Journal of Anxiety Disorders 24 (2010) 629634

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

The prevalence of specic phobia and associated co-morbid

features in children and adolescents
Soo-Jin Kim, Bung-Nyun Kim , Soo-Churl Cho, Jae-Won Kim,
Min-Sup Shin, Hee-Jung Yoo, Hyo Won Kim
Division of Child and Adolescent Psychiatry, Department of Neuropsychiatry, College of Medicine, Seoul National University, 101 Daehakro, Chongno-Gu, Seoul, Korea

a r t i c l e

i n f o

Article history:
Received 9 October 2009
Received in revised form 9 April 2010
Accepted 9 April 2010
Keywords:
Specic phobia
Subtype
Co-morbidity
DISC-IV
CBCL

a b s t r a c t
Objective: The aims of this study were to investigate the prevalence, associated co-morbid psychiatric
disorders and behavioral/emotional problems associated with the subtypes of specic phobia in children
and adolescents.
Methods: A total of 2673 randomly selected children and adolescents from Seoul, Korea were assessed
using the parent version of the Diagnostic Interview Schedule for Children (DISC-IV) and Childrens Behavior Checklist (CBCL). We analyzed differences in psychiatric co-morbidities and CBCL proles among the
subtypes of specic phobia.
Results: The 1-year prevalence of specic phobia was 7.9% (95% CI 7.638.17). Animal phobia was associated with anxiety disorder (OR 8.68, 95% CI 1.9139.51) and oppositional deant disorder (OR 2.55,
95% CI 1.275.12). Natureenvironment phobia was associated with anxiety disorder (OR 25.70, 95% CI
6.16107.10). Bloodinjectioninjury phobia showed associations with attention-decit/hyperactivity
disorder (ADHD: OR 6.74, 95% CI 2.8116.15). Subjects with natureenvironment phobia scored higher
than did controls on the anxious/depressed, social problems, attention problems, and total behavioral
problem proles of the CBCL. Subjects with bloodinjectioninjury phobia scored signicantly higher
than did controls on the attention problems, aggressive behaviors, and externalizing problem proles.
Conclusions: Contrary to animal phobias, natureenvironment and bloodinjectioninjury phobias were
associated with various behavioral and emotional problems and approximately correlated to their comorbid psychiatric disorders. Among these subtypes, signicant differences were found in demographic
characteristics, co-morbid psychiatric disorders, and emotional/behavioral problems. These ndings suggest that distinctive clinical characteristics might be related with different subtypes of specic phobia
and clinician must consider psychiatric co-morbidities when treating children & adolescents with specic
phobia.
2010 Elsevier Ltd. All rights reserved.

1. Introduction
Only a small body of literature examines the epidemiology and
clinical features of childhood specic phobia based on DSM-IV or
ICD-10 dened criteria. Moreover, few studies have specically
examined the subtypes of specic phobia. According to DSM-IV, the
prevalence rates of specic phobias vary across cultures and ethnicities. Previous studies of children have found prevalence rates
of between 2.4% and 3.6% in New Zealand (Anderson, Williams,
McGee, & Silva, 1987; McGee, Feehan, Williams, & Anderson,
1990), 2.6% in Puerto Rico (Bird et al., 1988), 2.6% in Switzerland
(Steinhausen, Metzke, Meier, & Kannenberg, 1998), and 3.5% in Germany (Essau, Conradt, & Petermann, 2000). Using a sample of 3021

Corresponding author. Tel.: +822 2072 3647; fax: +822 747 5774.
E-mail addresses: kbn1@snu.ac.kr, b.kim2@uq.edu.au (B.-N. Kim).
0887-6185/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.janxdis.2010.04.004

