Fears in preschool-age children

F e a r s in P r e s c h o o l - A g e Children

Donna M. Murphy University of Virginia

ABSTRACT: Although several comprehensive reviews of the literature on children's fears are available, none clearly distinguishes among different age levels of children in any way other than to describe developmental trends regarding specific fears. Dif- ferentiating younger from older children for the purpose of examlning their fears may be crucial for accurate classification and assessment and effective intervention. To that end, this review extrapolates from the research on children's fears information that is specific to preschool-age children, with particular emphasis on intervention. Relevant literature regarding prevalence, developmental trends, and prognoses is also reviewed, and various assessment techniques are presented and discussed in relation to preschoolers. Directions for further investigation into the fears of preschool-age children are suggested.

Scientific interest in children's fears is not new, dating back to classic case studies (Freud, 1909/1962; Jones, 1924; Watson & Rayner, 1920) and normative survey research (e.g., Hagman, 1932: Jersild & Holmes, 1933, 1935). Extensive reviews of investigations of children's fears over the last 70 years are available (Barrios, Hartmann, & Shigetomi, 1981; Graziano, DeGiovanni, & Garcia, 1979; Miller, Barrett, & Hampe, 1974; Ollendick, 1979; see also Morris & Kratoch- will, 1983). Although comprehensive, the reviews have not differentiated research relevant to preschoolers from research involving older children, other than to describe developmental trends regarding specific fears. The results of studies involving school-age children, however, are not necessarily generalizable to preschoolers. Not only do young children differ from older children in the types of fears considered fearsome, but they are also, in comparison, cognitively and behaviorally immature. Critical age-related variables such as language comprehension, verbal facility, psycho-motor skills, and the ability to follow diverse directions must be taken into account when selecting and evaluating assessment or intervention techniques. To disregard the very real differences among different age levels of children could lead to an inaccurate classification system of childhood fears in individual children (see Kendall, Lerner, & Craighead, 1984).

The purpose of this review was to extrapolate from the literature on children's fears that information most relevant to the topic of fears in

Requests for reprints should be sent to Donna M. Murphy, Department of Special Education, 152 Ruffner Hall, University of Virginia, Charlottesville, VA 22903.

Child Care Quarterly, 14(3), Fall 1985 o~9s5 by H ~ sci~e~ p ~ 171

172 Child Care Quarterly

preschool-age children, i.e., children between approximately two and five years of age.

Definition and Etiology

The term "fear" is fraught with multiple meanings, depending upon one's theoretical and experiential perspectives. For the purpose of this paper, fear is defined as a complex reaction to a specific stimulus that is perceived by an individual to be threatening. It is a complex reaction in that it typically involves three types of responses: behavioral ex- pression {particularly avoidance of the feared stimulus}, physiological arousal, and cognitive-emotional distress (c.f. Marks, 1969; Miller et al., 1974}. The specific stimulus feared may be either real, such as dogs, thunder, or sickness, or imaginary, such as ghosts or monsters. Fur- thermore, the individual's perception of the stimulus as threatening may be either rational, such as fearing a dog that has bitten, or apparently irrational, such as fearing the dark.

The most frequently espoused theories of the development and maintenance of fears in children are psychodynamic and behavioral; both have their limitations. The psychodynamic model, which describes phobias as symptoms of unconscious, instinctual conflicts, is empirically untenable. According to the various behavioral para- digms-respondent, operant {including modelling}, and two-factor Ca combination thereof}--fear responses are learned. But as Graziano et al. {1979} note, behavioral models do not adequately address the roles of cognitive and developmental variables that may be integral to the acquisition and maintenance of fears.

Several less prevalent theories of childhood fears have been proposed. Miller and his colleagues {1974}, for instance, suggest ap- plying a cognitive-developmental model of behavior, which is primarily concerned with the effects of maturation on an individual's interpretation of and reactions to his or her environment, to the un- derstanding of childhood phobias. Without a specific behavioral component, however, such a model would have limited utilitarian value in terms of intervention. A transactional theory described by Miller et al. {1974} emphasizes the "mutually influencing relationships of a phobic child and the significant persons in his environment, particularly the mother" {p. 118) and finds early limited validation of that perspective in a classic study of preschoolers' fears {Hagman, 1932}. Despite its promise, however, the transactional model is built on questionable, un- derlying, personality constructs.

In summary, it appears that none of the theories of the etiology of

Donna M. Murphy 173

fears is entirely acceptable. Childhood fears are undoubtedly too complex to be explained by any single theory, and most probably result from an interaction of numerous factors (Barrios et al., 1981; Graziano et al., 1979; Ollendick, 1979).

Prevalence

As has been demonstrated by several classic investigations, fears are not uncommon during childhood. Most normal children experience specific fears of mild to moderate intensity; estimates range from approximately 50% to 90% or more of children of various ages (e.g., Lapouse & Monk, 1959; MacFarlane, Allen, & Honzik, 1954). Fears of a greater intensity, or phobias--which have been described as excessive, persistent, maladaptive fears that are neither age- nor stage- specific, and that can be neither reasoned nor explained away (Marks, 1969; Miller et al., 1974)--are apparently much less widespread. Prevalence estimates of severe fears in school-age children are generally quite low, ranging from about 3% to 7% {e.g., Graham, 1964: cited in Marks, 1969; Graziano & DeGiovanni, 1979; S.B. Johnson & Melamed, 1979; Miller et al., 1974}. These estimates are typically determined by either surveying large samples of normal children or ap- plying restrictive criteria to the fears of children referred for clinical intervention. Graziano et al. {1979}, for instance, suggest that a serious, or "clinical", fear be defined as one "with a duration of over 2 years or an intensity that is debilitating to the client's routine life-style" tp. 805).

