A 5-year-old boy is brought to the office by his parents for evaluation of behavioral concerns. The mother states that for the past year, the patient has had difficulty remaining calm during thunderstorms. His fear has worsened to the point that it is starting to disrupt his sleep schedule and school attendance. Each time the patient notices storm clouds or hears thunder, he starts to cry and hides under his bed. The patient has started refusing to leave the house if the sky looks cloudy and becomes very worried if one of his parents is not at home when it is raining. If a storm occurs while he is at school, he becomes upset and asks the teacher if he can go home. Vital signs are within normal limits; height and weight are tracking consistently at the 60th percentile. Physical examination shows no abnormalities. Which of the following is the most appropriate recommendation to provide the parents?
Specific phobia | |
History & |
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Treatment |
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This child's intense fear of thunderstorms resulting in avoidance behaviors (ie, refusal to leave the house, asking to leave school) are suggestive of specific phobia (SP), a common psychiatric disorder of childhood. SP is characterized by an intense fear of a specific object or situation that is avoided when possible or endured under duress. Although it is normal for children to have fears, when the intensity of fear results in avoidance and daily functional interference (eg, impacting the child's school attendance and sleep schedule), it has risen to the level of an anxiety disorder. Reassurance alone is insufficient, and intervention is warranted to limit further impairment and suffering (Choice D).
The first-line treatment of SP is exposure therapy, a form of cognitive-behavioral therapy that targets avoidance behavior by gradually exposing the patient to the feared object or situation (also known as systematic desensitization) to bring about an extinction response. The exposure should begin with something less anxiety provoking that is related to the object or situation. In this case, reading a book about thunderstorms (also known as bibliotherapy), would be an appropriate first step. After the initial exposure is tolerated, increasingly proximate exposures to the feared object or situation can occur, such as listening to the sound of storms or watching a video of a thunderstorm. Through continued, graded exposure to the feared object or situation, anxiety diminishes.
(Choice A) Although this response may provide temporary relief, it serves to perpetuate avoidance behaviors in the long term and will not decrease the child's fear response.
(Choice B) Providing examples of other classmates may result in shame and will not help this child develop confidence in his ability to manage his fear.
Educational objective:
Specific phobia is characterized by an intense fear of an object or situation that is avoided when possible and causes significant impairment. The treatment of choice is gradual exposure to the feared object or situation.