individuals aged 1424 years in Munich, Wittchen, Nelson, and

Lachner (1998) reported a lifetime prevalence of specic phobia
of 2.3% and a 12-month prevalence of 1.8%.
Just a few epidemiological studies have assessed the psychiatric co-morbidities of specic phobia, and even less information
is available on co-morbidity with regard to its specic subtypes.
Lewinsohn, Zinbarg, Seeley, Lewinsohn, and Sack (1997) examined lifetime co-morbidities of anxiety disorders in a community
sample of high school adolescents aged 1419 years. Specic phobia was found to be highly co-morbid with separation anxiety
disorder (odds ratio (OR): 4.7) and social phobia (OR: 7.2). In an
epidemiologic study of 36 adolescents aged 1217 years with specic phobias, Essau et al. (2000) reported that 47.2% of subjects
had co-morbid anxiety disorders, 36.1% had co-morbid depressive disorders, 33.3% had co-morbid somatoform disorders, and
8.3% had co-morbid substance use disorders. Becker et al. (2007)
reported the lifetime prevalence of co-morbidity among the sub-

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S.-J. Kim et al. / Journal of Anxiety Disorders 24 (2010) 629634

types of specic phobia in a community sample of young women

aged 1824. In their study, animal phobias were signicantly associated with other anxiety disorder (OR 2.36), affective disorder (OR
3.07), somatoform disorder (OR 3.99), and substance disorder (OR
4.00) but not with eating disorders. Height phobia was only associated with anxiety disorders (OR 2.72). The bloodinjectioninjury
subtype of specic phobia was also related to anxiety disorders (OR
5.24).
As mentioned above, co-morbid psychiatric disorders among
the specic phobia subtypes in samples of young adults or adolescents have been examined in several studies. However, no studies
have evaluated those co-morbid features in samples including children. In addition, very few studies have examined differences in
behavioral or emotional characteristics among the subtypes of specic phobia. Moreover, to the best of our knowledge, no previous
study has used an Asian community sample. Thus, the aim of the
current study was to investigate the prevalence of specic phobias and to explore whether different co-morbidities and different
behavioral/emotional characteristics was associated with each subtype of specic phobia in a community sample of Korean children
and adolescents.
2. Methods
2.1. Subjects and procedures
This study formed a part of the Seoul Mental Health Epidemiologic Study for Children and Adolescents (Cho et al., 2006a,b),
which is a cross-sectional study that was conducted in Seoul,
Korea, between September 2005 and February 2006. The subjects were 617 year old children and adolescents attending
schools in Seoul, Korea. Subjects for the study were recruited
using a multi-stage stratied random selection method. For the
present study, Seoul was divided into six school districts based
on the socioeconomic status of residents. Seven elementary, six
middle, and six high schools were randomly selected to provide a representative sample. Ten classes were randomly selected
from each elementary school, and three classes were randomly
selected from each middle and high school. The interviewers
were educated lay volunteers, all of whom were educated to at
least to the bachelors degree level. All had previously been educated in the practice of the Diagnostic Interview Schedule for
Children version IV, parent version (DISC-IV) by skilled psychiatrists, and they received constant quality control monitoring by
psychiatrists from the Department of Child and Adolescent Psychiatry at Seoul National University Hospital. The interviewers
scheduled interviews with subjects parents by phone and then
conducted the interviews at the relevant schools. They gave full
explanations of the study procedures to the subjects parents and
obtained informed consent for their childrens participation in the
study. Parents of 2673 students completed the Diagnostic Interview Schedule for Children, 4th edition (DISC-IV). The students
consisted of 1645 children and 1028 adolescents. The children
and adolescents completed the Korean version of the Childrens
Depression Inventory (CDI); thus, the assessment of depressive disorder was made not by parents, but by the children themselves.
The subtypes of specic phobia were determined according to
DSM-IV criteria based on questions in DISC-IV about what makes
their child fearful. Specic phobias included (1) animal type; (2)
natureenvironment type, including height, thunder, lightning,
darkness and water; (3) bloodinjectioninjury type including needles, blood, seeing laceration wounds, and injection; (4) situational
type, including bridges, tunnels, highways, elevators, and escalators. The parents of the subjects also lled out the parents version
of the Korean edition of the Children Behavior Checklist (K-CBCL).
Control subjects were randomly selected from an age- and gender-