The number of preschoolers suffering severe fears has not as yet been established. Young children apparently do, however, experience multiple fears, as has been determined by early investigators concerned with identifying specific fear stimuli during childhood. Although Hagman's (1932) data suggest, upon careful examination, that three- and four-year-olds experience only about one fear per child, he reported an average of 2.7 fears for the combined group of two- to six-year-olds. In contrast, Jersild and Holmes found somewhat higher average occurrences of fears in children of comparable ages: 4.6 fears per child among two- to six-year-olds (1935), and 3.8 and 4.2 fears among three- and four-year-olds, respectively (1933).

The results of these and other early surveys, most of which relied on mothers' perceptions of their children's fears, are probably quite con- servative; studies comparing the enumeration of children's fears by both children and their mothers indicate that mothers tend to un- derreport their children's fears by as much as 41% (Lapouse & Monk, 1959; see also Jersild & Holmes, 1935; Miller, Hampe, Barrett, & Noble, 1971).


Developmental Trends

The fears of most preschoolers, like those of older children, are apparently overcome within at most several years {Cummings, 1946; Hagman, 1932; Jersild & Holmes, 1935; MacFarlane et al., 1954). Beginning in infancy and continuing through adolescence, specific types of fears are associated with various stages of development.

Jersild and Holmes (1933, 1935; see also Jersild, 1968), in their investigations of young children, observed that fears of strange objects and events and of separation from mother begin to decline after age two, while fears of animals, of imaginary creatures, of the dark, and of being alone tend to increase among three- and four-year-olds. Children between the ages of four and six report that animals, imaginary creatures, and the dark continue to be fearsome (Bauer, 1976; Maurer, 1965), although most parents note only limited fear of such things in their five- and six-year-olds (Shepherd, Oppenheim, & Mitchell, 1971). The n a t u r e of these types of fears, such as the particlar animals that are perceived as threatening, may differ between very young children and those approaching school age.

Fear of visiting the dentist--which may actually involve several separate fears, such as fear of strangers or of separation from mother --is apparently also related to age. According to a recent extensive review by Winer {1982), most children in dental settings exhibit "a marked diminution in overtly fearful behavior" (p. 1123) accompanied by an increase in cooperative behavior by about age four or five. The findings are not definitive, however; although behavioral and self- report measures indicate a developmental decrease in dental fear, physiological measures do not substantiate this trend. Moreover, there is some indication that, among older children, dental fear may actually increase with age (Winer, 1982).

Investigations of older children generally indicate that as children mature and their range of experience broadens, they tend to lose many of their early fears and to develop fears associated with school, in- terpersonal situations, personal health and safety, and, eventually, more abstract social concerns (Angelino, Dollins, & Mech, 1956; Bauer, 1976; Lapouse & Monk, 1959; Maurer, 1965; Sherer & Nakamura, 1968).

It is important to note that most surveys of childhood fears involved children no younger than five years of age. The results of those studies that included young children are of questionable validity in regard to both the prevalence estimates and the developmental characteristics of that population. One threat to the validity of the findings is that the surveys were apparently not sensitive to the cognitive and behavioral

Donna M. Murphy 175

limitations of preschool-age children and could easily have overlooked some major fears of that age group. For instance, the fear of being lost or kidnapped--which would be difficult for a young child to ex- p r e s s - m a y cause intense discomfort to preschoolers but be unnoticed by parents or other adult observers. A second limitation is that the few studies that examined only very young children are quite dated. Major technological advances and sociological changes have occurred since those early investigations. The nearly universal presence of television and the increasing popularity of day-care centers and nursery schools, for example, have provided opportunities for very young children to experience ideas and events that were not readily available to them several decades ago. Has exposure to people and events outside of the home made children fearful of more and different things? Has such exposure, through frequent repetition, allowed children to become desen- sitized to stimuli that their age-cohorts of the past found painfully fearsome? What effect have increased opportunities to vicariously experience potentially fearsome situations had on young children? Whether increased exposure to the world has affected either the nature or the prevalence of fears among preschoolers has yet to be determined.

Prognosis and Natural History

Most of the developmental studies seem to have involved children with mild to moderate levels of fear. The limited follow-up and retrospective research regarding phobias suggests that severe fears in children may be more persistent than lesser fears, but conclusions about the course of these fears are tentative, and are influenced in part by the design of the research undertaken.

In a retrospective study of phobias, Solyom and his associates (Solyom, Beck, Solyom, & Hugel, 1974} found that significantly more of the 47 adult out-patients {whose primary symptom was phobia}, as compared to matched non-patient controls, had experienced each of seven specific childhood fears: school phobia, nightmares, darkness, strangers, imaginary, alone, and bodily harm. Moreover, of the 21 non- patients who were judged to be phobic at the time of the study, 57% reported that their first phobic experience began during childhood. Similarly, Marks and Gelder {1966} report that most of the specific animal and situational phobias of their population of adult phobics originated during childhood (see also Abe, 1972; Marks, 1971}. On the other hand, a follow-up study of treated phobic children aged 6 to 15 revealed that only 7% remained severely phobic after two years, while


80% were symptom-free (Hampe, Noble, Miller, & Barrett, 1973). Agras, Chapin, and Oliveau (1972; see also Agras, Sylvester, & Oliveau, 1968} similarly report that all ten "children" (under 20 years of age} in their follow-up study were improved or recovered, without treatment, at the end of five years.

Taken together, these few studies suggest that although many children will have lost their fears by adulthood, the specific fears suf- fered by phobic adults have most often persisted since childhood. However, the evidence is too scarce and inconsistent to allow valid generalizations. More comprehensive retrospective and follow-up research that includes very young children is obviously needed to determine the treated and untreated course of fears during childhood.

