August 2008
Vol. 10 No. 2
www.pediatric-pain.ca/ppl
Editor: Carl L. von Baeyer, carl.vonbaeyer@usask.ca
© 2008, Patrick J. McGrath & G. Allen Finley


Please visit the website for information on submission and review

Commentary
Theories of fear acquisition:
The development of needle phobia in children
Siyao Du, Tiina Jaaniste, G. David Champion and Carol S.L. Yap

Fear is a normal emotional response to a
their fear as excessive (Nir et al., 2003). In an early
perceived threatening stimulus, and is a common
epidemiological study, fear of blood and injury was
feature of early development. Developmental fears,
found to be present in approximately one-third of
including fear of the dark, strangers, and loud
children 6 to 12 years old (Lapouse & Monk, 1959).
noises, are typically transitory and usually resolve
However, epidemiological studies on blood-
in childhood (Mineka & Öhman, 2002). In some
injection-injury phobia have been hampered by a
cases however, intense fear of certain situations or
lack of precise definition for the disorder. The most
objects may continue throughout adolescence and
recent prevalence rate based on the DSM-IV criteria
remain problematic into adulthood. When fear
for blood-injection-injury phobia indicates that this
becomes excessive beyond that which is justified by
disorder is present in approximately 3% in the adult
external threat and markedly interferes with the
population (Bienvenu & Eaton, 1998).
individual’s ability to function optimally, these

This commentary provides a critical overview
fears may then meet criteria for an anxiety spectrum
of proposed pathways for fear acquisition, with
disorder such as Specific Phobia in the Diagnostic
particular emphasis on the etiology of needle
and Statistical Manual of Mental Disorders (DSM-
phobia. The pathways of fear acquisition will be
IV, 2000; see also Barlow & Durand, 2005). Needle
considered within two broad frameworks: (1) the
phobia is categorized under Specific Phobia blood-
environmental learning pathways (e.g. direct
injection-injury subtype in DSM-IV, a cluster of
conditioning, vicarious learning, and negative
phobias that also includes fear of blood, injury, or
information), and (2) the non-associative pathways
any invasive medical procedure. Blood-injection-
(e.g. biological preparedness, genetic mechanisms).
injury phobia has been linked to serious
The literature has been drawn from work in both
consequences including refusal of insulin injections
pediatric and adult samples because studies
for diabetes, and avoidance of life-saving surgery
focusing principally on needle fear in children are
for cancer (Marks, 1988).
limited. Therefore, etiological inferences had to be
Epidemiological
studies have reported that
drawn from studies on general fear and other
identifiable needle phobia has a median age of onset
specific fear (e.g. fear of spiders) in children and
at 5.5 years (Bienvenu & Eaton, 1998) and remains
adults.
quite common in adulthood (Nir et al., 2003). For
Environmental learning pathways
instance, in a sample of young adult travellers
attending a vaccination clinic, 21.7% reported that

Rachman (1977) proposed that fears are
they were afraid of injections and 8.2% described
learned through one or a combination of the

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following learning pathways: (1) direct conditioning,
literature is that infants actively search for
(2) vicarious learning, and (3) negative
emotional information from their caregiver and use
information/instruction.
this to appraise an uncertain situation; this search is
known as social referencing (see Feinman et al.,

1. Direct conditioning. According to early
1992). Social referencing is thought to be the basis
conditioning models of fear acquisition, a single
for vicarious learning of fear, and therefore,
exposure to cues associated with an intensely
potentially contributes to the development of
aversive event can cause a person to remain fearful
specific phobias and related anxieties (de Rosnay et
of those cues. Specifically, the pairing of a
al., 2006).
conditioned stimulus (CS; e.g. needle) with an

Recently, Askew and Field (2007) provided
aversive unconditioned stimulus (US; e.g. tactile
prospective and experimental evidence supporting
pain) establishes an association between the CS and
the role of vicarious learning in the development of
US. Therefore, the individual exhibits ‘conditioned
childhood fears. In their study, children aged 7 to 9
fear’ to the needle because he/she has learned to
years were shown pictures of novel animals paired
expect tactile pain (US) following needle
with faces depicting scared, happy or neutral facial
presentation (CS). Mowrer’s (1960) two-factor
expressions. The perceived threat was self-reported
theory of phobia development further suggests that
to increase for novel animals they had seen paired
excessive fear is the result of a direct conditioning
with pictures of scared faces. These changes
experience and its maintenance by avoidant
persisted after 1 week when measured explicitly and
behavior.
after 3 months when measured indirectly.

