Discussion: Issues with Young Children

J Psychopathol Behav Assess (2007) 29:47–54 DOI 10.1007/s10862-006-9021-1

ORIGINAL PAPER

Psychopathology of Adolescent Social Phobia Deborah C. Beidel · Samuel M. Turner · Brennan J. Young · Robert T. Ammerman · Floyd R. Sallee · Lori Crosby

Published online: 1 July 2006 C© Springer Science+Business Media, Inc. 2006

Abstract Sixty-three adolescents with social phobia and 43 with no psychiatric disorders were compared across a number of clinical variables. In addition to clinically impair- ing social fear, adolescents with social phobia had signifi- cantly higher levels of loneliness, dysphoria, general emo- tional over-responsiveness and more internalizing behaviors than normal controls and 57.1% of socially phobic adoles- cents had a second, concurrent diagnosis, 75% of which were other anxiety disorders. In addition, adolescents with social phobia were significantly less socially skilled. Though sim- ilar in some respects to childhood social phobia, adolescent social phobia has a unique clinical presentation. The impor- tance of developmental differences on the development of age-appropriate interventions is discussed.

D. C. Beidel · S. M. Turner · B. J. Young Maryland Center for Anxiety Disorders, Department of Psychology, University of Maryland, College Park, MD, USA

R. T. Ammerman Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA

F. R. Sallee Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA

L. Crosby Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA

D. C. Beidel (�) Penn State College of Medicine, Department of Psychiatry, H073, 500 University Drive, Hershey, PA, 17033-0850, USA e-mail: dbeidel@psu.edu

Keywords Social phobia . Comorbidity . Functional impairment . Adolescent

Social phobia, characterized by “a marked and persistent fear of one or more social situations in which the person is exposed to unfamiliar people or to possible scrutiny by oth- ers” (American Psychiatric Association [APA], 1994), has been relatively well-studied in both adults (e.g., Liebowitz, Gorman, Fyer, & Klein, 1985; Turk, Heimberg, & Hope, 2001; Turner & Beidel, 1989) and children (e.g., Beidel, Turner, & Morris, 1999; Velting & Albano, 2001). Social phobia in adolescents, however, has received considerably less attention and most studies actually report data from mixed samples of children and adolescents (e.g., Francis, Last, & Strauss, 1992; Spence, Donovan, & Brechman- Toussaint, 1999; Strauss & Last, 1993) or adolescents and adults (e.g., Wittchen, Stein, & Kessler, 1999). Rarely has the psychopathology of this group been examined separately.

Prevalence rates for adolescent social phobia range from 5 to 16% of the general population (Essau, Conradt, & Peterman, 1999; Hayward, Killen, Kraemer, & Taylor, 1998; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Wittchen et al., 1999), and several studies have begun to describe its presentation. Adolescents with social phobia typically fear formal and informal social interactions, pub- lic observation and performance, and situations requiring assertive behavior (Hofmann et al., 1999; Wittchen et al., 1999). Among mixed samples of children and adolescents, depression, social isolation, and fear of failure and criticism are elevated (Francis et al., 1992; Strauss & Last, 1993). In addition, social phobic adolescents are at risk for aca- demic impairment (Wittchen et al., 1999) and substance abuse (Clark et al., 1995; DeWit, MacDonald, & Offord, 1999).

Springer

48 J Psychopathol Behav Assess (2007) 29:47–54

There are conflicting reports regarding the presence and type of comorbid disorders in youth with social phobia (Ollendick & King, 1998). Using DSM-III-R criteria, over- anxious disorder was the most common comorbid condition among mixed samples of children and adolescents with pri- mary social phobia (Francis et al., 1992; Last, Perrin, Hersen, & Kazdin, 1992; Strauss & Last, 1993). Among a small sam- ple of 17 German adolescents, the most common comorbid condition was somatoform disorder, followed equally by ma- jor depression, agoraphobia, and alcohol abuse (Essau et al., 1999). Consistent with the adult literature (e.g. Regier, Rae, Narrow, Kalber, & Schatzberg, 1998), several studies sug- gest that adolescents with social phobia are at increased risk for a major depressive disorder (Essau et al., 1999; Last et al., 1992). However, one large epidemiological sample of 2,242 high school students did not find higher rates of major depression among adolescents with social phobia (Hayward et al., 1998). Thus, the relationship between social phobia and depression, as well as the presence of other disorders, requires further elucidation.