Assessment

As was noted previously, fear is a multidimensional construct involving three types of responses: behavioral, cognitive-emotional, and physiological; a number of instruments have been developed to assess each of these elements. Most of the instruments available for measuring children's fears have been designed for school-age children, and, in general, "are unstandardized, lack norms, and have in- adequately evaluated reliability and validity" (Barrios et al., 1981, p. 296). Nevertheless, these assessment devices are the only means of identifying fearful children--other than through clinical referrals--and are employed in experimental intervention studies, including those involving preschoolers.

For a comprehensive, critical examination of the assessment of children's fears, the reader is referred to Barrios et al., {1981); for assessment specific to dental fears in children, see Winer (1982}. A brief description of available measurement techniques and their ap- plication to preschool-age children follows.

Behavioral Measures

Retrospective rating scales and checklists for parents or teachers to complete at home, in school, or during clinical interviews have been employed for both limited and extensive surveys of children's fears (e.g., Hagman, 1932: Lapouse & Monk, 1959; Shepherd et al., 1971}. The Louisville Fear Survey Scales for Children (Miller, Barrett, Hampe, & Noble, 1972}, for example, requires parents to rate their children as young as four according to a five-point scale of fear intensity on approximately 100 items that have been shown to elicit fear in

Donna M. Murphy 177

children. Reliability for this scale has been reported at about .80, and some clinical validity has been established (O.G. Johnson, 1976}. In general, retrospective rating scales measure an adult's perceptions of child's typical fear reactions; although they may be helpful for screening preschoolers for potentially serious fears, they should be followed up with more direct, reliable measures.

Direct observational rating scales and checklists, which measure a number of different motor responses in a variety of fear- or anxiety- producing situations, are less subjective but are prone to the same weaknesses--such as observer drift and bias--as other observational devices {Barrios et al., 1981}. Observational rating scales have been employed to assess preschoolers' fears of, among other things, the dark {Jackson & King, 1981}, the dentist (R. Johnson & Machen, 1973; Oppenheim & Frankl, 197D, separation from mother {Glennon & Weisz, 1978}, and miscellaneous stimuli (Jersild & Holmes, 1933}. Although Glennon and Weisz examined only separation anxiety and validated their instrument (the Preschool Observation Scale of Anxiety} against other measures of that particular fear, their list of behavioral indicators is extensive {30 items} and may be effective in assessing other kinds of fear as well.

Behavioral avoidance tests {BATs} measure the extent of specific approach and avoidance behaviors in children confronted with a feared {or potentially fearsome} stimulus. BATs are simple to administer and are used frequently in fear research. However, BATs have little reported reliability or validity, and because they are typically designed by individual researchers to meet the demands of a particular study, BATs are unstandardized {Barrios et al., 1981}. Among the specific fears in preschoolers assessed through BATs have been fear of dogs {Bandura, Grusec, & Menlove, 1976; Bandura & Menlove, 1968; Hill, Liebart, & Mott, 1968} and fear of the dark {Holmes, 1936; Kanfer, Karoly, & Newman, 1975; Kelley, 1976; Leitenberg & Callahan, 1973}.

Physiological Measures

Several devices for measuring children's physiological reactions to feared stimuli, such as heart rate and galvanic skin response, are available (see Barrios et al., 1981}. These instruments require specialized selection, monitoring, and interpretation, which renders them somewhat impractical. In addition, as Barrios et al. note, many children cannot remain still for such tests; preschoolers, who have not yet adjusted to sitting at tables for extended periods, may be too mobile for successful physiological assessment.

For those youngsters who are able to withstand physiological tests,


the results may be invalid. In a recent study of 115 young cancer patients about to undergo a painful medical procedure (Katz, Keller- man, & Siegel, 1980}, fewer than one-third of the children in the youngest group {ages 8 months to 6 years, 4 months; X=3 years, 10 months} exhibited muscular rigidity, a reaction commonly considered to be a physiological indicator of fear. In contrast, symptoms of muscle tension were observed in nearly two-thirds of the oldest group (X=12 years, 7 months}. Although the measures employed in this study were behavioral rather than physiological, i.e., trained observers rather than mechanical devices were used to detect muscle tension, the results suggest that physiological assessment of preschoolers may not provide accurate information about their fears. Moreover, the use of physiological assessment devices with very young children is ethically questionable. A young child, already under stress due to the in- troduction of a feared stimulus, could be further threatened by the equipment and recording processes themselves. Additional research into the advisability of subjecting young children to physiological assessment is clearly indicated.

Cognitive-Emotional Measures

The cognitive-emotional assessment of children's fears involves, by necessity, the self-reporting of a child's own thoughts and/or feelings concerning potentially fearsome stimuli. The extent of cognitive- emotional self-revelation required of a child depends upon the type of device employed. General surveys of fear typically involve the simple identification of what a child fears based on her/his ratings of a number of predetermined items. The Children's Fear Survey Schedule (Ryall & Dietiker, 1979} is purported by its authors to be applicable to children as young as four. Ryall and Dietiker found their measure to be clinically valid and to have a test-retest reliability of .85. The previously described Louisville scales {Miller et al., 1972} can also be employed as a self-report measure.

Some researchers have developed techniques specifically for the eliciting of self-reports of particular fears from the very young. Kelley {1976}, for instance, designed a "fear thermometer" to allow her four- and five-year-old subjects to differentiate their levels of fear of the dark according to different colors. A similar device, displaying drawings of children's faces, was employed by Giebenhain and O'Dell {1984}. Venham {1979} asked young children in a dental setting to select pictures that best expressed how they were feeling. In an investigation of the structure of different fears in children, Bauer {1976} requested that his subjects {including 19 aged four to six) draw pictures of and talk about what they feared most. Ryall and Dietiker

Donna M. Murphy 179

(1978), in a study that has implications for the assessment of fears in preschoolers, report that their four- and five-year-old subjects tended to prefer the words" afraid" and" scared" to"nervous", "worried", or "tense" when describing cartoons of fearful children; for the five-year- olds alone, however, no significant differences were found in their fear word choices.

