Assessment of childhood phobias

Pergamon

Clinical Psychology Review, Vol. 17, No. 7, pp. 667--687, 1997 Copyright © 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/97 $17.00 + .00

PII S0272-7358(97)00029-9

ASSESSMENT OF C H I L D H O O D PHOBIAS Neville J. King Faculty of Education, Monash University

Thomas H. Ollendick Department of Psychology, Virginia Polytechnic Institute and State University

Gregory C. Murphy Faculty of Health Sciences, La Trobe University

ABSTRACT. Childhood phobias can be successfully treated using a variety of behavioral

strategies, provided there has been a psychometrically sound assessment. Measures are also important for the evaluation of treatment efficacy and the testing of hypotheses generated by new ideas and theories of children's phobias. This paper outlines broad-based assessment procedures used in the evaluation of children's phobias, including the behavioral or problem-focused interview, the diagnostic interview, self-report inventories, caregiver completed instruments, behavioral observations, self-monitoring and physiological assessment. Reflecting recent theoretical and clinical advances in the study of childhood internalizing disorders, we also explore laboratory-based measures and family assessment measures. Particular attention is given to psychometric issues and developmental sensitivity in our discussion of these assessment procedures. © 1997 Elsevier Science Ltd

CHILDREN EXPERIENCE m a n y fears over the course of development. N u m e r o u s studies have d o c u m e n t e d the quantitative a n d qualitative changes that occur in the n o r m a l developmental fear pattern (reviews by King, Hamilton, & Ollendick, 1988; Morris & Kratochwill, 1983). These fears are usually short-lived and not of sufficient magnitude to be problematic. On the o t h e r hand, some children exhibit fear reactions that are maladaptive, persist for a considerable period of time a n d cause m u c h Correspondence should be addressed to Neville King, School of Graduate Studies, Faculty of Education, Monash University, Clayton, Victoria, 3168, Australia.

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distress. Fears of this nature are referred to as "clinical fears" or "phobias." C o m m o n examples of these phobias include excessive fears of animals, water, heights, thunderstorms, darkness, and medical and dental procedures. Following the tripartite model originally developed by Lang (1968, 1977), childhood fears and phobias can be conceptualized in terms of three response systems: cognitive, physiological, and overt-behavioral. King et al. (1988) have d o c u m e n t e d the variety of cognitive responses (e.g., thoughts of being scared, self-deprecatory thoughts), physiological responses (e.g., increased heart rate and changes in respiration), and overt- behavioral responses (e.g., rigid posture, thumbsucking, and avoidance) that may occur in the fearful or phobic child. In recognition of their seriousness and stability, phobias are included in the two most widely accepted diagnostic classification systems (American Psychiatric Association, 1994; World Health Organization, 1992). For example, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) specifies the following criteria for "specific" phobia: (a) marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation; (b) exposure to the phobic stimulus almost invariably provokes an immediate anxiety response or panic attack; (c) the person recognizes that the fear is excessive or unreasonable; (d) the phobic situation(s) is avoided or else e n d u r e d with intense anxiety; (e) the phobia causes significant interference to functioning or there is marked distress about having the phobia; (f) in individuals u n d e r 18 years, the duration is at least 6 months, and (g) the anxiety or phobic avoidance are not better accounted for by another disorder, such as obsessive-compulsive disorder or separation anxiety disorder. In relation to developmental factors, the DSM-IVacknowledges that children may not recognize their fears as excessive or unreasonable. Thus, phobias in young children may be expressed in " c h i l d h o o d " ways, such as crying, tantrums, freezing, or clinging. A similar definition of specific phobia (referred to as "isolated" phobia) is given in the ICD-10. Fortunately, childhood phobias can be successfully treated using behavioral strategies, such as desensitization and its variants, modeling, cognitive restructuring, and contingency m a n a g e m e n t procedures (see King & Ollendick, 1997). However, successful intervention hinges on a sound behavioral/diagnostic assessment. Consistent with contemporary definitions of child and adolescent behavioral assessment (Ollendick & Hersen, 1984, 1993), we see the assessment of childhood phobias as an exploratory, hypothesis-testing process in which a range of specific assessment procedures are used to understand the child and the relevant social ecology and to provide the basis for formulating and evaluating intervention strategies. Because of their specific relevance to the behavioral assessment of childhood fears and phobias, we shall address the following procedures: the behavioral interview, diagnostic interviewing, self-reports, caregiver-reports, behavioral observations, self-monitoring, and physiological recordings. Reflecting more recent theoretical and clinical developments, we also explore laboratory-based measures and family assessment measures (Ronan, 1996). Consideration will be given to issues of empirical validity and developmental sensitivity. For more detailed information on the assessment of childhood phobias, the reader is referred to other sources (King et al., 1988; Morris & Kratochwill, 1983; Ollendick, King, & Yule, 1994).

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BEHAVIORAL INTERVIEW T h e b e h a v i o r a l interview is a crucial step in the assessment process. T h e p u r p o s e s o f the interview are to establish r a p p o r t with the child a n d family, obtain inform a t i o n as to the n a t u r e of the p h o b i c b e h a v i o r as well as its a n t e c e d e n t s a n d c o n s e q u e n c e s , assess the child's d e v e l o p m e n t a l level, d e t e r m i n e the b r o a d e r sociocultural c o n t e x t in which the p h o b i c b e h a v i o r occurs, a n d to f o r m u l a t e t r e a t m e n t plans ( B i e r m a n & Schwartz, 1986; Murphy, H u d s o n , King, & Remenyi, 1982; O l l e n d i c k & Cerny, 1981). Several s t r u c t u r e d behavioral interviews have b e e n r e p o r t e d in the literature (e.g., King et al., 1988; M u r p h y et al., 1982). I n t e r v i e w i n g a p h o b i c child requires an u n d e r s t a n d i n g that such a child may be timid, shy, fearful, anxious, a n d relatively u n r e s p o n s i v e to interview questions. It also d e m a n d s an a p p r e c i a t i o n o f the child's d e v e l o p m e n t a l level a n d how his or h e r cognitive d e v e l o p m e n t places constraints on the types of questions that can be asked a n d how they should be phrased. It is f r e q u e n t l y necessary to p h r a s e questions in specific, direct t e r m s so that the child will u n d e r s t a n d t h e m a n d to provide the child with additional s u p p o r t a n d e n c o u r a g e m e n t to respond. Generally, o p e n - e n d e d questions, such as " H o w do you feel?" or " H o w are things g o i n g in school?" result in u n e l a b o r a t e d responses, such as " O K " or "I d o n ' t know." Specific questions, such as " W h a t kinds o f things do you get scared a b o u t ? " or " W h a t do y o u r p a r e n t s do w h e n you tell t h e m you are afraid?" are m o r e easily a n d readily r e s p o n d e d to by the child. In addition, it is helpful to use the child's own words w h e n discussing these fears. For e x a m p l e , children may distinguish " n e r v o u s " feelings (scared, upset) f r o m " a n x i o u s " (eager, anticipatory) ones. In o r d e r to assist the child in describing the a n t e c e d e n t s a n d c o n s e q u e n c e s of the p h o b i a it may be beneficial to instruct the child to i m a g i n e the f e a r - p r o d u c i n g situation a n d to describe exactly what is h a p p e n i n g . At this time the child can be o b s e r v e d for overt signs of fear such as crying, tremors, or flushing (Ollendick & G r u e n , 1972; Smith & Sharpe, 1970). D u r i n g the behavioral interview, it is also i m p o r t a n t to obtain i n f o r m a t i o n f r o m the family r e g a r d i n g p e r c e p t i o n s of the child's p h o b i c behavior, as well as inform a t i o n a b o u t its a n t e c e d e n t s a n d c o n s e q u e n c e s . Again, it is helpful to ask specific questions, such as " W h a t does A n d r e w do that leads you to say he is afraid of dogs?" With behavioral interviews, as well as o t h e r assessment p r o c e d u r e s , t h e r e are p s y c h o m e t r i c concerns. Often, children a n d p a r e n t s are inconsistent a n d unreliable r e p o r t e r s o f behavior, particularly past behavior. T h a t is, p a r e n t s a n d c h i l d r e n may n o t agree on the o c c u r r e n c e of behaviors, particularly anxious or p h o b i c behaviors a n d w h e t h e r such behaviors are a significant p r o b l e m . O n e way to m a x i m i s e the reliability o f r e p o r t i n g is to focus on the c u r r e n t b e h a v i o r p r o b l e m ( s ) a n d the conditions u n d e r which it occurs (e.g., Herjanic, Herjanic, Brown, & Wheatt, 1975; O l l e n d i c k & Cerny, 1981). Thus, the focus of the interview should be on the p h o b i c b e h a v i o r a n d its a n t e c e d e n t s a n d c o n s e q u e n c e s in the h e r e and now. STRUCTURED DIAGNOSTIC INTERVIEWING T h e diagnostic status o f the child with a severe p h o b i a should be c o n s i d e r e d in a c o m p r e h e n s i v e assessment. Typically, children with severe p h o b i a s m e e t D S M - I V diagnostic criteria for specific p h o b i a (APA, 1994). Research on clinical samples of p h o b i c c h i l d r e n shows that p h o b i a s often co-occur with o t h e r internalizing disor-

