Phobias

Many kids (and adults, too) are afraid of the same things that children with phobias fear. But the difference between a “normal” fear and a phobia is the degree of anxiety involved, and the length of time that a high level of anxiety persists. A child with a phobia has a high level of anxiety and dread—and even abject terror—when he comes into contact with the object of their phobia. If a child has a phobia, he experiences this level of fear for a period of six months or more.

What is a phobia?
A phobia is an extreme fear of something specific, such as:

• a person or type of person
• an animal or insect
• an object
• a place or type of place
• a situation

Phobias create feelings of fear so intense that they disrupt the child’s daily life and routine.  They go far beyond the ordinary fears of childhood, and do not subside even with reassurance from parents or other caregivers.

Some common phobias in children include:

• animals
• blood
• the dark
• enclosed spaces
• flying
• getting sick
• having a parent, sibling, or pet get sick or hurt
• heights
• insects and spiders
• needles (“getting shots” at the doctor’s office)
• thunder and lightning

Many kids struggle with a specific fear of being physically separated from their parents or other family members. This is known as separation anxiety disorder (SAD).

Children with phobias might worry about the same subjects as children who don’t have an anxiety disorder. The difference is that for a phobic child, there is no “on-off” switch for the fear: It’s ever-present and so extreme that it interferes with her ability to relax, concentrate and enjoy activities.

Causes

What causes a phobia?
A phobia is a type of anxiety disorder, a condition that activates the “fight or flight” response and creates feelings of imminent danger that are out of proportion to the reality of the situation. Kids can develop anxiety disorders for many reasons, including:

• biological factors: The brain has special chemicals, called neurotransmitters, that send messages back and forth to control the way a person feels. Serotonin and dopamine are two important neurotransmitters that, when “out of whack,” can cause feelings of anxiety.
   
• family factors: Anxiety and fear can be inherited. Just as a child can inherit a parent’s brown hair, green eyes and nearsightedness, a child can also inherit that parent’s tendency toward excessive anxiety. In addition, anxiety may be learned from family members and others who are noticeably stressed or anxious around a child. For example, a child whose parent shows immense fear of spiders may learn to fear spiders, too.
   
• environmental factors: A traumatic experience (such as a divorce, illness or death in the family) or even just a major life event like the start of a new school year may also trigger the onset of an anxiety disorder.

Types

What types of phobias do children experience?
Children may experience specific phobia, panic disorder (with or without agoraphobia) or social phobia.

Specific phobia
A child with specific phobia feels and exhibits intense fear of a particular person or type of person, place, object, activity, or situation.

Panic disorder
Panic disorder can develop at any age, though it most often emerges in adolescence or young adulthood. This disorder causes unexpected, unpredictable periods of intense fear and anxiety, often in response to “triggers” that may not be readily apparent.

Agoraphobia
Some children and adolescents experience panic disorder combined with agoraphobia, an intense fear of the outside world. In these cases, children are so terrified of encountering or experiencing the object of their fear that they feel unsafe anywhere but at home, and will resist venturing out for any reason.

Social phobia, also known as social anxiety disorder, is rare, estimated to occur in only 1.4 percent of children and adolescents. Symptoms typically emerge during early adolescence, but can develop in younger children, as well.

Children with social phobia experience intense fear of one or more social or performance situations. While specific fears may vary, at the root of any case of social phobia is the child’s overwhelming dread of being humiliated.

Here are some Q & A about social phobia with Joseph Gonzalez-Heydrich, MD, chief of Boston Children's Hospital's Psychopharmacology Clinic:

What are the typical features of social anxiety disorder?
Those with social anxiety disorders have an intense and persistent fear of situations in which they're exposed to unfamiliar people or scrutiny. In social situations, they're afraid that people are looking at them, and overestimate the chances that people are going to reject them or that they're going to be embarrassed. Exposure to these situations provokes anxiety responses like panic, freezing, blushing, tantrums, crying and clinging. People with social anxiety disorder tend to avoid these situations for obvious reasons. Over time, this gets in the way of social development and can become a real cost to them in terms of education, family functioning, employment and overall happiness.

How are children affected by social anxiety disorder?
The rate in children is thought to be 0.5 percent to 4 percent. In adolescents, it may be as high as 7 percent. It's not known why certain children are affected, but it's thought that it may be hereditary. Parents with panic disorder, for example, have a higher rate of children who have social anxiety disorder.

Read more.