matched group of those without a specic phobia. The control

group was used as the reference group when CBCL mean T-scores
for specic phobia subtypes were compared. The study protocol
was approved by Seoul National University Institutional Review
Board.
2.2. Assessment measures
(1) Diagnostic Interview Schedule for Children, 4th edition (DISCIV): psychiatric disorders, as dened by the DSM-IV, were
assessed using the Korean version of the DISC-IV. Interviews
were organized into six diagnostic sections: anxiety disorders,
mood disorders, disruptive behavior disorders, substance use
disorders, Schizophrenia, and miscellaneous disorders (eating,
elimination, and tic disorders, pica and trichotillomania). In this
study, the DISC-IV scoring algorithms for ascertaining the presence of a diagnosis were derived based on data from parents.
Good testretest reliability of the DISC-IV has been reported
(Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). The reliability and validity of the Korean version of the DISC-IV have
been previously determined and reported (Cho et al., 2006a,b).
(2) Child Behavior Checklist (CBCL): the empirically derived CBCL
(Achenbach, 1991) is one of the most-studied instruments for
the evaluation of child and adolescent psychopathology. It contains 112 behavioral items, which are scored by a parent. The
social competence scale can be subdivided into three areas;
activities, social, and school scales, and the sum of the scores
on these subscales yields a total competence score. The behavioral/emotional problem scores are divided into three broad
dimensions: internalizing, externalizing and mixed categories,
which form a total behavior problem score (excluding items 2
and 4). The internalizing scale consists of three subscales; withdrawn, somatic complaints and anxious/depressed syndromes;
the externalizing scale consists of the delinquency and aggression scores, and the mixed category includes thought, social,
and attention problems. Parents were asked to rate childrens
behavior problems on a 02 scale (0 = not true; 1 = somewhat
or sometimes true; 2 = very true or often true) for the previous 6 months. Numerous studies have conrmed the stability of
the instruments psychometric properties, showing good validity in both clinical and non-clinical populations (Biederman et
al., 1993, 2001). The Korean version of the CBCL was standardized in 1997 (Oh & Lee, 1997).
(3) The Childrens Depression Inventory (CDI): the Childrens
Depression Inventory (CDI; Kovacs, 1985), which was completed by the 717 year old children and adolescents, is the
self-rating scale measuring the severity of depressive symptoms, scored from 0 to 2. Subjects are asked to refer to their
feelings, cognitions, and behavior during the past 2 weeks
through 27 items. The Korean version of the CDI was standardized in 1990 (Cho & Lee, 1990) and its validity and reliability in
Korea has been previously been well established and reported
(Cronbachs = 0.88). A total score of 22 was considered to be
a cutoff point for screening depression in the Korean version.
2.3. Data analysis
The ratio of children to adolescents, gender differences, and
socioeconomic status (SES) of each specic phobia group was compared with those of the control group using a chi-squared test. We
divided age into four groups to assess prevalence according to age:
68, 911, 1214, and 1517 years. A one-way ANOVA was performed to assess differences in mean age between each subtype
group and the control group. Co-morbid psychiatric disorders were
also assessed by DISC-IV. Logistic regressions were performed to
analyze the odds ratio of co-morbidities of each subtype compared

S.-J. Kim et al. / Journal of Anxiety Disorders 24 (2010) 629634

631

Table 1
Demographic characteristics among the subjects with the three subtypes of specic phobia and the control.
Animal
a

Subjects number (%)

Children (<13 y), n (%)
Adolescents (13 y), n (%)
Agea
Mean years (SD)

Naturalenvironmental

Bloodinjection injury

SP

No SP

91 (49.2)
71 (78.0)
20 (22.0)

60 (32.4)
48 (80.0)
12 (20.0)

34 (18.4)
30 (88.2)
4 (11.8)

185 (100)
149 (80.5)
36 (19.5)

1952(100%)
1261 (64.6)
691 (35.4)

9.78 (2.88)

9.9 (2.78)

9.38 (2.37)

9.75 (2.76)

11.09 (3.14)

Gender number (%)b

Boys
Girls

28 (30.7)
63 (69.2)

31 (51.7)
29 (48.3)

16 (47.1)
18 (52.9)