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ders, such as separation anxiety disorder and o v e r a n x i o u s / g e n e r a l i z e d anxiety disorder or externalizing disorders, such as c o n d u c t disorder (Last, Strauss, & Francis, 1987; Silverman & Rabian, 1994). T h e r e are now many s t r u c t u r e d diagnostic interviews available to clinicians and researchers interested in the diagnosis of c h i l d h o o d phobias. Representative of these instruments are the Anxiety Disorders Interview Schedule for Children (ADIS-C; Silverman & Nelles, 1988), the Interview Schedule for Children (ISC; Kovacs, 1983) and the Diagnostic Interview for Children and Adolescents (DICA; Herjanic & Reich, 1982). O f these, we r e c o m m e n d the ADIS-C as a useful structured interview for the diagnosis of phobic disorder as well as any c o m o r b i d disorders (cf. Ronan, 1996). The ADIS-C is a downward extension o f its adult c o u n t e r p a r t , the Anxiety Disorder Interview Schedule (DiNardo, O'Brien, Barlow, Waddel, & Blanchard, 1983). T h e ADIS-C is designed specifically for the diagnosis of c h i l d h o o d anxiety and phobic disorder based on DSM-III-R diagnostic criteria (APA, 1987). T h e interview schedule has a diagnostic section on specific phobia. T h e child interview makes use o f visual analogue scales and pictorial material to facilitate accurate child ratings of i n t e r f e r e n c e . T h e r e is also a p a r e n t version of the interview schedule (ADIS-P), which is administered after the child interview. Guidelines are provided to assist in the f o r m u l a t i o n of a composite diagnosis that draws on both child and p a r e n t interview data. Silverman and her colleagues have u n d e r t a k e n a revision of the interview schedule in the light o f the recently published DSM-IV (APA, 1994). In an examination o f the i n t e r r a t e r reliability of the ADIS-C/P, pairs o f clinicians e x a m i n e d child outpatients and their mothers, and assigned p r i m a r y and secondary diagnoses (Silverman & Nelles, 1988). Due to small sample size, i n t e r r a t e r a g r e e m e n t could be c o m p u t e d only for simple phobia, school phobia, and overanxious disorder. I n t e r r a t e r a g r e e m e n t was m o d e r a t e to high for these diagnostic categories, although simple p h o b i a had consistently high i n t e r r a t e r a g r e e m e n t for the child interview, p a r e n t interview and composite diagnosis (KS = 1.00, .64, and 1.0, respectively). Subsequently, Silverman and Eisen (1992) established the testretest reliability of the ADIS-C/P with 50 children over an interval o f 10 to 14 days. Test-retest reliability was e x a m i n e d for three parameters: (a) an exact match on primary anxiety diagnoses; (b) symptom scale scores; and (c) clinician's agreem e n t on severity ratings. Satisfactory test-retest reliability across the three parameters was f o u n d for simple phobia. Further, Rapee and colleagues also r e p o r t e d high levels of i n t e r r a t e r a g r e e m e n t for all of the c h i l d h o o d anxiety and phobic disorder categories in an Australian sample (Rapee, Barrett, Dadds, & Evans, 1994). However, parent-child a g r e e m e n t was f o u n d to be p o o r for most of the diagnostic categories including simple p h o b i a (K = .33). O f course, differences between child and p a r e n t reports are not u n c o m m o n in the assessment of childh o o d anxiety disorders. Nonetheless, while f u r t h e r research needs to be undertaken on this clinically useful but relatively new diagnostic tool, the initial results for its reliability are quite encouraging. SELF-REPORT INSTRUMENTS A wide variety of self-report instruments is available to s u p p l e m e n t i n f o r m a t i o n o b t a i n e d from the interview. In general, instruments consist o f fear survey schedules that provide lists o f fear-evoking stimuli and anxiety measures that provide the

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child with a set o f responses with which to describe subjective experiences felt, or anticipated, in fear-producing situations. O u r review is c o n f i n e d to the Fear Survey Schedule for Children, the Children's Manifest Anxiety Scale and the Child Anxiety Sensitivity Index.

Fear Survey Schedule for Children Revised M o d e l e d on scales d e v e l o p e d for adults, the Fear Survey Schedule for Children was d e v e l o p e d by S c h e r e r and N a k a m u r a (1968). This scale consists o f 80 stimulus items; representative stimuli include dogs, getting lost and going to school. For each item, children are r e q u i r e d to rate their fear on a 5-point scale. T h e i n s t r u m e n t was originally d e v e l o p e d for use with children aged between 9 and 12 years. In a revision o f the i n s t r u m e n t (FSSC-R), Ollendick (1983) i n t r o d u c e d a 3-point scale (none, some or a lot). T h e rationale for the 3-point scale was to e n h a n c e its use with y o u n g e r children and h a n d i c a p p e d children. In a psychometric evaluation o f the FSSC-R, Ollendick (1983) o b t a i n e d high internal consistency in two samples of children (coefficient alphas of .94 and .92). Test-retest reliability over 1 week was high (r = .82) with m o d e r a t e reliability over a 3-month interval (r = .55). T h e validity of the scale was s u p p o r t e d t h r o u g h a c o m p a r i s o n of scores with related psychometric instruments, namely, the Trait Scale of the State-Trait Anxiety I n v e n t o r y for Children (Spielberger, 1973), the Piers-Harris Children's Self-Concept Scale (Piers & Harris, 1969) and the NowickiStrickland Locus-of-Control Scale (Nowicki & Strickland, 1973). Further, Ollendick (1983) has r e p o r t e d a five factor solution: Factor 1 " F e a r of failure and criticism"; Factor 2 " F e a r of the u n k n o w n " ; Factor 3 " F e a r o f injury and small animals"; Factor 4 " F e a r of d a n g e r and d e a t h " and Factor 5 "Medical fears." In addition, Ollendick and Mayer (1984) r e p o r t e d that the FSSC-R discriminated between " s c h o o l p h o b i c " children whose fears were related to separation anxiety, and school phobic children whose fears were related to specific aspects of the school situation itself. Because of its s o u n d psychometric characteristics, the FSSC-R has b e e n used to g e n e r a t e a rich body o f normative data describing c h i l d h o o d fears in various countries including America, Australia, Africa, and China (King, Ollier, Icuone, Schuster, Gullone, Bays, & Ollendick, 1989; Ollendick, Yang, King, Dong, & Akande, 1996). T h e FSSC-R has also proven to be a useful clinical tool for the identification of specific fears, such as fear o f darkness and school (e.g., King, Cranstoun, & J o s e p h s , 1989; Last, Francis, & Strauss, 1989). In addition to being useful as an ipsative i n s t r u m e n t for the identification of specific fear sensitivities in children, the FSSC-R has also b e e n used as a criterion measure in a n u m b e r o f t r e a t m e n t evaluations (e.g., F r i e d m a n & Ollendick, 1989; King et al., 1995; Ollendick, Hagopian, & Huntzinger, 1991).