Signs and symptoms 

What are the symptoms of a specific phobia?
Symptoms of specific phobia can include any or all of the following:

• avoiding the object of the phobia
• fearfully anticipating an encounter or experience with the phobic object
• enduring an encounter or experience with the phobic object while feeling such a high level of anxiety that the child’s normal routines and activities are significantly disrupted

What are the symptoms of panic disorder?
The extreme fear and anxiety caused by panic disorder can manifest in such physical symptoms as:

• increased heart rate
• sweating
• trembling or shaking
• shortness of breath
• a “choking” feeling
• chest pain or discomfort
• upset stomach
• feeling dizzy or faint
• a feeling of losing control or “going crazy”
• an “I’m going to die” feeling
• numbness
• chills or hot flashes 

Experiencing four or more of these symptoms in a single episode is referred to as a panic attack. While panic attack symptoms can last for several hours at a time, they usually peak and then subside after 10 minutes.

What are the symptoms of agoraphobia?
Children with agoraphobia will resist or outright refuse to leave home (or another place deemed “safe”) for any reason.

What are the symptoms of social phobia?
Children with social phobia experience intense fear of one or more social or performance situations, including:

• being introduced to new people (whether peers or authority figures like teachers)
• interacting at parties or other gatherings
• giving a speech or presentation in front of the class
• asking questions in class
• being onstage for a school play or recital
• going out to eat at a restaurant
• using a public restroom when others are around
• talking on the phone

While specific fears may vary, at the root of any case of social phobia is the child’s overwhelming dread of being humiliated. Children with social phobia:

• feel extreme levels of anxiety while anticipating or experiencing a situation that may cause them embarrassment

• usually will seek to avoid potentially embarrassing situations at any cost

• often resort to drastic measures to avoid or escape these situations (for example, refusing to go to school on the day of a book report or feigning illness when invited to a social gathering)

FAQ

Q: How common are phobias in children?
A: Up to 9.2 percent of children and adolescents are believed to experience some type of phobia.

Q: How can I tell if my child is experiencing a phobia or just going through a phase?
A: It’s important to distinguish phobias from normal childhood fears, also known as transient fears, which are temporary. 

Nearly all infants and toddlers go through phases of one or more of the following at some point:

• demonstrating anxiety around strangers or in unfamiliar settings 
• clinging to parents when introduced to new people
• becoming emotionally distressed when separated from a parent

Many kids struggle with a specific fear of being physically separated from their parents or other family members. This is known as separation anxiety disorder (SAD).            

Similarly, most older children go through periods of fearing and worrying about:

• imaginary things, such as ghosts and monsters
• getting sick, hurt or dying
• having a parent, sibling, or pet get sick, get hurt or die
• thunderstorms, fires and other natural disasters

However, your child may be suffering from a phobia, and not a transient fear, if she:

• experiences a particular fear for six months or longer
• feels such an extreme degree of fear and anxiety that daily activities, school life, family relationships and friendships are disrupted

Q: How can I tell if my child is suffering from social phobia, or is just shy?
A: A shy child may feel uneasy when meeting new people or getting up in front of the class, but won’t take extreme measures to avoid these situations and won’t experience significant disruptions in their day-to-day lives. 

By contrast, a child with social phobia has a degree of fear and anxiety so severe that it:

• limits or otherwise interferes with daily activities
• affects family relationships
• damages or impedes friendships
• impacts ability to function at school

Q: Can I prevent my child from developing a phobia?
A: There’s no known way to prevent phobias. However, you can make a significant difference for your child by being proactive and seeking the help of a trained clinician at the first sign of symptoms. The sooner you seek professional treatment, the better your child’s chances of successfully overcoming the phobia.

Here's some advice from Gary Gosselin, MD, medical director of the Psychiatry Inpatient Service at Children's:

"The signs of anxiety in a child can be difficult to pinpoint because all children should have a certain amount of normal anxiety. Beyond basic fears of the dark or strangers, younger children are exquisitely sensitive to their caregivers and environments. A child’s danger warning circuits signal them when things are unsafe. For example, the distress call of “Ma!” by the toddler unable to locate their mother quickly in an unfamiliar situation.

Absence of caregivers, neglect of basic emotional and physical needs and exposure to other stressful environments can push a child’s anxiety response too far. This is not to say that a child from a perfectly happy environment is immune to anxiety. In anxiety disorders, warning circuits in the brain can be too sensitive, causing worry or fear responses in safe situations.