75 (40.5)
110 (59.5)

1020 (52.2)
932 (47.8)

SES number (%)b

Low
Middle
High

1 (1.1)
36 (40.0)
54 (58.9)

4 (6.7)
34 (56.7)
22 (36.6)

1 (2.9)
21 (61.8)
12 (35.3)

6 (3.2)
91 (49.2)
88 (47.6)

62 (3.2)
1039 (53.2)
851 (43.6)

SP: specic phobia, SES: socioeconomic status.

a
All types of specic phobia showed signicant difference compared to No SP, p < 0.001.
b
Only animal phobia showed signicant difference compared to No SP, p < 0.001.

to subjects with no specic phobia after controlling the effect of age,

gender, and SES. To examine whether the mean CBCL scores of each
subtype group differed from those of the age- and gender-matched
controls, analysis of covariance (ANCOVA) adjusting for SES was
used. Post hoc Bonferroni pair-wise comparisons were computed
to analyze differences between study groups. Statistical analyzes
were performed using SPSS (v12.0), and the signicance level was
set at p = 0.05; all comparisons were two-tailed.
3. Results
3.1. Prevalence and demographic characteristics
Among the 2673 participants, 204 subjects were diagnosed with
specic phobia, with a 1-year prevalence rate of 7.90% (95% CI
7.638.17). Table 1 shows the demographic characteristics of three
specic phobia subtype groups, the total specic phobia group, and
the control group. Among 204 subjects with specic phobia, 185
subjects who had complete demographic and clinical data including co-morbid data and CBCL were included in the comparison
with control group. Demographic data showed that subjects with
specic phobia were younger on average (mean = 9.75, standard
deviation = 2.76 vs. mean = 11.09, standard deviation = 3.14 in controls), were more likely female (59.5% vs. 47.8% in controls) and
were more likely to be children (80.5% vs. 64.6% in controls), but
no signicant difference was found in SES. However, there were
several different characteristics among the subtypes. Contrary to
the overall pattern, there was no signicant difference found in the
gender ratio of those with bloodinjectioninjury phobias (52.9%
vs. 47.8%, p = 0.605). Those with animal phobias had a higher SES
than did controls (p = 0.007). As age increased, the 1-year prevalence rate showed a tendency to decrease (Fig. 1). No signicant
difference in prevalence was found among the subtypes according
to age.
Animal phobias were reported most frequently (n = 91,
49.2%), followed by natureenvironment phobias (n = 60, 32.4%),
bloodinjectioninjury phobias (n = 34, 18.4%), and situation phobias (n = 4, 0.2%). The situation subtype was excluded from the
statistical analysis due to the small number. Eighty-eight (43.1%)
subjects had only one subtype of specic phobia, whereas 64
(31.4%) and 44 (21.6%) subjects reported two and three types of fear
objects, respectively. The remaining 13 (3.2%) subjects reported all
types.

anxiety disorders included separation anxiety disorder, social

phobia, and generalized anxiety disorder (Table 2). The specic phobia group had signicantly higher co-morbid rates
compared to those of controls for the following psychiatric disorders (Table 2): anxiety disorder (OR = 12.48, 95% CI 3.8140.87),
attention-decit/hyperactivity disorder (ADHD) (OR = 2.62, 95% CI
17.574.39) and oppositional deant disorder (OR = 2.14, 95% CI
1.283.59). However, the results showed no correlation between
co-morbidity and any affective disorder, including major depressive disorder as measured by DISC-IV or CDI. Interestingly,
signicant differences were found in the features of the co-morbid
disorders among subtypes. Animal phobia was associated with
anxiety disorder (OR 8.68, 95% CI 1.9139.51) and oppositional
deant disorder (OR 2.55, 95% CI 1.275.12). Natureenvironment
phobia was strongly associated with anxiety disorder only
(OR 25.70, 95% CI 6.16107.10). Bloodinjectioninjury phobia
showed a signicant association with ADHD (OR 6.74, 95% CI
2.8116.15).
3.3. Co-morbid emotional and behavioral problems
The mean scores of all CBCL subscales in the three subtype
groups and the control group are shown in Table 3. Compared

3.2. Co-morbid psychiatric diagnosis

Of those in the specic phobia group (n = 185), 28.1% (n = 52)
had at least one co-morbid psychiatric diagnosis. Co-morbid

Fig. 1. The 1-year prevalence of specic phobia according to age groups.

