal (n =91)

N(%) 5(5.5) 5 (5.5) 11(12.1) 2 (2.2) 2 (2.2)

OR (95.0% CI) 8.68(1.9139.51) 1.17 (0.443.10) 2.55(1.275.12) 2.45 (0.5211.53) 0.94 (0.322.74)

Naturalenvironmental (n =60)

N(%) 6(10.0) 10 (16.7) 9 (15.0) 1 (1.7) 2 (3.3)

OR (95.0% CI) 25.70(6.16107.10) 2.48 (0.946.55) 1.93 (0.794.70) 1.22 (0.1510.10) 0.93 (0.302.93)

Bloodinjection injury (n =34)

N(%) 0 (0.0) 9(26.5) 4 (11.8) 2 (5.9) 2 (5.9)

OR (95.0% CI) 6.74(2.8116.15) 1.50 (0.464.88) 4.18 (0.8021.93) 0.98 (0.224.35)

All SP (n = 185)

N(%) 11(5.9) 24(13.0) 24(13.0) 5 (2.5) 6 (2.9)

OR (95.0% CI) 12.48(3.8140.87) 2.62(1.574.39) 2.14(1.283.59) 2.23 (0.776.49) 0.88 (0.321.79)

DISC-IV: Diagnostic Interview Schedule for Children version IV. ADHD: attention-deficit/hyperactivity disorder, ODD: oppositional Defiant Disorder. Logistic regression test

was performed to analyze the odds ratio after controlling for the effect of age, gender, and socioeconomic status. The reference group for determining the odds ratio was

control group without specific phobia. Bold and underline: statistically significant OR:p


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S.-J. Kim et al. / Journal of Anxiety Disorders24 (2010) 629634 633

Our results showed that different subtypes of specific phobia

seem to have their own CBCL profiles. The natureenvironment

and bloodinjectioninjury subtypes were associated with vari-

ous behavioral and emotional problems, whereas animal phobia

was not. The differences between the subtypes seemed well cor-

related with the CBCL profiles of each co-morbid psychiatric

disorder. Natureenvironment phobia was related to a high score

on the anxious/depressed and attention problems subscales, which

are known to be related to anxiety disorder (Eiraldi, Power,

Karustis, & Goldstein, 2000). Similarly, bloodinjectioninjury

phobia was related to a high score on the attention problems,

aggressive behavior, and externalizing problems, which are also

prominent in attention-deficit/hyperactivity disorder (Suh et al.,

2007).

There are a few limitations in the present study. Firstly, the

measurements obtained from parents might have been prone

to underestimation or overestimation depending on the type

of problem and may vary over the age of children. Regarding

adolescents, the prevalence of phobia and other internalizing

disorders (anxiety disorders and mood disorders) may be under-

estimated. Several previous studies have reported that specific

phobias showed co-morbidities with depressive disorder (Regier,

Rae, Narrow, Kaelber, & Schatzberg, 1998; Schatzberg, Samson,

Rothschild, Bond, & Regier, 1998),somatoform disorder, and sub-stance use disorder. However our results showed none of these

co-morbidities, although this finding is in accord with that of

The Seoul Child and Adolescent Mental Health Survey, which

revealed relevant low prevalence rate of these disorders generally

(Cho et al., 2006a,b). Nonetheless, the use of parental observa-

tion to obtain measurements might have been a limiting factor. A

discrepancy between reports by children and those by their par-

ents has been suggested (Edelbrock, Costello, Dulcan, Conover,

& Kala, 1986). In addition, parents tend to be more concerned

with externalizing problems, such as aggression, than in inter-

nalizing ones, such as depression (Edelbrock et al., 1986). For

the same reason, the prevalence of specific phobias in adoles-

cents might have been more greatly underestimated in children,

as it becomes easier for parents to overlook their childrens pho-bias as they grow older. However the prevalence of externalizing

disorders like ADHD and ODD may be overestimated by the par-

ents.

Secondly, despite using a large community sample, we had

insufficient number of subjects to obtain strong statistical power

when analyzing the co-morbidities according to subtypes. Thirdly,

the detailed demographic data like socioeconomic status and CBCL

data were lost in about 10% of subjects.

This present study suggests that specific phobias are com-

mon among children and adolescents in the community and are

heterogeneous with regard to subtypes. These data clarify that

the subtypes of specific phobia are distinguishable. In addition,

they contribute to the exploration of the neurobiological phe-

notypes of specific phobia, which differs according to the fearobject.

Further studies are warranted to evaluate whether the find-

ings of this study are replicable and genuinely identify the

distinctive features related to specific phobias in Korean chil-

dren and adolescents. To our knowledge, this is the first study

to investigate the associated co-morbid psychiatric disorders and

behavioral/emotional characteristics of children and adolescents

with the subtypes of specific phobia according to DSM-IV criteria.

Several studies have assessed objects that cause fear; however, few

have made their assessments according to strict DSM-IV specifiers.

In addition, previous studies confined their participants to young

women and adolescents; therefore, their results may not be gen-

eralized to children and adolescents. Moreover, none investigated

this area using an Asian community-based sample.

5. Conclusion

The strengths of this study include use of a large representative

community-based sample of children and adolescents and DISC-

based psychiatric co-morbidities of specific phobia with regard to

its specific subtypes, which has been understudied in children and

adolescents internationally. From our present study, the results

showed that contrary to animal phobias, natureenvironment

and bloodinjectioninjury phobias were associated with various

behavioral and emotional problems and approximately correlated

to their co-morbid psychiatric disorders. Among these subtypes,

significant differences were found in demographic characteristics,

co-morbid psychiatric disorders, and emotional/behavioral prob-

lems. These findings suggest that distinctive pathophysiologies

might be occurring according to phobic objects and clinician must

consider psychiatric co-morbidities when evaluating children &

adolescents with specific phobia.

Acknowledgments

This work was supported by the Grant from Seoul Metropolitan

Government and Grant from College of Medicine, Seoul National

University and Clinical Research Institute, Seoul National Univer-

sity Hospital (Grant Number:800-20070124 & 0720080650).

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