There is some support for the classical
Maternal
modeling
of pain behavior in
conditioning theory. In a sample of 7- to 18-year-
response to a cold pressor stimulus has also been
olds, 63% recalled having experienced a very
found to affect pain behavior in children (Goodman
unpleasant and painful injection (Duff & Brownlee,
& McGrath, 2003). In that study, mothers were
1999). Of these children, 46% rated themselves as
instructed to display either exaggerated or minimal
having “very” or “extremely” high levels of
pain responses to a cold pressor task. Toddlers
subsequent fear. A limitation of this pathway noted
exhibited more facial pain responses in the cold
by several investigators is that many adults with
pressor task after they had seen their mothers
intense fears or phobias cannot recall a specific
display exaggerated negative pain behaviors
learning incident (McNally & Steketee, 1985;
(Goodman & McGrath, 2003). Moreover, parental
Menzies & Clarke, 1995). Furthermore, many
anxiety is positively correlated with child distress
individuals exposed to traumatic experiences do not
during venipuncture (Wolfram & Turner, 1996),
develop anxiety disorders (Poulton & Menzies,
and parental use of distraction has been shown to be
2002; see however, Mineka & Öhman, 2002). Thus,
beneficial in alleviating child distress (Bauchner et
direct conditioning alone does not sufficiently
al., 1994).Taken together, the literature suggests
explain the development of all phobias, including
that vicarious learning of fear from caregivers
excessive fear of needles. Although the classical
potentially contributes to the development of needle
conditioning theory for phobias remains
fear.
controversial, it is worth noting that the most
effective clinical intervention (i.e. exposure therapy)

3. Negative information provision. Negative
in the treatment of specific phobias is based on
information about a stimulus may also explain the
conditioning principles (Barlow & Durand, 2005;
development and exacerbation of feared situations
Tryon, 2005).
and objects that have not been personally
experienced (Field et al., 2001). Negative

2. Vicarious learning. Another pathway for
information may increase beliefs about the danger
childhood fear development is through vicarious
posed by a particular stimulus. If a subsequent
learning. Learned fear may occur by observing the
interaction with the stimulus is encountered, this is
fear responses of others without experiencing direct
likely to produce a fear reaction (Davey, 1992;
conditioning. A well-established finding in the

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Muris et al., 2003). Information-induced fear may
involvement of “multiple genes of small effect size”
result in avoidance of the particular stimulus or
(Gregory & Eley, 2007, p. 209).
situation, thus reducing the chance of correcting
Conclusion
erroneous expectations. For example, Field &
Lawson (2003) demonstrated that children are more
Environmental, biological and genetic
reluctant to approach an animal associated with
pathways have been suggested to account for the
negative information, which reduces their chance to
manifestation of needle phobia in children.
prove to themselves that this animal is in fact, non-
Researchers have typically focused exclusively
threatening. Similarly, negative expectations
either on one or a few associative learning pathways
regarding an injection can lead to short term
of fear acquisition, or on biological or genetic
avoidance of the injection experience, and facilitate
factors. Given that these pathways suggested for
persisting resistance.
needle phobia are unlikely to operate independently,
researchers need to expand their focus and consider
Non-associative accounts: biological
the possible interactions between genetic and
preparedness and genetics
acquired influences. Moreover, prospective studies

1. Biological preparedness. There are certain
are needed to determine the unique contribution of
fears that are thought to be innate, such as the fear
these pathways in the developmental trajectory of
of heights, strangers, and loud noises (Poulton &
needle phobia. Studying fear acquisition at an
Menzies, 2002). Although fear responses to these
earlier age, particularly in childhood and
stimuli may have some evolutionary advantages
adolescence, would provide a better understanding
such as avoiding dangerous situations or objects,
of the onset of needle fears, and facilitate the
they are usually outgrown as individuals mature and
development of targeted early interventions. Given
develop more adaptive responses (Mineka &
the prevalence of blood-injection-injury phobia in
Öhman, 2002). Similarly, fear of pain and injury is
adults and children, it is clear that the genesis,
universal and protective, promoting responses that
development, and effective intervention for needle
enable an individual to avoid threats and dangers
phobia merit further constructive research.
(Poulton & Menzies, 2002). Therefore, one


possibility is that needle fear may be a hard-wired
Siyao Du
fear response (Bracha et al., 2005).
Medical student, University of New South Wales,

2. Genetic factors. Twin studies have found
and Pain Medicine Unit, Sydney Children’s
that the fear response of one twin could be predicted
Hospital, Australia
by a co-twin’s fear response (Rose & Ditto, 1983;

Stevenson et al., 1992). The intensity of fears has
Tiina Jaaniste, MPsychol
also been found to be more similar in monozygotic
Senior Research Officer/Clinical Psychologist, Pain
than dizygotic twins (Stevenson et al., 1992).
Medicine Unit, Sydney Children’s Hospital,
Moreover, a strong parent-child correlation has
Australia
been noted in fainting reactions to stimuli

associated with blood-injection-injury phobias
G. David Champion, MB BS, MD
(Kleinknecht & Lenz, 1989). This is possibly
Director of Paediatric Pain Research, Sydney
related to genetic traits in blood-injury phobics who
Children’s Hospital, Australia
display high levels of disgust-sensitivity (Manassis

et al., 2004). Despite studies indicating a genetic
Carol S.L. Yap, PhD
component in the experience of fears, progress in
Senior Research Officer, Pain Medicine Unit,
this field has been modest, largely due to the
Sydney Children’s Hospital, Australia
email: cyap@psy.unsw.edu.au



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