Attempts such as these to adjust the cognitive and linguistic requirements of a fear assessment device to fit the abilities of preschoolers should provide a more accurate reflection of the nature and extent of fear in a young child. Valid conclusions about the relationship between the self-reports of preschoolers and other measures of their fear cannot be made at this time, however. Although most researchers report nonsignificant or inconclusive correlations (Glennon & Weisz, 1978; Kelley, 1976; Sheslow, Bondy, & Nelson, 1983; Venham & Gaulin-Kremer, 1979} suggesting that young children may be unable to report fearful thoughts and feelings accurately, some have achieved more promising results. Melamed and her colleagues (Melamed, Yur- cheson, Fleece, Hutcherson, & Hawed, 1978), for example, found significant, positive correlations between several behavioral measures and the self-reported "anticipatory anxiety" of 80 children aged 4 to 11 about to undergo dental treatment {unfortunately, separate data for the youngest children were not reported for these particular correlations). It must also be noted that those studies that include correlational analyses are for the most part not comparable. Further research under uniform conditions and involving single, previously evaluated assessment and intervention methods would help to clarify the relationship between young children's self-reports of fear and their treated and untreated behavior in fearsome situations.

I n t e r v e n t i o n

The treatment of children's fears has been reviewed in depth elsewhere {Gelfand, 1978; Graziano et al., 1979; Ollendick, 1979; see also Hatzenbuehler & Schroeder, 1978; Morris & Kratochwill, 1983}. Virtually all of the behavioral interventions employed with children have involved some form of desensitization to the feared stimulus, most typically though a) gradual exposure (imaginal or "in vivo") to the stimulus, often paired with reciprocal inhibition of the fear response {through muscle relaxation, emotive imagery, or primary reinforcement}, b) reinforced practice in coping with the stimulus, and/or c) modelling {symbolic or "in vivo") by peers interacting with the stimulus. In addition, several researchers have incorporated self-


statements of fearlessness or coping stategies into the desensitization process. As will be noted presently, variations of these procedures have been specifically applied to preschoolers as well.

W h e n to In t e rvene

The decision that a preschooler's fear is serious enough to warrant intervention depends on several factors. One consideration is the developmental nature of the fear. Is the fear common among children of the same age as the child in question? Is it likely to be of mild in- tensi ty and short duration? As mentioned previously, several specific fears have been found to be characteristic of preschool-age children, but the research on which these findings are based are dated and may not accurately reflect the typical fears of today 's preschoolers. A comprehensive classification scheme based on normative data tha t include very young children would allow psychopathological fears requiring immediate, intensive t reatment to be differentiated from common childhood fears (see Garber, 1984; Kendall et al., 1984).

Even if a particular fear is typical at a given child's age and is ex- pected to diminish with time, the discomfort the fear causes the child and her/his parents, teachers, peers, and others with whom the child comes in contact must also be taken into account. Ollendick (1979), upon examination of the previously mentioned s tudy by Agras and associates (1972) in which their subjects ' untreated fears diminished or disappeared within five years, observes that:

For nearly all children, excessive fears of phobic proportions were persistent lasting up to 3 years. For 60% of the children, the fears persisted at least 5 years. Thus, even though all 100% were 'improved' in 5 years, it appears that considerable distress was experienced during those years. {p. 136}

To avoid needless suffering in young children, a child-care worker confronted with a fearful child should ask the following questions: Has the fear been persistent? Is it painful to the child? Is it adversely affecting the child's usual behviors or relationships? Is it preventing the child from participating in activities that are conducive to health or hap- piness? For cases of intrusive, distressing fears, a simple desensitization procedure designed along the lines of those described below should be considered. Most are inexpensive, require no special training, and are adaptable to a variety of fears.

Donna M. Murphy 181

Intervention Research with Preschoolers

Among preschoolers, the specific fears most often targeted for behavioral interventions are fear of the dark and fear of dogs, presumably because they are more easily identified and more aversive to parents than most other fears. Preschoolers have also been included in t reatment studies specific to children's dental visits. Following are brief descriptions of several intervention studies of these kinds of fears in young children.

Fear of the Dark. A number of researchers have at tempted to eliminate fear of the dark in preschoolers through both case studies {Holmes, 1936; Jackson & King, 1981; Kellerman, 1980} and experimental investigations (Kanfer, Karoly & Newman, 1975; Kelley, 1976; Lietenberg & Callahan, 1973; Shestow et al., 1983). Both Holmes (1936) and Lietenberg and Callahan {1973} successfully employed reinforced practice as part of their desensitization techniques. Holmes reported extinguishing, in 13 of 14 pretested preschoolers, fear of en- tering and crossing a dark room to reach a light switch. Intervention consisted of guided practice {providing unsystematic coping strategies during training sessions} and reinforcement {praise and game-playing} upon each successful completion of the task. Lietenberg and CaUahan measured the length of time that 15 fearful nursery schoolers and kin- dergarteners {five and six years old} remained in a dark room; the experimental subjects received praise and prizes for each training session that lasted longer than the one previous. Trained subjects remained in the room significantly longer than control subjects who demonstrated little change in time between pre- and posttest.

Kelley {1976}, in contrast, found no significant change in either observed or self-reported fear of the dark in 40 four- and five-year olds after employing "play desensitization" {role playing, with dolls, the time spent in dark} with and without contingent edible reinforcement. She did observe, however, that instruction to "try as hard as you can" (p. 80} resulted in significantly longer periods of time spent in the dark during posttest; interestingly, increased contact with the dark under this high-demand condition was associated with an increase in self- reported fear among the initially most fearful children.