Revised Children's Manifest Anxiety Scale In contrast to fear survey schedules, measures o f anxiety have b e e n used to d e t e r m i n e the subjectively e x p e r i e n c e d effects of being in p h o b i c or anxietyp r o d u c i n g situations. Representative o f these instruments is the Children's Manifest Anxiety Scale (CMAS; Castaneda, McCandless, & Palermo, 1956), a scaleddown version o f the Manifest Anxiety Scale for Adults (Taylor, 1951). Subsequently, Reynolds and R i c h m o n d (1978) d e v e l o p e d a revised version o f the CMAS (R-

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CMAS) titled, " W h a t I T h i n k a n d Feel." T h e p u r p o s e of this revision was to clarify the wording of items, decrease administration time, a n d lower the r e a d i n g level o f the items. T h e R-CMAS consists of 37 items (e.g., "I am nervous, "My h a n d s feel sweaty") designed to assess the p r e s e n c e or absence of a variety of anxiety-related symptoms. Children r e s p o n d to each of the items in a y e s / n o format. H i g h internal consistency and test-retest reliability have b e e n r e p o r t e d for the R-CMAS with n o r m a l samples of children (Reynolds & Paget, 1983; Wisniewski, Mulick, Genshaft, & Coury, 1987). Reflecting the validity of the i n s t r u m e n t as a m e a s u r e of c h r o n i c anxiety, a significant c o r r e l a t i o n has b e e n f o u n d between the R-CMAS a n d the A-trait scale of the State Trait Anxiety I n v e n t o r y for C h i l d r e n (STAIC, Spielberger, 1973). As well as a total anxiety score, the R-CMAS yields scores on three subscales: physiological, worry/oversensitivity, a n d c o n c e n t r a t i o n (Reynolds & R i c h m o n d , 1978). T h e r e are also " l i e " items that are i n t e n d e d to assess social desirability in r e s p o n d i n g . C o n s i d e r a b l e n o r m a t i v e data are now available for A m e r i c a n children a n d youth, aged 6 to 19 years (Reynolds & Paget, 1983). As would be e x p e c t e d , the R-CMAS has b e e n f o u n d to differentiate high anxious children f r o m low anxious children (e.g., King, Mietz, Tinney, & Ollendick, 1995). N o t e w o r t h y however, is an investigation by Last, Francis, H e r s e n , Kazdin, a n d Strauss (1987), which f o u n d that the R-CMAS failed to discriminate between children with s e p a r a t i o n anxiety disorders a n d those with school phobia, a finding that suggests the general n a t u r e of the scale in the assessment of anxiety. Thus, as a general m e a s u r e of anxiety, the R-CMAS has p r o v e n to be a useful clinical i n s t r u m e n t in the assessment a n d t r e a t m e n t of c h i l d h o o d phobias (e.g., H e a r d , Dadds, & Conrads, 1992).

Child Anxiety Sensitivity Index Over the past decade, tile notion of "anxiety sensitivity" has gained increasing a c c e p t a n c e in the child anxiety a n d p h o b i a literature. Anxiety sensitivity refers to the belief that the e x p e r i e n c e of anxiety or fear signals or results in f u r t h e r " c a t a s t r o p h i c " c o n s e q u e n c e s , such as physical or m e n t a l illness, e x t r e m e e m b a r rassment, or additional anxiety, a n d is c h a r a c t e r i z e d by an individual's t e n d e n c y to r e s p o n d fearfully to the s y m p t o m s of anxiety (Reiss & McNally, 1985). For example, s o m e o n e who e x p e r i e n c e s high anxiety sensitivity m i g h t believe that a rapid h e a r t rate associated with anxiety signals an i m p e n d i n g h e a r t attack, or m i g h t believe that a s t o m a c h ache is a sign of s o m e serious illness. The Child Anxiety Sensitivity Index (CASI) is an 18-item scale modified by Silverman, Fleisig, Rabian, and Peterson (1991) from the Anxiety Sensitivity I n d e x develo p e d by Peterson and Reiss (1987) for adults. It measures anxiety sensitivity in children by asking them to indicate how aversively they view anxiety symptoms. Representative items include "It scares me when my heart beats too fast," and " W h e n I am afraid, I worry that I might be going crazy." Children select from three response choices, none, some, or a lot, to describe the degree to which each item applies to themselves. Items are scored t to 3, and total scores range f r o m 18 to 54. T h e CASI has b e e n f o u n d to possess s o u n d p s y c h o m e t r i c characteristics, especially with older children a n d adolescents (Silverman et al., 1991). Two-week test-retest reliability has b e e n r e p o r t e d at .76 for an unselected n o r m a l sample of school children a n d .79 for a clinical sample of e m o t i o n a l l y disturbed children. In

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addition, internal consistency as d e t e r m i n e d t h r o u g h i t e m / t o t a l correlations has b e e n r e p o r t e d at .87 for b o t h n o r m a l and clinical samples. In r e c e n t studies, Rabian, Peterson, Richters, and J e n s e n (1993) have f o u n d the CASI to discriminate between an anxiety-disordered sample and a n o r m a l control sample; Chorpita, Albano, and Barlow (1996) have d e t e r m i n e d that the i n s t r u m e n t is predictive of anxiety scores above and b e y o n d that due to general fearfulness and anxiety f r e q u e n c y in an adolescent clinical sample of anxiety-disordered youth; and Mattis and Ollendick (in press) have shown that the CASI predicts internalizing and catastrophic symptoms associated with panic in children and adolescence. In short, the CASI should prove to be a useful clinical and research tool for those interested in e x p l o r i n g the relations between h e i g h t e n e d sensitivity to anxiety cues and the d e v e l o p m e n t and expression of c h i l d h o o d phobias. In brief, fear survey schedules and anxiety measures a p p e a r useful as ipsative instruments to identify specific fear sensitivities and anticipated anxiety experiences in children. C o m p a r e d to o t h e r assessment p r o c e d u r e s (e.g., physiological m o n i t o r i n g ) , they are m o r e cost effective (Morris, Kratochwill, & Dodson, 1986). However, they also possess the limitations o f many self-reports. A basic point is the lack of detail (situational specificity) s u r r o u n d i n g items to which children are r e q u i r e d to r e s p o n d (James, Reynolds, & Dunbar, 1994). This can result in uncertainty and h e n c e inconsistent responses. Many self-report scales also lack normative data (e.g., CASI), although this situation has improved over the years particularly for the FSSC-R and R-CMAS. Further, the d e g r e e to which self-report data accurately reflect actual fear, and the fact that children's reports do not always c o r r e s p o n d to teacher or p a r e n t reports, have always b e e n major issues. Improving the quality of their normative data, and f u r t h e r establishing the reliability and validity claims of those self-report instruments are on-going c o n c e r n s for those involved in the self-report assessment of c h i l d h o o d phobias (see reviews by Finch & Rogers, 1984; James et al., 1994).

PARENT A N D TEACHER REPORTS

As in the case of child e m o t i o n a l and behavior problems in general, caregiver c o m p l e t e d checklists and rating scales play an i m p o r t a n t role in the assessment of c h i l d h o o d phobias. In a r e c e n t review, Piacentini (1993) points out a n u m b e r of advantages associated with the use o f such checklists and rating scales. First, rating scales provide a standardized f o r m a t for the collection of data, facilitating systematic and c o m p r e h e n s i v e coverage of the behaviors in question. This s t r u c t u r e d f o r m a t also serves to r e d u c e the subjectivity i n h e r e n t in the j u d g e m e n t s of parents and teachers a b o u t p r o b l e m behavior and to increase the reliability o f the ratings made. Second, rating scales draw on the i n f o r m a n t ' s past e x p e r i e n c e with the child across a range of situations and circumstances. This b r e a d t h of e x p e r i e n c e enhances the reliability and validity of caregiver ratings. Third, rating scales are efficient and e c o n o m i c a l to use in terms of both cost and time to c o m p l e t e and score the ratings, and i n t e r p r e t the results. Broad-band scales (e.g., Child Behavior Checklist) can be used to provide a b r o a d overview of the phobic child's social, behavioral, and e m o t i o n a l functioning, while o t h e r scales (e.g., Louisville Fear Survey Schedule for Children) can be used to provide m o r e in-depth examination o f specific disorders, such as fears and phobias.