There are signs of anxiety difficulties that parents can notice when a child’s fears seem out of proportion to reality and begin to interfere with life. Do they interfere with your child’s ability to go to bed, get in the car or go to school? Is anxiety consistently undercutting your child’s ability to function in social settings? School work and the social aspects of school can cause anxiety, especially when a child is being bullied." Read more.

Q: What is the long-term outlook for a child with a phobia?
A: Your child may continue to have some symptoms of fear and anxiety and have difficulty with treatment at times—but the majority of children with phobias see substantial improvement when treated with talk therapy or a combination of therapy and medication. By closely working with the treatment team, you can help your child go on to enjoy a fulfilling family, school and community life.

As one of the largest pediatric psychiatric services in New England, our team at Boston Children's Hospital is made up of expert psychiatrists, psychologists, and social workers ready to help your child and family cope with a phobia.

How do we diagnose phobias?

A Boston Children’s mental health clinician (typically a child and adolescent psychiatrist, child psychologist, or psychiatric social worker) determines if your child has a phobia after making a comprehensive psychiatric assessment with you and your child. During the assessment, you talk about your child’s fears and any panic attack symptoms. You also are also asked to provide an overview of your child’s family history, medical history, academic life, and social interactions.

If my child is diagnosed with a phobia, what happens next?

Your mental health clinician will explain the diagnosis and answer any questions you or your child may have. The next step is developing a mutually agreed-upon treatment plan that works for you, your child, and your family.

How do we treat phobias?

At Boston Children's Hospital, we typically treat phobias with:

• psychotherapy
• in some cases, a combination of therapy and anti-anxiety medication

Psychotherapy

Psychotherapy, or “talk therapy,” is designed to help the child learn new ways of controlling his fear, anxiety, and panic attacks, if and when they occur. A clinician teaches your child to address his phobia (and the feelings it causes) by using such techniques as:

• recognizing that the sense of danger associated with the object of the phobia is out of proportion (for example, if a child has a phobia of birds, recognizing that birds rarely come into direct contact with people and can't cause significant injury if they do)
• realizing that the imagined outcomes of encountering the feared object or situation are impossible or highly unlikely (for example, being alone in a dark bedroom won't cause the child to be attacked by monsters)
• practicing “self-talk” to remember what is real and what is imagined (for example, “I'm OK. I might feel like I'm going to die because I'm so scared, but that's just my brain creating panic. I am not in any real danger. If I take deep breaths and think calmly, this feeling will go away.”)
• relaxation exercises to control breathing and lessen muscle tension when feeling anxious
• role-playing with the clinician and/or a parent to “practice” worst-case scenarios related to the phobia (for example, “Imagine you are about to give a speech in front of your class and you mix up your notes”), use newly learned coping and problem-solving skills to lessen anxiety, and eventually accept that the fear is not based in reality
• gradually increasing exposure to situations that “trigger” the phobia (for example, getting up on a stage or being near a spider), so that over time, as the child realizes a dreaded outcome is unlikely to happen, the feelings of fear go away

Anti-anxiety medications

If your child's phobia doesn't adequately respond to therapy, your clinician may add an anti-anxiety medication to his treatment plan. These medications can be very beneficial in helping your child feel more relaxed while working on problem-solving and coping skills in therapy.

Medication is never a “standalone” treatment here; we consider it part of a two-prong approach, with psychotherapy as a necessary component. Our Psychopharmacology Clinic is devoted to helping children, families, and clinicians decide whether medication might be a useful part of treatment.

Occasionally prescribed anti-anxiety medications include:

• alprazolam (Xanax)
• lorazepam (Ativan)
• diazepam (Valium)
• clonazepam (Klonopin)
• diphenhydramine (Benadryl)
• hydroxizine (Vistaril)

Less commonly prescribed medications that can also treat fear and anxiety include:

• buspirone (BuSpar)
• zolpidem (Ambien)

For persistent problems with anxiety treatment, an anti-anxiety/antidepressant drug may be recommended. These medications include:

• prozac
• zoloft
• effexor
• celexa
• lexapro

Learn more about psychiatric medications.

Coping and support

The ups and downs experienced by a child — and family — living with a phobia can feel overwhelming. In addition to the information provided here, you may find comfort and support from the following resources:

Patient and family resources at Boston Children's

The Hale Family Center for Families is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families, and health professionals are welcome to use the center's services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information.