Jackson and King {1981) employed reciprocal inhibition--the elicitation of behavioral, physiological, emotional, and/or cognitive responses that are incompatible with, and thereby inhibitive of, fear and anxiety--in their systematic desensitization of fear of the dark in a 5~A-year-old boy. The child was taught the anxiety-inhibiting


technique of emotive imagery, i.e., he was instructed to imagine that "a fictional character [Batman] with whom the subject was extremely enthralled"(p. 326; see also Lazarus & Abramovitz, 1962} accompanied him in each of the fear-producing scenarios described by the therapist. The scenarios were presented in a previously determined order of least to most fearsome and reflected the child's typical nighttime ex- periences.

Jackson and King (1981} report generalization and maintenance of treatment effects in the home setting for up to 18 months. Tasto (1969), however, found that the fear-reductive effects of emotive imagery did not transfer to real-life situations in the case of a four- year-old's fear of loud noises. Only when voluntary muscle relaxation was paired with the systematic "in vivo" presentation of the feared stimuli did the child overcome his fear, suggesting that the cognitive demands of emotive imagery may be beyond the abilities of very young chldren. Comparably, Montenegro (1968) reports that systematic desensitization in conjunction with "in vivo" reciprocal inhibition--in which food was used, after a period of deprivation, to counteract fear--was successful in treating a case of separation anxiety in a 31A-year-old girl. (Reciprocal inhibition techniques have not been limited to treating fear of the dark in young children. They have also been used, although much less frequently, in case studies of fears as diverse as fear of a preschool bathroom [McNamara, 1968] and fear of bees [Ney, 1968].)

Fear of the dark in preschoolers has also been treated by teaching them specific self-statements, a self-control technique that has been described by one of its users in terms of reciprocal inhibition, i.e., "incompatible response training" and "counter-anxious behaviors" elicitation (Kellerman, 1980, pp. 9, 10). Sheslow et al. {1983), for instance, investigated the effects of imaginal and "in vivo" verbal coping strategies in fear of the dark in 32 4- and 5-year olds. The children were assigned to one of four conditions: a) graduated exposure, in which each child attended at least 54 sessions of gradually decreasing illumination; b) systematic verbal coping skills, during which each child was taught three coping phrases (e.g., "I can always turn the lights on") and applied them during imaginal games; c) combined exposure and coping skills; and d) contact control, in which each child was taught neutral phrases from nursery rhymes. Under each condition, children talked, played, and snacked with the experimenter. During posttest, low-demand directives (e.g., "try to stay in the dark as long as you can") were counterbalanced with high-demand directives (e.g., " try very, very hard this time"). Results indicated that a) increased exposure to the dark both with and without verbal coping

Donna M. Murphy 183

strategies was associated with increased tolerance; b) verbal coping without exposure did not lead to significant increases in tolerance {However, the comparative effectiveness of exposure without coping strategies and exposure with coping strategies is unclear}; and c) in contrast to Kelley {1976}, demand conditions were not significantly related to tolerance.

In a comparable but less complex study of 45 five- and six-year-olds {Kanfer et al., 1975}, those children taught to use self-statements of confidence {"I am a brave boy/gir l . . . ") or encouragement {"The dark is a fun place to b e . . . ") voluntarily decreased illumination in a lab room to significantly lower intensity levels than did those taught neutral self-statements. Similarly, Kellerman {1980} successfully taught a five-year-old boy verbalizations and behaviors designed to help him cope with his bedtime fears and nightmares.

A noteworthy aspect of the Kellerman {1980} study is the role of the parents: they were instructed to record their children's sleep behavior and reinforce specific, appropriate behaviors. In a recent study that relied entirely on parental intervention {Giebenhain & O'Dell, 1984}, fear of the dark in six children of whom two were thre~years-old and two were five-years-old was successfully treated with a technique involving desensitization and positive self-statements. Parents were given manuals with instructions for performing simple data collection, providing reinforcement, implementing desensitization procedures, and teaching their children to relax and use specific self-statements. Using a rheostat, children controlled the illumination levels of their rooms; each morning, parents graphed their children's progress and recorded their self-reported fear as determined according to a fear thermometer {cf. Kelley, 1976; Sheslow et al., 1983}. Within two weeks of the intervention--and at follow-up investigations up to one year later--all of the children were sleeping throughout the night at illumination levels voluntarily set at criterion level or lower.

Fear of Dogs. Young children's fear of dogs has also been treated with a variety of desensitization procedures. Lazarus {1960} imple- mented a form of reciprocal inhibition when he temporarily ad- ministered to a 3V2-year-old boy with a severe phobia of dogs small doses of tranquilizing drugs to induce muscle relaxation, then gradually introduced a variety of animals without incident: the child was still free of his fear at a one-year follow-up investigation.

Bandura and his associates applied an entirely different form of desensitization to fears in preschoolers by adding controlled peer modelling to the procedure (Bandura et al., 1967; Bandura & Menlove, 1968; See also: Hill et al., 1968}. Although Holmes {1936} reports no change in a young child's fear of heights after observing fearless peer


models, the more recent modelling (Bandura et al., 1967) and symbolic modelling {Bandura & Menlove, 1968; Hill et al., 1968) techniques-which targeted fear of dogs--were successful in significantly decreasing avoidance behaviors in their subjects as compared to control groups. Their success is presumably attributable to their inclusion of vicarious desensitization. The models displayed gradual approach behavior over several training sessions. This procedure not only allows the fearful observers to become slowly acclimated to the threatening situations, but also provides opportunities to learn appropriate approach behaviors at each step of the process. Bandura and Menlove {1968) also found that using a variety of models and dogs produced the most daring approach behaviors in their young subjects.