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T h e Child Behavior Checklist (CBCL; A c h e n b a c h 1991a,b,c; A c h e n b a c h & Edelbrock, 1983) allows for the r e c o r d i n g of behavior problems and c o m p e t e n c i e s for children aged 4 to 18 years. T h e r e are separate checklists for parents and teachers (as well as a self-report measure for youth over 11 years of age). T h e i n f o r m a n t is asked to rate a child on 113 behaviors using a 3-point rating scale to designate how well each item describes the child. Social c o m p e t e n c y items assess the child's participation in social organizations, activities, and schools. Principal c o m p o n e n t analyses have p r o d u c e d two " b r o a d - b a n d " behavioral dimensions internalizing and externalizing. Such analyses have also p r o d u c e d several " n a r r o w b a n d " statistically derived syndromes that vary somewhat by age and gender. T h e CBCL allows for the identification of children who display anxiety, social withdrawal, depression, obsessions-compulsions, n o n c o m m u n i c a t i v e behavior, hyperactivity, aggression, and somatic complaints. T h e r e is an ever-increasing a m o u n t of s u p p o r t i n g research on the reliability and validity of the CBCL (see Daugherty & Shapiro, 1994, for an excellent discussion). T h e CBCL is frequently used in the assessment of phobic and anxious children. In relation to the investigation of t r e a t m e n t effects, it is noteworthy that behavioral interventions for phobic child r e n often p r o d u c e improvements b e y o n d the presenting problem(s). Nontargeted i m p r o v e m e n t s regarding social and family relationships, academic performance, self-concept, and general adjustment are frequently r e p o r t e d by clinicians and researchers (e.g., Graziano & Mooney, 1982; H a m p e , Noble, Miller, & Barrett, 1973; McMenamy & Katz, 1989; Sanders &Jones, 1990). We e n d o r s e the CBCL as a potentially useful i n s t r u m e n t for the systematic appraisal of n o n t a r g e t e d improvements in behavior. T h e Louisville Fear Survey for Children (LFSC; Miller, Barrett, H a m p e , & Noble, 1972a) is an 81-item scale covering a variety of specific fears and has b e e n designed for use with children between ages 4 and 16. In this survey, the rater (parent, teacher) is instructed to indicate the child's level of fear on a 3-point scale ranging from no f e a r to normal or reasonable fear to unrealistic or excessive fear. Although the i n s t r u m e n t is primarily for c o m p l e t i o n by caregivers, it can also be c o m p l e t e d by the child. Consequently the LFSC allows for a c o m p a r i s o n of caregiver ratings and the child's self-report. A factor analysis of p a r e n t ratings has revealed three p r i m a r y factors: fear of physical injury (e.g., war and surgery), natural and supernatural dangers (e.g., animals and darkness) and interpersonal-social (e.g., examinations and criticism). Although internal consistency has b e e n r e p o r t e d to be high, data on test-retest reliability and validity have yet to be r e p o r t e d (James et al., 1994). In addition to being used for the identification of specific fears in children, the LFSC has also been used as an o u t c o m e measure in the evaluation of i n t e r v e n t i o n programs for phobic children (Miller, Barrett, H a m p e , & Noble, 1972b). Nonetheless, f u r t h e r study needs to be u n d e r t a k e n on the psychometric properties of the LFSC before it can be widely r e c o m m e n d e d to clinicians and researchers. O f course, it is b e y o n d the scope of this review to address the many o t h e r relevant instruments for c o m p l e t i o n by parents or teachers. In view of the proliferation of such scales, McMahon (1984) r e c o m m e n d s that clinicians and researchers be selective in the use of these instruments. Even with the use of b e t t e r r e s e a r c h e d instruments, many factors can influence their reliability and validity in the clinic or o t h e r settings. For example, parents may rate their child as m o r e fearful at the initial assessment to access treatment, and rate their child as less

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fearful at t r e a t m e n t t e r m i n a t i o n for reasons of social desirability. F u r t h e r m o r e , the f u n d a m e n t a l question o f the e x t e n t to which o t h e r - r e p o r t s c o r r e s p o n d to selfr e p o r t s a n d behavioral o b s e r v a t i o n s has still n o t b e e n investigated sufficiently in the assessment o f c h i l d h o o d p h o b i c disorders (see O l l e n d i c k & Francis, 1988).

BEHAVIORAL OBSERVATIONS T h e m o s t direct a n d least inferential way to assess fearful a n d p h o b i c behaviors is to o b s e r v e these behaviors in the situations in which they occur. Specific behaviors reflective of fears a n d p h o b i a s are o p e r a t i o n a l l y d e f i n e d a n d r e c o r d e d . For e x a m ple, G r a z i a n o a n d M o o n e y (1980) detailed a set of o p e r a t i o n a l l y d e f i n e d behaviors reflective o f n i g h t t i m e fears in 6- to 12-year-old children. T h e behavioral m e a s u r e s d e s c r i b e d i n c l u d e d the n u m b e r of m i n u t e s the child r e q u i r e d to get to b e d after b e i n g asked; the n u m b e r o f m i n u t e s the child took to fall asleep; the avoidance a n d delay b e h a v i o r displayed, such as crying, getting out of bed, arguing, a n d asking for a glass o f water; a n d an overall rating o f the child's b e d t i m e behavior. O f course, direct b e h a v i o r a l o b s e r v a t i o n s m u s t be as n o n o b t r u s i v e as practically feasible to e n s u r e the validity of the i n f o r m a t i o n . An excellent discussion of behavioral o b s e r v a t i o n s has b e e n p r o v i d e d by Dadds, Rapee, a n d Barrett (1994). W h e n direct behavioral o b s e r v a t i o n s in the natural setting are n o t possible, a simulated setting m i g h t be used to m e a s u r e the p h o b i c responses (Behavioral Avoidance Test). Typically, this p r o c e d u r e involves having a child e n t e r a r o o m c o n t a i n i n g the f e a r - p r o d u c i n g object a n d to a p p r o a c h , a n d ultimately handle, the object. In the assessment o f a child evincing an a n i m a l (dog) p h o b i a , for e x a m p l e , the child is r e q u e s t e d to p e r f o r m a g r a d u a t e d series o f stimulus-related tasks (Bandura, Grusec, & Menlove, 1967). T h e s e r a n g e f r o m taking a few steps closer to the d o g to actual physical c o n t a c t with the dog. Despite reassurances a b o u t the safety o f the situation, children with severe p h o b i a s invariably " f r e e z e " a n d refuse to a p p r o a c h the dog. O n e strength of the BAT, as n o t e d by Kazdin (1973), is that it provides highly reliable behavioral m e a s u r e s o f avoidance, such as a m o u n t of time s p e n t in the p r e s e n c e o f the anxiety-provoking object, distance f r o m the object, a n d n u m b e r a n d latency o f a p p r o a c h responses. I n t e r - o b s e r v e r reliability has b e e n f o u n d to be very high for various behavioral a v o i d a n c e tests (e.g., B a n d u r a et al., 1967), a l t h o u g h less is known a b o u t their t e m p o r a l stability. Recently, H a m i l t o n a n d King (1991) investigated the t e m p o r a l stability of a BAT in the assessment o f 14 d o g p h o b i c children. Two test administrations were c o n d u c t e d 7 days a p a r t p r i o r to t r e a t m e n t , a n d high test-retest reliability was o b t a i n e d (r = .97). Ten c h i l d r e n o b t a i n e d identical total a p p r o a c h scores o n each test a n d within subtasks test-retest a g r e e m e n t over all subjects was 97%. T h e o t h e r f o u r c h i l d r e n showed slight increases in a p p r o a c h b e h a v i o r at retest. T h e s e c h i l d r e n h a d relatively high initial scores a n d so received l o n g e r a n d m o r e intimate e x p o s u r e to the d o g t h a n did the o t h e r children. A n o t h e r i m p o r t a n t question that awaits f u r t h e r research inquiry is the e x t e n t to which the child's p e r f o r m a n c e on a BAT actually c o r r e s p o n d s with p h o b i c behavior in natural settings. Avoidance tests are often restricted to fairly safe exercises with the c l i n i c i a n / r e s e a r c h e r a n d p e r h a p s a n o t h e r caregiver in close proximity to the child. This, o f course, constitutes a situation quite d i f f e r e n t f r o m the e x p o s u r e s that o c c u r in the natural setting. For e x a m p l e , in an avoidance test, the d o g - p h o b i c child is r e q u i r e d to a p p r o a c h a d o g that is s e c u r e d in s o m e way. But in the