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S.-J. Kim et al. / Journal of Anxiety Disorders 24 (2010) 629634

Table 2
The prevalence and odds ratio of psychiatric co-morbidities in the three subtypes of specic phobia according to DISC-IV.
Anxiety disorder

ADHD

ODD

Elimination disorder

Tic disorder

5 (5.5)
8.68 (1.9139.51)

5 (5.5)
1.17 (0.443.10)

11 (12.1)
2.55 (1.275.12)

2 (2.2)
2.45 (0.5211.53)

2 (2.2)
0.94 (0.322.74)

Naturalenvironmental (n = 60)
N (%)
6 (10.0)
OR (95.0% CI)
25.70 (6.16107.10)

10 (16.7)
2.48 (0.946.55)

9 (15.0)
1.93 (0.794.70)

1 (1.7)
1.22 (0.1510.10)

2 (3.3)
0.93 (0.302.93)

Bloodinjection injury (n = 34)

N (%)
0 (0.0)
OR (95.0% CI)

9 (26.5)
6.74 (2.8116.15)

4 (11.8)
1.50 (0.464.88)

2 (5.9)
4.18 (0.8021.93)

2 (5.9)
0.98 (0.224.35)

All SP (n = 185)
N (%)
OR (95.0% CI)

24 (13.0)
2.62 (1.574.39)

24 (13.0)
2.14 (1.283.59)

5 (2.5)
2.23 (0.776.49)

6 (2.9)
0.88 (0.321.79)

Animal (n = 91)
N (%)
OR (95.0% CI)

11 (5.9)
12.48 (3.8140.87)

DISC-IV: Diagnostic Interview Schedule for Children version IV. ADHD: attention-decit/hyperactivity disorder, ODD: oppositional Deant Disorder. Logistic regression test
was performed to analyze the odds ratio after controlling for the effect of age, gender, and socioeconomic status. The reference group for determining the odds ratio was
control group without specic phobia. Bold and underline: statistically signicant OR: p < 0.05.

to the age- and gender-matched control group (n = 408), subjects with natureenvironment phobia showed higher mean scores
for the anxious/depressed (54.7, 95% CI 52.357.2 vs. 51.5, 95%
CI 51.151.8 in control, p < 0.001), social problems (56.3, 95% CI
53.659.0 vs. 52.1, 95% CI 51.652.6 in control, p < 0.001), attention problems (54.9, 95% CI 52.557.3 vs. 51.8, 95% CI 51.552.2
in control, p < 0.001), and total behavioral problems (55.2, 95%
CI 52.957.5 vs. 52.3, 95% CI 51.952.8 in control, p = 0.004) proles of the CBCL. Subjects with bloodinjectioninjury phobia
scored signicantly higher in the attention problems (55.5, 95% CI
53.157.9 vs. 51.8, 95% CI 51.552.2 in control, p < 0.001), aggressive behavior (54.1, 95% CI 51.756.5 vs. 51.3, 95% CI 50.151.6
in control, p = 0.006), and externalizing problems (53.7, 95% CI
51.355.9 vs. 51.3, 95% CI 51.051.6 in control, p < 0.05) proles
of the CBCL than did the controls. No signicant differences in the
CBCL proles were found between subjects with animal phobia and
controls.
4. Discussion
Interestingly, our results showed signicant differences among
the subtypes of specic phobia with regard to co-morbid psychiatric disorders and emotional/behavioral problems. The prevalence
of specic phobia in Korean children and adolescents was 7.90%,
which is similar to that reported in other countries (Silverman &
Kearley, 1992; Silverman & Treffers, 2001). Of those with specic
phobia, the overall proportion of girls was 61.6% with some variation by phobia types (Animal = 69.7, natureenvironment = 50.6,
and bloodinjectioninjury phobia = 55.2%). One previous study
reported that 7590% of those with animal, natureenvironment,