Fear of Dental Visits. Although, as Winer {1982) notes, several treatment studies of children's dental fears have produced inconclusive results, those employing behavioral techniques have met with greater success.

Johnson and Machen {1973) compared the effects of symbolic modelling and a systematic exposure technique in a study involving 58 3- to 5½-year olds who were undergoing their first dental visit. The modelling group viewed a videotape of an older child demonstrating appropriate behavior and receiving verbal reinforcement during dental treatment; the systematic exposure group was introduced to dental equipment that had been "prearranged in a hierarchy of anxiety production" {p. 273) while listening to a description of the dental routine. Although both groups exhibited more positive behaviors than control subjects, only for the modelling group was the difference significant. Comparable investigations that included older children as well as preschoolers have also found modelling to be superior to exposure to dental instruments and routines in alleviating dental phobia (Melamed et al., 1978; White & Davis, 1974). Although studies such as these suggest that modelling is a promising behavioral approach to the treatment of dental fears in preschool-age children, conclusions about its effectiveness relative to simple exposure are tentative. Variables such as amount of information provided during exposure and subjects' prior experience with dental visits are apparently related to young children's self-reports of fear (Melamed et al.) and should be explored further.

Summary and Implications

Most children of preschool age suffer from one or more fears. Usually, these fears diminish over time, and different types of fears

Donna M. Murphy 185

emerge. Because of the transient nature of most childhood fears, and because of the extensive behavioral and cognitive changes children undergo as they mature, researchers need to discriminate more carefully--in both their investigations of fears and their generalizations of f indings--among children of different age levels.

Drawing firm conclusions from the literature on children's fears relative to the fears of preschoolers is hampered by numerous procedural inconsistencies and methodological problems {for a detailed discussion of the methodological shortcomings in the research of children's fears, see Graziano et al., 1979}. Nevertheless, several trends are evident. In general, the transient fears experienced by most children between the ages of two and five, as determined by early normative survey research, include fear of animals, imaginary creatures, the dark, and being alone. Additional investigations are required to determine if these types of fears have changed over the last several decades; if the nature of these fears (e.g., the severity of fear and the specific stimuli feared) differs within this age group, between preschoolers and older children, between clinically referred and non- referred children, and/or among special child populations such as the handicapped or various cultural/ethnic groups; and if preschoolers report having fears different from those reported for them by their parents or other adults. A valid classification scheme of fears throughout childhood--perhaps as a subset of a comprehensive system of diverse childhood behaviors--would be an invaluable diagnostic tool.

Before an assessment or intervention technique is selected, consideration must be given to the cognitive level and behavioral reper- toire of the fearful child. The assessment procedures currently employed with children of preschool age are the same as or similar to those used with older children and adults. Those tes ts that are most promising for use with young children are observational measures that assess overt behaviors made in response to potentially fearsome stimuli and those cognitive-emotional measures that have been adapted to allow young children to report their own internal reactions to these stimuli. However, neither technique has yet been stan- dardized and for neither, has adequate reliability and validity been established. For children with profound and incapacitating fears, intensive clinical case studies in which the parents are also involved may be most enlightening.

The literature regarding fear intervention reveals that many different forms of desensitization to a feared stimulus have been successfully employed with preschoolers as well as with older children and adults. Since methods of subject selection, pre- and post-assessment,


and specific training techniques are so diverse, valid comparisons of these interventions are impossible at this time. In addition, most of the early studies lacked experimental rigor (see Hatzenbuehler & Schroeder, 1978}. Nevertheless, two types of procedures appear most promising: systematic desensitization leither modelled or "in vivo"} and cognitive self-control.

Gradual, systematic exposure to the feared stimulus has been used successfully to treat a variety of fears in preschool-age children. Desensitization through modelling has the added benefit of allowing the fearful child to learn appropriate coping behaviors. Providing a comforting variable such as food, toys or a nurturing adult to elicit positive emotions and thus inhibit fear while the feared stimulus is being introduced {reciprocal inhibition } has also been successful. The effectiveness of that approach relative to desensitization without a fear-inhibing component, however, has not been empirically determined. It may be that reciprocal inhibition is more useful in cases of such extreme fear that the child cannot tolerate the slightest hint of the feared stimulus.

Intervention procedures that incorporate a cognitive component, designed for young minds, have been successful in alleviating fear of the dark in young children and are likely to be effective in treating other fears as well. Most researchers using such a procedure have taught simple self-statements of fearlessness or coping strategies to their young subjects. For an intersting variation of this approach, popular songs or nursery rhymes could be selected or adapted to fit a particular child's fear Isee Bankart & Bankart, 1984, for an example of the creative use of a "rock" song in the treatment of school phobia in a nine-year-oldl. The cognitive aspect of fear intervention is enticing in that is has--theoreticUy, at least--the potential to increase the likelihood of maintenance of effects and feelings of self-control.

On a final note, the importance of additional research into fear prevention must be mentioned. Once a comprehensive classification system of fears common to preschoolers has been established, community prevention programs tsee Graziano et al., 1979} should be im- plemented in local libraries, day-care centers, preschools, and other in- stitutions where young children normally assemble. Modelling films or videotapes that systematically portray young children coping with typically fearsome events or objects should be developed, perhaps in conjunction with a local research center {e.g., a university or state agency}, and stored in a central location for periodic showing by local community organizations. On an individual basis, those who work with young children should organize their activities to include preven- tative desensitization to fearsome stimuli. For instance, an in-

Donna M. Murphy 187

structional unit on a potentially fearsome object or event, either real or imaginary, might be developed, beginning with humorous stories and rhymes about the stimulus and proceeding over time with arts and crafts activities, group discussions, and simple role-playing. If the selected stimulus is real, the unit might eventually include real-life photographs and a field trip to observe suitable examples. Providing opportunities for early desensitization to potentially fearsome situations and for learning specific coping and approach behaviors appropriate to those situations may result in fewer and less painful fears among preschool-age children.