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c o m m u n i t y the d o g may be u n r e s t r a i n e d a n d a p p r o a c h the child, thus r e p r e s e n t ing a different set of a n t e c e d e n t conditions. To date, it m u s t be a c k n o w l e d g e d that the validity claims of such tests w h e n used with p h o b i c children have not b e e n c o m p r e h e n s i v e l y r e s e a r c h e d (King et al., 1987; Morris & Kratochwill, 1983). SELF-MONITORING T h e p r o c e d u r e known as self-monitoring requires the target individual (in this case the phobic child) to first self-observe and then systematically self-record occurrences of the designated behavior (Haynes, 1978). Self-monitoring is a potentially useful m e t h o d of gathering baseline data on the frequency of the target behavior, as well as a n t e c e d e n t and consequent events. In certain instances, self-monitoring can be used to gather data on children's cognitions about the problem. Ratings on the severity of anxiety experienced during exposure to the phobic stimulus might also be obtained through self-monitoring. A n u m b e r of methods have been developed to facilitate self-monitoring, including the behavioral diary, and counting devices, such as wrist counters. When self-monitoring procedures are applied to children it is imperative that the behaviors be well-defined and that the recording procedures be uncomplicated (Shapiro, 1984). The age of the child should be an i m p o r t a n t factor in deciding on the use of self-monitoring (young children do not have the necessary abilities for self-recording). Self-monitoring has b e e n applied relatively infrequently to the assessment o f c h i l d h o o d fears a n d phobias. King et al. (1988) used self-recording in the assessm e n t o f a 14-year-old girl who exhibited an excessive fear o f dogs. C o n d u c t e d for several weeks p r i o r to i n t e r v e n t i o n , self-monitoring in this case p r o v i d e d i n f o r m a tion on the f r e q u e n c y of e n c o u n t e r s with the feared stimulus. Significant clinical i n f o r m a t i o n was also o b t a i n e d on a n t e c e d e n t and c o n s e q u e n t events, as well as the subject's i m m e d i a t e t h o u g h t s a b o u t contact with dogs (e.g., "I d i d n ' t want friends to see what was h a p p e n i n g " ) . In the assessment a n d t r e a t m e n t of three adolescents with specific phobia, H e a r d et al. (1992) r e q u i r e d the youths to m o n i t o r daily the o c c u r r e n c e of the p r o b l e m behavior(s) on t o r m s p r o v i d e d by the therapist (stating the date, setting, target b e h a v i o r a n d c o n c u r r e n t p o s i t i v e / n e g a t i v e t h o u g h t s ) . Feelings of anxiety resulting f r o m c o n f r o n t a t i o n with the p h o b i c stimulus were also rated on a 0 to 10 subjective units of distress scale by the adolescents. Self-monitoring also played a central role in a self-control p r o g r a m for c h i l d r e n ' s n i g h t t i m e fears d e v e l o p e d by Graziano and colleagues (Graziano, Mooney, Huber, & Ignasiak, 1979; Graziano & Mooney, 1980). T h e 6- to 13-year-old children were given a b o o k l e t that c o n t a i n e d b o t h written instructions for the daily practice o f self-control exercises a n d space to r e c o r d the n u m b e r of tokens e a r n e d each night. H e n c e the children were able to record their progress t h r o u g h assessment a n d self-monitoring. Recently, Ollendick (1995) has used self-monitoring successfully in the assessment a n d t r e a t m e n t o f four adolescents d i a g n o s e d with Panic D i s o r d e r with A g o r a p h o b i a . W h e n self-monitoring is selected as an assessment strategy, a t t e n t i o n should be given to several issues. A p r i m a r y c o n c e r n is the accuracy of self-monitoring. Accuracy can be e n h a n c e d with s o m e p r e l i m i n a r y training, which m i g h t include e x p l a n a t i o n a n d examples. T e l e p h o n e contact between sessions provides a g o o d o p p o r t u n i t y to r e m i n d or praise children for their efforts. A l t h o u g h the p u r p o s e of self-monitoring may be assessment, a c h a n g e in b e h a v i o r is by no m e a n s

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i n f r e q u e n t p r i o r to t r e a t m e n t (King et al., 1988). For e x a m p l e , we have o b s e r v e d such reactive effects for various c h i l d h o o d fears (especially n i g h t t i m e fears) within 2 to 3 weeks o f r e c o r d i n g . While the factors that a c c o u n t for reactivity are unclear, s o m e f o r m of behavioral s e l f - m a n a g e m e n t is p r e s u m a b l y b e i n g instigated by c h i l d r e n ( F r i e d m a n & Ollendick, 1989). Nonetheless, p r o v i d e d these cautions are u n d e r s t o o d , self-monitoring is a useful p r o c e d u r e in the assessment of c h i l d r e n ' s phobias.

PHYSIOLOGICAL ASSESSMENT T h e physiological assessment of c h i l d r e n ' s p h o b i a s is i m p o r t a n t since physiological arousal is a significant c o m p o n e n t of m o s t p h o b i c reactions (Beidel, 1989). Scientific i n s t r u m e n t a t i o n p e r m i t s the r e c o r d i n g o f m a n y physiological responses ( h e a r t rate, b l o o d pressure, muscle tension, GSR, etc.) in the assessment of the individual's reactivity to p h o b i c stimuli (Barrios & H a r t m a n n , 1988; King, Ollendick, & Gullone, 1990). A r e c e n t i n n o v a t i o n in the physiological assessment of p h o b i c c h i l d r e n is the " C o m p u t e r I n s t r u m e n t s H e a r t Watch," an electronic i n s t r u m e n t that looks like a watch a n d is p l a c e d on the child's wrist in o r d e r to m e a s u r e c h a n g e s in h e a r t rate d u r i n g a behavioral avoidance test or o t h e r exposure trials (Silverman & Rabian, 1994). Following the behavioral avoidance test, the child's h e a r t rate signals are c o u n t e d by a c o m p u t e r . A l t h o u g h attractive in t e r m s of scientific sophistication a n d d e v e l o p m e n t a l sensitivity, the r e s e a r c h e r s caution that the ultimate clinical utility o f the m e a s u r e has yet to be d e t e r m i n e d . T h e m o s t c o m m o n l y used m e a s u r e s of physiological r e s p o n d i n g in children are those that assess cardiovascular a n d e l e c t r o d e r m a l r e s p o n d i n g (King, 1994; Morris & Kratochwill, 1983). Cardiovascular r e s p o n d i n g can be assessed by m e a s u r e s of h e a r t rate, b l o o d pressure, a n d p e r i p h e r a l b l o o d flow. Typically, h e a r t rate has b e e n the m o r e c o m m o n m e a s u r e , because it is m e a s u r e d easily a n d is least sensitive to m e a s u r e m e n t artifacts (Nietzel & Bernstein, 1981). In the " t r i p a r t i t e " assessment of an 11-year-old m u l t i p h o b i c boy, Van Hasselt a n d colleagues assessed the child's responses in the motoric, cognitive, a n d physiological r e s p o n s e systems (Van Hasselt, H e r s e n , Bellack, R o s e n b l u m , & Lamparski, 1979). In this case, h e a r t rate a n d finger pulse v o l u m e were taken as m e a s u r e s of physiological arousal. T r e a t m e n t consisted of relaxation training a n d systematic desensitization. I m p o r tantly, physiological i m p r o v e m e n t s were not as strong as gains on subjective a n d overt-behavioral indices. In r e c e n t years, Beidel (1988) e x a m i n e d the cardiovascular responses of test-anxious children w h e n e n g a g e d in two social-evaluative tasks, namely, a t i m e d v o c a b u l a r y test a n d an oral r e a d i n g session. T h e anxious c h i l d r e n displayed significantly h i g h e r h e a r t rates on these tasks than their n o n a n x i o u s peers; however, t h e r e were no differences b e t w e e n the g r o u p s on systolic a n d diastolic b l o o d pressure. As e m p h a s i z e d by m a n y authorities, physiological assessment can p r e s e n t a variety of p r o b l e m s (Barrios & H a r t m a n n , 1988; Morris & Kratochwill, 1983). Access to e q u i p m e n t , selection of electrodes, r e c o r d i n g a n d c o n t r o l l i n g m o v e m e n t artifacts are c o m m o n frustrations. F u r t h e r m o r e , it is d o u b t f u l that o n e physiological m e a s u r e of arousal is sufficient in view o f the individual differences that are often o b s e r v e d in a u t o n o m i c r e s p o n s e patterns. A n o t h e r c o m p l e x i t y is the considerable d e s y n c h r o n y across the t h r e e r e s p o n s e systems as illustrated by the findings o f Van Hasselt et al. (1979) in the t r e a t m e n t o f the m u l t i p h o b i c boy.