The Advocating Success for Kids (ASK) Program provides multidisciplinary evaluation, referral, and advocacy services for children under age 14 with behavioral, emotional, learning, or developmental problems, either at home or at school. ASK works with children who receive their primary care either at Boston's Bowdoin Street Community Health Center, Boston Children's at Martha Eliot, or Joseph M. Smith Community Health Center, or at the Children's Hospital Primary Care Center. For more information about ASK, please call 617-355-4690.

The Experience Journal was designed by Boston Children's psychiatrist-in-chief David DeMaso, MD, and members of his team. This online collection features thoughts, reflections, and advice from kids and caregivers dealing not only with physical illnesses like asthma and diabetes, but also with such mental health conditions as ADHD and depression.

Our Integrative Therapies Team provides a number of services for hospitalized children, their families, and their caregivers, including:

• massage therapy
• acupuncture
• yoga
• therapeutic touch

Why are my friendships changing? How can I convince my parents that being a vegetarian is heathy and right for me? What types of birth control are available to me, and how do I use them? Young men and young women may have some concerns specific to their gender, and some that they share. The Center for Young Women's Health and Young Men's Health Site offer the latest general and gender-specific information about issues including fitness and nutrition, sexuality and health, health and development, and emotional health.

Helpful links

Please note that neither Boston Children's Hospital nor the Department of Psychiatry and Behavioral Sciences unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.

Helpful links for parents and families

• Anxiety Disorders in Children Support Group at DailyStrength.org
• Mental Health America Fact Sheet – Phobias
• The Child Anxiety Network – Fears, Phobias, and Anxiety
• WorryWiseKids

Helpful links for teens

• ULifeline

Helpful links for younger children

• The Storm in My Brain (.pdf file)

We’re dedicated to proving the effectiveness of our treatment approaches through rigorous scientific testing. Our research program is one of the largest and most active of any pediatric hospital in the world. 

Each day, we work toward important discoveries that propel new advances in preventing, diagnosing and treating mental and behavioral disorders. This research reinforces our ongoing commitment to enhancing mental health for all children and adolescents. 

Some of our research projects with potential implications for treating phobias and other anxiety disorders are:

• Michelle Bosquet Enlow, PhD, staff psychologist at Children’s, is examining how infants and children develop psychologically when their mothers are suffering from anxiety.
• Almost seven million Americans suffer from chronic anxiety. David Clapham, MD, PhD, of Children’s Department of Cardiology, with collaborators, found a molecular "on-off" switch for innate fear that could potentially lead to a more effective anti-anxiety drug. Unlike fear that’s learned from experience, innate fear is embedded in our genes (enabling us to escape from predators, for example). Innate fear gone awry is thought to be a component of anxiety disorders.
• David R. DeMaso, MD, Children’s psychiatrist-in-chief, is exploring the use of new technologies to help physically ill children cope with—and communicate—their feelings of worry and stress.
• Baruch Krauss, MD, attending physician in Children’s Division of Emergency Medicine, is studying new treatments—both those that involve medication, and those that do not—to help relieve acute anxiety in children who are undergoing procedures in the Emergency Room.
• Jennifer LeBovidge, PhD, and her colleagues in the Children’s Division of Immunology are conducting a study of a group approach to treating children with food allergies. They aim to determine how to best help these children, and their parents, manage their allergies and cope with related feelings of anxiety.

Clinical trials

It’s possible that your child will be eligible to participate in one of Boston Children's Hospital's current clinical trials. These studies are useful for a multitude of reasons:

Some trials are designed to evaluate the effectiveness of a particular drug, treatment or therapy on a specific disease; others help doctors to better understand how and why certain conditions occur. At any given time, we have hundreds of clinical trials underway. Of course, your motives as a parent needn’t be entirely altruistic — you’ll naturally want to know how taking part in a trial can immediately benefit your child. If your child’s physician recommends participation in one of Children’s clinical trials, that likely means that your child’s physician believes that the plan outlined in that trial represents the absolute best, latest care your child can possibly receive.

And participation in any clinical trial is completely voluntary: We will take care to fully explain all elements of the treatment plan prior to the start of the trial, and you may remove your child from the medical study at any time.

Find a clinical trial

To search current and upcoming clinical trials at Boston Children’s, go to:
https://www.childrenshospital.org/clinical-trials

To search the NIH’s list of clinical trials taking place around the world, go to:
http://www.clinicaltrials.gov/ct2/search