References

Abe, K. Phobias and nervous symptoms in childhood and maturity: Persistence and associations. British Journal of Psychiatry, 1972,120, 275-283.

Agras, W.S., Chapin, H.N., & Oliveau, D.C. The natural history of phobia: Course and prognosis. Archives of General Psychiatry, 1972, 26, 315-317.

Agras, S., Sylvester, D., & Ollveau, D. The epidemiology of common fears and phobias. Comprehensive Psychiatry, 1969, 10, 151-156.

Angelino, H., Dollins, J., & Mech, E.V. Trends in the "fears and worries" of school children as related to socio-economic status and age. The Journal of Genetic Pychology, 1956, 89, 263-276.

Bandura, A., Grusec, J.E., & Menlove, F.L. Vicarious extinction of avoidance behavior. Journal of Personality and Social Psychology, 1967, 5, 16-23.

Bandura, A., & Menlove, F.L. Factors determining vicarious extinction of avoidance behavior through symbolic modeling. Journal of Personality and Social Psychology, 1968, 8, 99-108.

Bankart, C.P., & Bankart, B.B. The use of song lyrics to alleviate a child's fears. Child & Family Behavior Therapy, 1984, 5, 81-83.

Barrios, B.A., Hartmann, D.P. & Shigetomi, C. Fears and anxieties in children. In E.J. Mash & L.G. Terdal (Eds.), Behavioral assessment of childhood disorders, New York: Guilford Press, 1981.

Bauer, D.H. An exploratory study of developmental changes in children's fears. Jour- nal of Child Psychology and Psychiatry, 1976, 17, 69-74.

Cummings, J.D. A follow-up study of emotional symptoms in school children. British Journal of EducationaI Psychology, 1946, 16, 163-177.

Freud, S. Analyses of a phobia in a five-year-old boy. Complete psychological works (Vol. 10). London: Hogarth Press, 1962. (Original work published 1909.)

Garber, J. Classification of childhood psychopathology: A developmental perspective. Child Development, 1984, 55, 30-48.

Gelfand, D.M. Social withdrawal and negative emotional states: Behavior therapy. In B.B. Wolman, J. Egan, & A.O. Rose (Eds.), Handbook of treatment of mental disorders in childhood and adolescence. Englewood Cliffs, N J: Prentice-Hall, 1978.

Giebenhain, J.E., & O'Dell, S.L. Evaluation of a parent-training manual for reducing children's fear of the dark. Journal of Applied Behavior Analysis, 1984, 17, 121- 125.

Glennon, B., & ~Veisz, J.R. An observational approach to the assessment of anxiety in young children. Journal of Consulting & Clinical Psychology, 1978, 46, 1246-1257.

Graziauo, A.M., & DeGiovanni, I.S. The clinical significance of childhood phobias: a note on the proportion of child-clinical referrals for the treatment of children's fears. Behavior Research and Therapy, 1979, 17, 161-162.


Graziano, A.M., DeGiovanni, I.S., & Garcia, K.A. Behavioral treatment of children's fears: A review. Psychological Bulletin, 1979, 86, 804-830.

Hagman, E.K. A study of fears in children of preschool age. Journal of Experimental Education, 1932, 1, 110-130.

Hampe, E., Noble, H., Miller, L.C., & Barrett, C.L. Phobic children one and two years posttreatment. Journal o f A bnormal Psychology, 1973, 82, 446-453.

Hatzenbuehler, L.C., & Schroeder, H.E. Desensitization procedures in the treatment of childhood disorders. PsychologicalBuUetin, 1978, 85, 831-844.

Hill, J.H., Liebert, R.M., & Mort, D.E.W. Vicarious extinction of avoidance behavior through films: An initial test. PsychologicalReports, 1968, 22, 192.

Holmes, F.B. An experimental investigation of a method of overcoming children's fears. Child Development, 1936, 7, 6-30.

Jackson, H.J., & King, N.J. The emotive imagery treatment of a child's trauma-induced phobia. Behavior Therapy and Experimentat Psychiatry, 1981,12, 325-328.

Jersild, A.T. Child Psychology {6th ed.}. New Jersey: Prentice-Hall, 1960. Jersild, A.T., & Holmes, F.B. A study of children's fears. Journal of Experimental

Education, 1933, 11, 109-118. Jersild, A.T., & Holmes, F.B. Children's fears. Child Development Monograph, No. 20.,

1935. Johnson, O.G. Tests and measurements in child development: Handbook I I (Vol. 1). San

Francisco: Jossey-Bass, 1976. Johnson, R., & Machen, J.B. Behavior modification techniques and maternal anxiety.

Journal of Dentistry for Childrenl 1973, 40, 272-276. Johnson, S.B., & Melamed, B.G. The assessment and treatment of children's fears. In

B.B. Lahey & A.E.Kazdin tEds.), Advances in clinical child psychology (Vol. 2) New York: Plenum Press, 1979.

Jones, M.C. A laboratory study of fear: The case of Peter. Pedagogical Seminar, 1924, 31, 308-315.

Kanfer, F.H., Karoly, P., & Newman, A. Reduction of children's fears of the dark by competence-related and situational threat-related verbal cues. Journal of Con- sulting and Clinical Psychology, 1975, 43, 251-258.

Katz, E.R., KeUerman, J., & Sigel, S.E. Behavioral distress in children with cancer undergoing medical procedures: Developmental considerations. Journal of Con- sulting and Clinical Psychology, 1980, 48, 356-365.