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A l t h o u g h the investigation of the physiological c o m p o n e n t o f c h i l d r e n ' s p h o b i a s is of theoretical interest, it seems p r e m a t u r e to advocate regular use o f such assessment t e c h n i q u e s in clinical practice at this time (Ollendick & Francis, 1988).

LABORATORY-BASED MEASURES In r e c e n t years, c o n s i d e r a b l e e n e r g y has b e e n directed toward the identification of i n f o r m a t i o n - p r o c e s s i n g biases that a p p e a r to characterize children with phobias. Briefly, as with p h o b i c adults (see L o g a n & Goetsch, 1993, for a review), research has suggested that children with p h o b i c disorders exhibit a bias in processing i n f o r m a t i o n related to t h r e a t cues (see Vasey & Daleiden, 1996). T h a t is, p h o b i c youth a p p e a r to be excessively vigilant a n d to actively m o n i t o r the e n v i r o n m e n t for t h r e a t cues that signal potential danger. Importantly, such biases m i g h t function as an early warning device to cue avoidance or escape, as suggested by McNally (1990). However, w h e n they exist or c o n t i n u e to persist in the a b s e n c e o f real or g e n u i n e t h r e a t cues, they may be less adaptive a n d lead to excessive worry, physiological arousal, and behavioral avoidance. A l t h o u g h the origin o f these p h o b i a - r e l a t e d attentional biases r e m a i n s unclear, o n c e p r e s e n t they are likely to play a critical role in the m a i n t e n a n c e of the phobia. Thus, identification a n d m e a s u r e m e n t of these attentional biases takes on a d d e d i m p o r t a n c e . Several l a b o r a t o r y - b a s e d m e a s u r e s have p r o v e d useful in this regard. T h r e e such m e a s u r e s will be p r e s e n t e d for illustrative purposes. Based on the work o f Watts, McKenna, Sharrock, a n d Trezise (1986) with spider-phobic adults, Martin, H o r d e r , a n d J o n e s (1992) used a m o d i f i e d Stroop task to e x p l o r e i n f o r m a t i o n - p r o c e s s i n g biases in spider-phobic children. In the standard Stroop I n t e r f e r e n c e Task, the n a m e s of colors are written on an i n d e x card (or m o r e c o m m o n l y p r e s e n t e d on a c o m p u t e r m o n i t o r ) in ink colors that either differ f r o m the color n a m e s or are the same as the color names. Participants are instructed to n a m e the ink colors a n d to disregard the c o n t e n t of the actual word. For e x a m p l e , the word " r e d " m i g h t be p r e s e n t e d in the color " b l u e . " In this e x a m p l e , the child is asked to n a m e the color that is seen (i.e., " b l u e " ) , i g n o r i n g the written word (i.e., " r e d " ) . Color n a m e s that differ f r o m the ink color in which they are p r i n t e d result in significantly l o n g e r r e s p o n s e times (labeled the " S t r o o p I n t e r f e r e n c e Effect"). Such an effect is t h o u g h t to be due to the allocation of attentional a n d cognitive resources to the semantic processing o f the d i s c o r d a n t versus c o n c o r d a n t color n a m e words. Recently, the standard Stroop has b e e n m o d i f i e d to include t h r e a t e n i n g a n d n o n t h r e a t e n i n g words for studies of p h o b i c adults (cf. Watts et al., 1986) a n d children (cf. Martin et al., 1992). As with the s t a n d a r d Stroop, participants are asked to ignore the words a n d simply to n a m e the colors in which the words are printed. L o n g e r r e s p o n s e times to the t h r e a t e n i n g words by p h o b i c participants are h y p o t h e s i z e d to o c c u r because the m e a n i n g of the words attracts a t t e n t i o n a n d semantic processing, despite instructions to ignore or disregard their meanings. Such Stroop i n t e r f e r e n c e implies differential a t t e n t i o n to t h r e a t or o t h e r stimulusspecific words. Martin et al. (1992) p r e s e n t e d such a task to spider-phobic a n d n o n - s p i d e r p h o b i c children between 6 a n d 13 years of age. Spider-relevant words i n c l u d e d " w e b , " "crawl," "hairy, . . . . body," a n d "legs"; control or neutral words consisted of "fly, .... colors," " s p o t s , " "wings," a n d " l a d y b i r d . " T h e s t a n d a r d Stroop was also