and situation phobias were female, and 5570% of those with

bloodinjectioninjury phobias were female (American Psychiatric
Association, 1994). While we nd higher rates in girls, the gender
differences previously found are less prevalent in our sample.
Regarding co-morbid psychiatric conditions, animal and
natureenvironment phobias were associated with anxiety disorders, which is consistent with previous studies (Becker et
al., 2007; Lewinsohn et al., 1997). Additionally, animal and
bloodinjectioninjury phobias had signicant associations with
externalizing disorders such as oppositional deant disorder and
ADHD, respectively.
Evidence that supports these differences in co-morbidity is
scarce. Based on animal models of fear of learning (Davis &
Whalen, 2001; LeDoux, 2000), one hypothesis predicts that amygdalar dysfunction is common to a variety of anxiety disorders.
Indeed, amygdalar hyperactivity has been observed during symptom provocation or negative emotional processing in patients with
posttraumatic stress disorder (PTSD) (Rauch et al., 2000; Shin et al.,
2004, 2005), social anxiety disorder (Phan, Fitzgerald, Nathan, &
Tancer, 2006; Stein, Goldin, Sareen, Zorrilla, & Brown, 2002), panic
disorder (van den Heuvel et al., 2005) and obsessivecompulsive
disorder (van den Heuvel et al., 2004) as well as specic phobia (Dilger et al., 2003; Schienle, Schfer, Walter, Stark, & Vait,
2005; Straube, Mentzel, & Miltner, 2006; Veltman et al., 2004).
Shared symptoms of anxiety disorders, such as an exaggerated
fear response, might be reected in shared neurobiology (Etkin &
Wager, 2007). It is well documented that specic phobia has high
co-morbidity with other anxiety disorders; however, few studies
or theories have addressed the co-morbidity of ADHD and anxiety.
Further studies would be needed in this research area.

Table 3
Comparisons of Child Behavior Checklist score among the subjects with the three subtypes of specic phobia and age- and gender-matched control.
Animal (n = 91)

Withdrawn
Somatic complaints
Anxious/depressed
Social problems
Thought problems
Attention problems
Delinquent behavior
Aggressive behavior
Internalizing problems
Externalizing problems
Total behavioral problems

Naturalenvironmental (n = 60)

Bloodinjectioninjury (n = 34)

Control (n = 408)

Mean

(SD)

Mean

(SD)

Mean

(SD)

Mean

(SD)

64.8
53.9
52.6
52.8
52.6
51.9
51.8
52.1
54.9
52.0
52.9

(16.5)
(7.8)
(4.2)
(5.3)
(6.2)
(3.7)
(4.0)
(4.4)
(7.4)
(4.1)
(5.2)

67.4
54.3
54.7
56.3
54.0
55.0
52.1
53.2
57.4
52.9
55.3

(17.6)
(7.0)
(8.3)
(9.2)
(6.6)
(8.1)
(4.1)
(6.2)
(9.6)
(5.5)
(7.9)

64.2
54.7
53.7
54.6
53.4
55.3
52.5
54.2
55.7
53.7
54.8

(15.0)
(8.1)
(6.5)
(6.3)
(7.0)
(6.4)
(5.2)
(6.5)
(7.1)
(6.2)
(6.9)

64.7
53.1
51.5
52.1
52.3
51.8
51.3
51.3
54.9
51.3
52.3

(17.7)
(7.2)
(3.7)
(4.9)
(6.2)
(3.8)
(3.3)
(3.4)
(7.6)
(3.2)
(4.6)

SD: standard deviation. ANCOVA with socioeconomic status as a covariate & the Bonferroni post hoc analysis was performed. Bold, italic and underline: statistically signicant:
p < 0.05.