Kellerman, J. Rapid treatment of nocturnal anxiety in children. Behavioral Therapy and Experimental Psychiatry, 1980, 11, 9-11.

Kelley, C.K. Play desensitizaion of fear of darkness in preschool children. Behavior Research and Therapy, 1976, 14, 79-81.

Kendall, P.C., Lerner, R.M., & Craighead, W.E. Human development and intervention in childhood psychopathology. Child Development, 1984, 55, 71-82.

Lapouse, R., and Monk, M.A. Fears and worries in a representative sample of children. American Journal of Orthopsychiatry, 1959, 29, 803-818.

Lazarus, A.A. The elimination of children's phobias by deconditioning. In H.J. Eysenck (Ed.), Behavior therapy and the neuroses. New York: Pergamon Press, 1960.

Lazarus, A.A., & Abramovitz, A. The use of "emotive imagery" in the treatment of children's phobias. Journal of Mental Science, 1962,108, 191-195.

Leitenberg, H., & Callahan, E.J. Reinforced practice and reduction of different kinds of fears in adults and children. Behavior Research and Therapy, 1973,11, 19-30.

MacFarlane, J., Allen, L., & Honzik, M. A developmental study, of the behavior problems of normal children between twenty-one months and fourteen years. Berkeley: University of California Press, 1954.

Marks, I.M. Fears and phobias. New York: Academic Press, 1969. Marks, I.M. & Gelder. M.G. Different onset ages in varieties of phobia. American Jour-

nal of Psychiatry, 1966,123, 218-221. Maurer, A. What children fear. The Journal of Genetic Psychology, 1965,106, 265-277. McNamara, J.R. Behavior therapy in the classroom: A case report. Journal of School

Psychology, 1968, 7, 48-51.

Donna M. Murphy 189

Melamed, B.G., Yurcheson, R., Fleece, E.L., Hutcherson, S., & Hawes, R. Effects of film modeling on the reduction of anxiety-related behaviors in individuals varying in level of previous experience in the stress situation. Journal of Consulting and Clinical Psychology, 1978, 46, 1357-1367.

Miller, L.N., Barrett, C.L., & Hampe, E. Phobias of childhood in a prescientific era. In A. Davids (Ed.), Child personality and psychopathology: Current topics (Vol. 1), New York: Wiley & Sons, 1974.

Miller, L.C., Barrett, C.L., Hampe, E., & Noble, H. Factor structure of childhood fears. Journal of Consulting and Clinical Psychology, 1972, 39, 264-268.

Miller, L.C., Hampe, E., Barrett, C.L., & Noble, H. Children's deviant behavior within the general population. Journal of Consulting and Clinical Psychology, 1971, 34, 503-511.

Montenegro, H. Severe separation anxiety in two preschool children: Successfully treated by reciprocal inhibition. Journal of Child Psychology and Psychiatry, 1968, 9, 93-103.

Morris, R.J., & Kratochwill, T.R. Treating children's fears and phobias: A behavioral approach. New York: Pergamon Press, 1983.

Ney, P.G. Combined psychotherapy and deconditioning of a child's phobia. Canadian PsychiatricAssociationJournal, 1968,13, 293-294.

Ollendick, T.H. Fear reduction techniques with children. In M. Hersen, R.M. Eisler, & P.M. Miller (Eds.), Progress in behavior modification (Vol. 8), New York: Academic Press, 1979.

Oppenheim, M.N., & Frankl, S.N. A behavioral analysis of the preschool child when introduced to dentistry by the dentist or hygienist. Journal of Dentistry for Children, 1971, 3, 317-325.

Ryall, M.R., & Dietiker, K.E. Fear word choice in preschoolers. Journal of Behavior Therapy and ExperimentaI Psychiatry, 1978,9, 189-190.

Ryall, M.R. & Dietiker, K.E. Reliability and clinical validity of the Children's Fear Sur- vey Schedule. Journal of Behavior Therapy and Experimental Psychiatry, 1979, 10, 303-309.

Sherer, M.W., & Nakamura, C.Y. A fear survey schedule for children (FSS-FC): A factor analytic comparison with manifest anxiety (CMAS). Behavior Research and Therapy, 1968, 6, 173-182.

Sheslow, D.V., Bondy, A.S., & Nelson, R.O. A comparison of graduated exposure, verbal coping skills, and their combination in the treatment of children's fear of the dark. Child and Family Behavior Therapy, 1983, 4, (2), 33-45.

Shepherd, M., Oppenheim, B., & Mitchell, S. Childhood behavior and mental health. London: University of London Press, 1971.

Solyom, L., Beck, P., Sotyom, C., & Hugel, R. Some etiological factors in phobic neurosis. Canadian Psychiatric Association Journal, 1974, 19, 69-78.

Tasto, D. Systematic desensitization, muscle relaxation and visual imagery in the counter-conditioning of a four year old phobic child. Behavior Research and Therapy, 1969, 7, 409-411.

Venham, L.L. The effect of mother's presence on child's response to dental treatments. Journal of Dentistry for Children, 1979, 46, 219-225.

Venham, L.L., & Gaulin-Kremer, E. A self report measure of situational anxiety for young children. Pediatric Dentistry, 1979,/, 91-96.

Watson, J.B., & Rayner, P. Conditioned emotional reactions. Journal of Experimental Psychology, 1920, 3, 1-14.

White, W.C., & Davis, M.T. Vicarious extinction of phobic behavior in early childhood. Journal of Abnormal Child Psychology, 1974, 2, 25-32.

Winer, G.A. A review and analysis of children's fearful behavior in dental settings. ChildDevelopment, 1982, 53, 1111-1133.

Documents

Fears in preschool-age children