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a d m i n i s t e r e d . T h e c h i l d r e n were asked to n a m e a l o u d as fast as possible the color o f the ink in which each word was printed, while i g n o r i n g the m e a n i n g of the words. A l t h o u g h the two g r o u p s of c h i l d r e n did n o t differ on c o l o r - n a m i n g latencies on the s t a n d a r d Stroop, they did differ o n the m o d i f i e d Stroop. Specifically, c o l o r - n a m i n g latencies were g r e a t e r in the spider-phobic g r o u p t h a n the n o n - s p i d e r - p h o b i c group. Such findings c o n f i r m the e x p e c t e d i n f o r m a t i o n processing bias in the spider-phobic g r o u p o f children. Such effects have b e e n o b t a i n e d in n u m e r o u s studies with adult p h o b i c s as well (Logan & Goetsch, 1993). Vasey a n d his colleagues (Vasey, Daleiden, Williams, & Brown, 1995; Vasey, El-Hag, & Daleiden, 1996) have d e m o n s t r a t e d similar a t t e n t i o n a l biases in anxious a n d p h o b i c y o u t h using a s o m e w h a t d i f f e r e n t l a b o r a t o r y - b a s e d task. T h e s e researchers have used reaction time tasks to e x a m i n e the effects of t h r e a t stimuli on the direction of attentional responses. T h e s e tasks involve p r o b e d e t e c t i o n techniques to e x a m i n e w h e t h e r participants direct a t t e n t i o n toward or away f r o m t h r e a t - r e l a t e d a n d neutral words. T h e r e a c t i o n time task involves s i m u l t a n e o u s p r e s e n t a t i o n of word pairs on a m i c r o c o m p u t e r screen; o n e word a p p e a r s j u s t above the m i d d l e o f the screen a n d o n e j u s t below. I m m e d i a t e l y following termin a t i o n o f s o m e word pairs (but n o t all), a visual dot p r o b e occurs in the area of o n e of the words ( u p p e r or lower position). Participants press a b u t t o n u p o n d e t e c t i o n of the dot p r o b e to allow m e a s u r e m e n t of d e t e c t i o n latency (reaction time). T h r e a t words are p a i r e d with neutral words. Briefly, Vasey a n d colleagues have shown that a n x i e t y - d i s o r d e r e d youth a n d high test anxious y o u t h detect p r o b e s b o t h in the u p p e r a n d lower p o r t i o n s of the screen m o r e rapidly w h e n the p r o b e follows p r e s e n t a t i o n of a t h r e a t word in the same area than w h e n the p r o b e follows p r e s e n t a t i o n of a n o n t h r e a t word. T h e s e findings suggest that anxious children show a significant a t t e n t i o n a l bias toward t h r e a t e n i n g words. Such effects are yet to be d e m o n s t r a t e d for p h o b i c children, however. A third l a b o r a t o r y - b a s e d task is based on J e f f r e y Gray's (1987) biobehavioral t h e o r y of personality. Gray's t h e o r y p r o p o s e s that b o t h n o r m a l b e h a v i o r a n d a b n o r m a l b e h a v i o r have their roots in the relative balance o f two separate n e u r o logical systems. T h e b e h a v i o r inhibition system (BIS) inhibits reward-seeking b e h a v i o r in the p r e s e n c e o f cues for p u n i s h m e n t or n o n r e w a r d . T h e behavioral activation system (BAS) r e s p o n d s to signals of reward a n d n o n p u n i s h m e n t . Because the BIS a n d BAS are antagonistic systems, Gray's t h e o r y implies that it is the strength o f the BAS relative to the BIS that leads the acting out, conductd i s o r d e r e d child to focus on s h o r t - t e r m rewards without fear of p u n i s h m e n t (i.e., reward d o m i n a n c e ) . Conversely, strength of the BIS relative to the BAS leads the internalizing, a n x i e t y - d i s o r d e r e d child to inhibit r e s p o n d i n g in the face of puni s h m e n t or n o n r e w a r d (i.e., p u n i s h m e n t d o m i n a n c e ) . Based on this theory, several r e s e a r c h e r s ( D a u g h e r t y & Quay, 1991; O ' B r i e n , Frick, & Lyman, 1994) have utilized a c o m p u t e r i z e d card g a m e to d e t e r m i n e the relative s t r e n g t h o f the BAS a n d BIS. T h e card-playing task consists of a " d e c k " of 100 cards sequentially p r e s e n t e d in a p r e p r o g r a m m e d o r d e r of face cards a n d n u m b e r cards. For this task the probability of a losing card (i.e., a " n u m b e r " card) a p p e a r i n g is i n c r e a s e d by 10% ( f r o m 10% to 100%) with every s u c c e e d i n g block of 10 cards. Within each b l o c k of 10 cards, losing cards are r a n d o m l y s e q u e n c e d a m o n g winning cards (i.e., " f a c e " cards). Points, chips, or m o n e y are given or taken away f r o m the child as he or she wins or loses a p a r t i c u l a r trial. T h e child is e n c o u r a g e d to stop the g a m e w h e n e v e r he or she so desires. T h e n u m b e r of cards

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played is r e c o r d e d w h e n the child chooses to stop. Internalizing, anxietyd i s o r d e r e d children are hypthesized, a c c o r d i n g to Gray's theory, to stop or interr u p t the g a m e m o r e readily than acting out, c o n d u c t - d i s o r d e r e d children. T h e i r p e r f o r m a n c e is inhibited u n d e r such conditions. Acting out, c o n d u c t - d i s o r d e r e d children are theorized to c o n t i n u e to play the g a m e a n d to be highly responsive to reward d e m a n d s , however. Consistent with this theory, D a u g h e r t y a n d Quay (1991) a n d O ' B r i e n et al. (1994) o b t a i n e d such findings with anxiety-disordered a n d c o n d u c t - d i s o r d e r e d children. We are currently testing this t h e o r y with p h o b i c children in o u r clinics. C o m p a r e d to most traditional measures used in the assessment of childhood phobias, laboratory-based measures may not a p p e a r to be as feasible or clinically useful at first glance. However, initial research findings suggest their utility and provide rich detail a b o u t information-processing biases in anxious and phobic youth. In our own clinical settings, we have begun to use such measures to confirm such biases and to assist in treatment planning. It is also our intention to d e t e r m i n e their utility in treatment outcome research, m u c h as has been d o n e in the adult area (cf. Watts et al., 1986). If treatment is effective, the observed indicators of attentional bias should be reduced on these tasks. We are also attempting to d e t e r m i n e their relationship to other measures of avoidance and distress in phobic youth. FAMILY ASSESSMENT MEASURES P r o b l e m s in family relationships are often evident for anxious a n d p h o b i c children (see Ginsburg, Silverman, & Kurtines, 1995, for an excellent discussion). In retrospective investigations of family relationships, adults with anxiety disorders frequently depict their parents as " o v e r p r o t e c t i n g , " " a m b i v a l e n t , " " r e j e c t i n g , " a n d " h o s t i l e " (e.g., Gerlsma, E m m e l k a m p , & Arrindell, 1990). A l t h o u g h such reports may be q u e s t i o n a b l e in t e r m s of their accuracy, they are very m a r k e d a n d consistent in their depiction of early relationships. In addition, r e c e n t c o n t r o l l e d studies of clinical p o p u l a t i o n s have also f o u n d c o n s i d e r a b l e p a r e n t a l discord a n d d i s h a r m o n y in families of severely anxious children (e.g., Kashani et al., 1990; Stark, H u m p h r e y , Crook, & Lewis, 1990). Moreover, p a r e n t a l anxiety a n d p h o b i a s may a d d to the c o m p l e x i t y o f the family situation. Obviously, p r e s e n c e of such factors may c o m p r o m i s e the i m p l e m e n t a t i o n of t r e a t m e n t strategies (cf. Silverman, Ginsburg, & Kurtines, 1995). For e x a m p l e , anxious parents are m o r e likely to m o d e l avoidant behaviors t h a n positive c o p i n g behaviors. Finally, acute marital discord nearly always makes it impossible for caregivers to achieve the level o f c o o p e r a t i o n necessary for successful t r e a t m e n t via in vivo desensitization a n d c o n t i n g e n c y m a n a g e m e n t p r o c e d u r e s . In this section, we briefly e x a m i n e s o m e advances in family assessment relevant to the assessment o f c h i l d h o o d phobias. Although there are m a n y types of family assessment, this discussion is c o n f i n e d to observational m e t h o d s a n d self-report i n s t r u m e n t s (cf. Ronan, 1996). Typically, o b s e r v a t i o n m e t h o d o l o g i e s involve c o d i n g systems to facilitate the direct assessm e n t of p a r e n t - c h i l d interactions. In o n e of the m o r e e l e g a n t applications of this m e t h o d o l o g y to the assessment of anxious children, Dadds a n d colleagues develo p e d a Family Anxiety Coding Schedule (FACS), which they used to assess the interactions of family m e m b e r s in dealing with hypothetical anxiety p r o d u c i n g situations (Dadds et al., 1994). For e x a m p l e , anxious children a n d their parents were asked (separately) to i n t e r p r e t the following situation a n d how they would

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TABLE 1. Brief Category Definitions for the F a m i l y A n x i e t y Coding Schedule a Content categories Referent: Comments on the behavior or state of self or others. Scored "positive" vs. "negative" depending on the content and voice tone used and "self" or " o t h e r " according to the referent. Reassurance: Behaviors that aim to comfort or reduce threat perception to another person. Scored "ask for" vs. "give" and "physical" vs. "verbal." Respond: Behaviors that express "agreement" vs. "Disagreement" with the previous speaker or with the self ("sure" vs. "Unsure"). Describe: Comments that describe the problem at hand. Solution: Comments that suggest ways of dealing with the problem at hand. Scored "proactive" vs. "avoidant". Consequence: Comments that point out the consequences of a behavior. Scored "social" vs. "physical" and "positive" vs. "negative". Question: Any request for information. Scored according to the content of the request, that is, " p r o b l e m " , "solution", "consequence", or "ability" ("can you do it?") or affect ("How do you feel?"). Process categories Facilitate: Comments or questions that keep the family discussion on track. Hinder: Comments or questions or other behavior that blocks the family discussion. Listen: Active attending behavior. Affect ratings Each behavior by a family member is scored according to affect, using Happy, Anxious, Sad, Angry, or Neutral categories. These are scored using any or all cues from facial expression, tone of voice, body posture, and self-report. Laughter is scored as anxious unless it is an appropriate response to a funny comment or behavior. aFor each utterance by an family member, the observer records the speaker, the person addressed, a process or content category, and an affect rating. Source: Dadds, M. R. et al. (1994). Behavioral observations. In T. H. Ollendick, N.J. King, & W. Yule (Eds.), International handbook of phobic and anxiety disorders in children and adolescents. New York: Plenum Press.

