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.Even within a single anxiety disorder, important functionaloutcomes may vary in response to treatment.For example, anticipatoryanxiety in the acutely separation anxious child may be especially responsive to a benzodiazepine, and the critical functional outcome, reintroduction to school, to gradual exposure [7].Third, in the face of partial response, an augmenting treatment can be added to the initial treatment to improve theoutcome in the symptom domain targeted by the initial treatment.Forexample, CBT can be added to a selective serotonin reuptake inhibitor(SSRI) for OCD to improve OCD-specific outcomes.In an adjunctivetreatment strategy, a second treatment can be added to a first one in order to positively impact one or more additional outcome domains.For example,an SSRI can be added to CBT for OCD to handle comorbid depression or294 __________________________________________________________________________________________ PHOBIASpanic disorder.Each of these assertions forms a testable hypothesis at aclinical decision node in a stage of treatment framework: initial treatment, partial response, treatment resistance and, not mentioned, maintenancetreatment and treatment discontinuation [8].Looking back from this review to Thomas Ollendick’s early work on theassessment and treatment of phobic children [9,10], it is not too strong astatement to say that he and his students gave birth to the study of phobic disorders as an empirical discipline in much the same way that MichaelLiebowitz gave birth to social anxiety disorder.While, as is plain for all to see, there are plenty of unanswered questions to keep the next generation of researchers more than busy, the field is indebted to him for pointing us in the right direction.REFERENCES1.March J., Parker J., Sullivan K., Stallings P., Conners C.(1997) The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability and validity.J.Am.Acad.Child Adolesc.Psychiatry, 36: 554–565.2.Pine D.S.(2003) Developmental psychobiology and response to threats:relevance to trauma in children and adolescents.Biol.Psychiatry, 53: 796–808.3.Kraemer H.C., Wilson G.T., Fairburn C.G., Agras W.S.(2002) Mediators andmoderators of treatment effects in randomized clinical trials.Arch.Gen.Psychiatry, 59: 877–883.4.Foa E.B., Kozak M.J.(1991) Emotional processing: theory, research, and clinical implications for anxiety disorders.In Emotion, Psychotherapy and Change (Eds J.Safran, L.Greenberg), pp.21–49.Guilford Press, New York.5.March J., Wells K.(2003) Combining medication and psychotherapy.InPediatric Psychopharmacology: Principles and Practice (Eds A.Martin, L.Scahill, D.S.Charney, J.F.Leckman), pp.326–346.Oxford University Press, London.6.March J.S., Swanson J.M., Arnold L.E., Hoza B., Conners C.K., Hinshaw S.P., Hechtman L., Kraemer H.C., Greenhill L.L., Abikoff H.B.et al.(2000) Anxiety as a predictor and outcome variable in the multimodal treatment study ofchildren with ADHD (MTA).J.Abnorm.Child Psychol., 28: 527–541.7.Kratochvil C.J., Kutcher S., Reiter S., March J.(1999) Pharmacotherapy ofpediatric anxiety disorders.In Handbook of Psychotherapies with Children and Families (Eds S.Russ, T.Ollendick), pp.345–366.Plenum Press, New York.8.March J., Frances A., Kahn D., Carpenter D.(1997) Expert consensusguidelines: treatment of obsessive–compulsive disorder.J.Clin.Psychiatry, 58(Suppl.4): 1–72.9.Ollendick T.H.(1983) Reliability and validity of the Revised Fear SurgerySchedule for Children (FSSC-R).Behav.Res.Ther., 21: 685–692.10.Ollendick, T.H., Gruen, G.E.(1972) Treatment of a bodily injury phobia with implosive therapy.J.Consult.Clin.Psychol., 38: 389–393.PHOBIAS IN CHILDREN AND ADOLESCENTS: COMMENTARIES ________________ 2955.7Phobias: From Little Hans to a Bigger PictureGordon Parker1Ollendick et al.’s detailed, thoughtful and lucid review invites fewchallenges or quibbles.It is clear that Freudian interpretations of childhood phobias no longer inform us.For those whose psychiatric educationpreceded DSM-III, childhood phobias were interpreted as reflectingunconscious oedipal fears, with Freud’s Little Hans projecting oedipalthoughts as a fear of horses.Symptom remission required addressing the‘‘real’’ source of anxiety (‘‘horses for courses’’ or ‘‘courses for horses’’paradigms) rather than addressing anxiety per se.Turning to the current review, we are informed that anxiety disorders aremore prevalent in girls—but does this hold for all phobias in pre-pubescent groups? If so, why? Is there a differential gender effect across the anxiety disorders? If so, why?The authors identify but do not speculate on an interesting phenomenonwhereby phobic disorders are more likely to be associated with comorbidconditions in clinical than community samples.It may well be that seekingclinical attention is determined more by the ‘‘comorbid’’ condition or by a greater severity associated with multiple coterminous conditions.Irrespective of interpretation, we should suspect that treatment modality andtherapeutic success will be influenced by the presence or absence ofcomorbid disorders.Etiological considerations by the authors are intriguing and informative.Exposure to conditioning or triggering events does not appear salient (innot being over-represented in phobic children), so that we must presume aweighting to the diathesis factor in any diathesis–stress model.For theseemingly sizeable percentage of children not reporting a specific fearstimulus, a phobic diathesis is again to be suspected.It is disappointingthen that the authors judged that any consideration of the intriguing notion of ‘‘inherited phobia proneness’’ was beyond the scope of their review.Treatment is not always informed by etiological knowledge, but the latter is rarely irrelevant.The authors note work by Kendler and colleagues suggesting that geneticfactors have only a modest role in the etiology of phobias.However,expecting close genetic links to state disorders (i.e.phobias) may be unwise.A clearer genetic influence on a broader ‘‘upstream’’ diathesis platformsuch as ‘‘propensity to fearfulness’’—as explicated by the authors—is1 School of Psychiatry, University of New South Wales, High Street, Randwick 2031, Sydney, Australia296 __________________________________________________________________________________________ PHOBIAStheoretically more plausible for pursuing genetic underpinning.This leadsthe authors into consideration of temperament as a vulnerability factor.They note that responses or initial reactions to unfamiliar people and novel situations have variably been described as ‘‘shyness versus sociability’’,‘‘introversion versus extroversion’’ and ‘‘withdrawal versus approach’’.The possibility that such terms are essentially synonymous is strong
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