S.-J. Kim et al. / Journal of Anxiety Disorders 24 (2010) 629634

Our results showed that different subtypes of specic phobia

seem to have their own CBCL proles. The natureenvironment
and bloodinjectioninjury subtypes were associated with various behavioral and emotional problems, whereas animal phobia
was not. The differences between the subtypes seemed well correlated with the CBCL proles of each co-morbid psychiatric
disorder. Natureenvironment phobia was related to a high score
on the anxious/depressed and attention problems subscales, which
are known to be related to anxiety disorder (Eiraldi, Power,
Karustis, & Goldstein, 2000). Similarly, bloodinjectioninjury
phobia was related to a high score on the attention problems,
aggressive behavior, and externalizing problems, which are also
prominent in attention-decit/hyperactivity disorder (Suh et al.,
2007).
There are a few limitations in the present study. Firstly, the
measurements obtained from parents might have been prone
to underestimation or overestimation depending on the type
of problem and may vary over the age of children. Regarding
adolescents, the prevalence of phobia and other internalizing
disorders (anxiety disorders and mood disorders) may be underestimated. Several previous studies have reported that specic
phobias showed co-morbidities with depressive disorder (Regier,
Rae, Narrow, Kaelber, & Schatzberg, 1998; Schatzberg, Samson,
Rothschild, Bond, & Regier, 1998), somatoform disorder, and substance use disorder. However our results showed none of these
co-morbidities, although this nding is in accord with that of
The Seoul Child and Adolescent Mental Health Survey, which
revealed relevant low prevalence rate of these disorders generally
(Cho et al., 2006a,b). Nonetheless, the use of parental observation to obtain measurements might have been a limiting factor. A
discrepancy between reports by children and those by their parents has been suggested (Edelbrock, Costello, Dulcan, Conover,
& Kala, 1986). In addition, parents tend to be more concerned
with externalizing problems, such as aggression, than in internalizing ones, such as depression (Edelbrock et al., 1986). For
the same reason, the prevalence of specic phobias in adolescents might have been more greatly underestimated in children,
as it becomes easier for parents to overlook their childrens phobias as they grow older. However the prevalence of externalizing
disorders like ADHD and ODD may be overestimated by the parents.
Secondly, despite using a large community sample, we had
insufcient number of subjects to obtain strong statistical power
when analyzing the co-morbidities according to subtypes. Thirdly,
the detailed demographic data like socioeconomic status and CBCL
data were lost in about 10% of subjects.
This present study suggests that specic phobias are common among children and adolescents in the community and are
heterogeneous with regard to subtypes. These data clarify that
the subtypes of specic phobia are distinguishable. In addition,
they contribute to the exploration of the neurobiological phenotypes of specic phobia, which differs according to the fear
object.
Further studies are warranted to evaluate whether the ndings of this study are replicable and genuinely identify the
distinctive features related to specic phobias in Korean children and adolescents. To our knowledge, this is the rst study
to investigate the associated co-morbid psychiatric disorders and
behavioral/emotional characteristics of children and adolescents
with the subtypes of specic phobia according to DSM-IV criteria.
Several studies have assessed objects that cause fear; however, few
have made their assessments according to strict DSM-IV speciers.
In addition, previous studies conned their participants to young
women and adolescents; therefore, their results may not be generalized to children and adolescents. Moreover, none investigated
this area using an Asian community-based sample.

633

5. Conclusion
The strengths of this study include use of a large representative
community-based sample of children and adolescents and DISCbased psychiatric co-morbidities of specic phobia with regard to
its specic subtypes, which has been understudied in children and
adolescents internationally. From our present study, the results
showed that contrary to animal phobias, natureenvironment
and bloodinjectioninjury phobias were associated with various
behavioral and emotional problems and approximately correlated
to their co-morbid psychiatric disorders. Among these subtypes,
signicant differences were found in demographic characteristics,
co-morbid psychiatric disorders, and emotional/behavioral problems. These ndings suggest that distinctive pathophysiologies
might be occurring according to phobic objects and clinician must
consider psychiatric co-morbidities when evaluating children &
adolescents with specic phobia.
Acknowledgments
This work was supported by the Grant from Seoul Metropolitan
Government and Grant from College of Medicine, Seoul National
University and Clinical Research Institute, Seoul National University Hospital (Grant Number:800-20070124 & 0720080650).
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