r e a c t to it, "You see s o m e c h i l d r e n p l a y i n g in t h e b a c k g r o u n d at s c h o o l a n d y o u d e c i d e to j o i n in. As y o u a p p r o a c h , y o u n o t i c e t h e c h i l d r e n a r e l a u g h i n g . W h a t d o y o u t h i n k is h a p p e n i n g ? W h a t will y o u d o ? " I n p r e v i o u s s t u d i e s ( B a r r e t t , R a p e e , & D a d d s , 1992; D a d d s , B a r r e t t , & R a p e e , 1993) t h e s e r e s e a r c h e r s h a v e s h o w n t h a t a n x i o u s c h i l d r e n e x p r e s s m o r e t h r e a t i n t e r p r e t a t i o n s o f h y p o t h e t i c a l a n x i e t y - p r o d u c i n g s i t u a t i o n s , c o m p a r e d to n o n a n x i o u s c h i l d r e n . A f u r t h e r i m p o r t a n t f i n d i n g was t h a t m a n y a n x i o u s c h i l d r e n switch f r o m a p r o a c t i v e c o p i n g p l a n to a n a v o i d a n t p l a n a f t e r d i s c u s s i n g t h e p r o b l e m with t h e i r p a r e n t s . To l e a r n m o r e a b o u t t h e p r o c e s s o f h o w this h a p p e n s , t h e r e s e a r c h ers r e c o m m e n d t h e u s e o f t h e FACS as a m e a n s o f t r a c k i n g e a c h f a m i l y m e m b e r s ' u t t e r a n c e s . As d e t a i l e d in T a b l e 1, t h e o b s e r v e r is r e q u i r e d to c o d e t h e b e h a v i o r s in t e r m s o f c l e a r l y d e f i n e d c o n t e n t a n d p r o c e s s c a t e g o r i e s . A f f e c t r a t i n g s a r e also to b e p r o v i d e d by t h e o b s e r v e r f o r e a c h o f t h e u t t e r a n c e s . As a r e s u l t o f this

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particular m e t h o d o l o g y , Dadds a n d colleagues were able to d o c u m e n t the p o t e n c y of p a r e n t a l interaction in the d e v e l o p m e n t of t h r e a t p e r c e p t i o n s a n d avoidance in the child. I n t e r o b s e r v e r a g r e e m e n t for the various categories r a n g e d f r o m 84.0% to 99.9% in the assessment o f 10 families. At this stage, however, f u r t h e r work obviously n e e d s to be u n d e r t a k e n on the reliability a n d validity o f the FACS. Self-report instruments can be employed for the assessment of parental discord and family dysfunctioning. In relation to parental discord, for example, the Dyadic Adjustment Scale (Spanier, 1976) has proven to be an easily administered and psychometrically sound instrument with high test-retest reliability, and concurrent validity (see Fischer & Corcoran, 1994). There is now a plethora of self-report instruments designed for the assessment of family functioning. These usually comprise of a n u m b e r of subscales reflective of important areas of family functioning (see Jacob & Tennenbaum, 1988). For example, the Family Environment Scale (FES; Moos & Moos, 1986) comprises 10 subscales including cohesion, expressiveness, conflict, independence, achievement orientation, intellectualcultural orientation, active-recreational orientation, moral-religious emphasis, organization, and control. The FES is designed tbr completion by various family members. Although adolescents are capable of completing the FES, it is not suitable for use with children. Pino and colleagues have developed the Children's Family Environment Scale, a 30-item pictorial adaptation of the FES for children between the ages of 5 and 11 (Pino, Simons, & Slawinowski, 1983, 1984). The Children's FES yields an overall index of the quality of family relationships, which is composed of FES cohesion, expressiveness and conflict. The FES and Children's FES have high test-retest reliability and validity (see Moos & Moos, 1986). However, it should be emphasized that self-report instruments, such as the FES are grounded in a particular theory of family fimctioning (e.g., systems, psychoanalytic and behavioral), which needs to be considered in relation to the assessor's own conception of phobias and anxiety disorders in children and the role of family-related variables in the development and maintenance of these conditions (cf. Kendall et al., 1992). T h u s far there have b e e n few reports of such s t a n d a r d i z e d m e a s u r e s of family f u n c t i o n i n g b e i n g taken in the assessment a n d t r e a t m e n t of c h i l d h o o d phobias. A notable e x c e p t i o n is the work of H e a r d et al. (1992) on the cognitive-behavioral t r e a t m e n t of three adolescents with severe p h o b i c disorders. As well as using traditional clinical m e a s u r e s in the initial assessment, the DAS a n d FES were also a d m i n i s t e r e d in o r d e r to assess p a r e n t a l discord a n d family functioning. For each o f the families, scores on these measures were within the nonclinical range. However, the DAS a n d FES were r e a d m i n i s t e r e d at p o s t t r e a t m e n t a n d follow-up assessments as a m e a n s of d e t e r m i n i n g if the i n t e r v e n t i o n s had any adverse effects on the families. Despite the d e m a n d i n g n a t u r e a n d potential stress o f the p r o g r a m on the families, it was f o u n d that cognitive-behavioral t r e a t m e n t resulted in relief f r o m the phobias in the absence of any adverse effects on the families. U n d o u b t edly, m e a s u r e s of p a r e n t a l p s y c h o p a t h o l o g y a n d family f u n c t i o n i n g will play an increasingly significant role in the assessment o f c h i l d r e n ' s phobias. SUMMARY AND CONCLUSIONS

As n o t e d by Ollendick a n d H e r s e n (1984, 1993), child and a d o l e s c e n t behavioral assessment is d e f i n e d as an exploratory, hypothesis-testing process in which a r a n g e o f specific assessment p r o c e d u r e s are used in o r d e r to u n d e r s t a n d a given child, group, or social ecology and to f o r m u l a t e a n d evaluate specific i n t e r v e n t i o n

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strategies. Furthermore, child behavioral assessment is m u l t i m e t h o d in its approach, empirically based and developmentally sensitive. We argued that these precepts s h o u l d be observed in the assessment of c h i l d h o o d phobias. Following a behavioral approach to the assessment of c h i l d h o o d phobias, "specification" of the presenting problem is mandatory. The target behaviors encompass overt behavior, physiological states, and cognitions. A l t h o u g h the etiology of the child's p h o b i a is usually explored, an understanding of the current situation is more helpful. A functional analysis gives us vital information on the controlling antecedents (specific stimulus events plus more general setting events) and consequences (e.g., reaction of care providers). In addition, many practical considerations have to be entertained at this stage (e.g., the suitability of a care provider to act as a behavior-change agent). Consistent with the n o t i o n of m u l t i m e t h o d assessment we examined a variety of assessment strategies used with phobic children, including behavioral interviews, structured diagnostic interviews, self-report inventories, caregiver reports, behavioral observations, self-monitoring, and physiological assessment. Given recent developments in the study of the internalizing disorders, we also r e c o m m e n d e d consideration of information-processing measures and family assessment measures. The assessment measures were f o u n d to have varying degrees of developmental sensitivity, reliability, and validity. Nonetheless, it is evident that there have b e e n significant advances in the behavioral assessment of children's phobias, such that the thoughtful clinician or researcher is now relatively well resourced with respect to tools or instruments that will assist in clinical assessment and the evaluation of treatment effectiveness.

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