Whereas socially phobic children have impaired social skills (Beidel et al., 1999; Spence et al., 1999), skill deficits in adolescents with social phobia have yet to be documented. Developmentally, as peers increasingly become the focus of an adolescent’s attention, social anxiety may play an impor- tant role in the ability to join peer groups or establish and maintain friendships. Excessive social anxiety may inter- fere with the normal process of peer socialization (Ballenger et al., 1998; Inderbitzen, Walters, & Bukowski, 1997) as well as play a mediational role in decreased social support and social functioning, especially among girls (Inderbitzen et al., 1997; La Greca & Lopez, 1998; Vernberg, Abwender, Ewell, & Beery, 1992). Despite their hypothesized presence, the is- sue of social skill deficits among diagnosed social phobic adolescents remains largely unknown.

In summary, studies examining social phobia in adoles- cents are scarce, and often data are based on very small sam- ples or those that combine pre-adolescents and adolescents, making it difficult to draw conclusions specific to adolescents (Kashdan & Herbert, 2001). Additionally, to date, no study has addressed the impact of social phobia on adolescent so- cial and emotional functioning. Understanding its clinical presentation is necessary for the development of more effec- tive intervention strategies. The current study had two goals. The study was designed to (a) elucidate the clinical presen- tation of DSM-IV social phobia in adolescents by examining patterns of fear and avoidance and the presence of comor- bid disorders and (b) determine the impact of social phobia on aspects of social and emotional functioning by compar- ison to adolescents without psychiatric disorders. Although previous investigations have examined these factors in pre- adolescent children and adults (Beidel et al., 1999; Turner &

Beidel, 1989), to date, no data exist solely for an adolescent population.

Method

Participants

The sample consisted of 63 adolescents meeting DSM-IV diagnostic criteria for social phobia. Participants responded to media advertising for free treatment for “shy” adolescents and were recruited from two metropolitan areas in the East- ern and Midwestern United States. One hundred and fifty individuals responded to the media advertisements. Of that number, fifty chose not to participate once the treatment study was explained and an additional 37 of those screened by telephone were determined not to have social phobia as a primary diagnosis (i.e., these adolescents had comorbid di- agnoses of conduct disorder, oppositional disorder, attention deficit-hyperactivity disorder or significant depression and the primary diagnosis was unclear). The adolescents in this study ranged in age from 13 to 16 years (M = 14.30 years; SD = 1.07 years), and there were 30 boys (47.6%) and 33 girls (52.4%). Forty-three were Caucasian (68.3%), 16 were African American (25.4%), one was Asian American (1.6%), and one was Hispanic (1.6%). Ninety-one percent came from families classified in the middle three socioeco- nomic categories, as identified by the Hollingshead Index of Social Position (Hollingshead, 1957).

The normal control sample consisted of 43 adolescents, recruited from media advertisements for “friendly” peers to participate in a study with shy children. An examina- tion of the scores of this group on the inventories included in this investigation indicated that these children were best considered “typical” adolescents and did not represent a “super normal” group (i.e., their scores fell within 1 stan- dard deviation of the mean for normative samples, not in the extreme tail of the distribution). Normal control peers ranged in age from 13 to 16 years (M = 14.49 years; SD = 1.14 years), and there were 18 boys (41.9%) and 25 girls (58.1%). Twenty-one adolescents were African American (48.8%), 17 were Caucasian (39.5%), and one was Hispanic (2.3%). Only one demographic variable was found to differ significantly between the social phobic and control groups; there were significantly more African Amer- ican adolescents among the control group than the so- cial phobic group (X2 (1, N = 59) = 9.161, p < .005). None of the control group met criteria for any Axis I or II disorders based on an initial telephone screen and the follow- up diagnostic interview described below.

The study was approved by the Institutional Review Boards at the University of Maryland-College Park and

Springer

J Psychopathol Behav Assess (2007) 29:47–54 49

Cincinnati Children’s Hospital Medical Center. All parents signed consent forms and adolescents signed assent forms.

Assessment

The assessment described below constituted the pretreat- ment assessment battery developed for the treatment pro- tocol. Adolescents were informed that this assessment was part of the intake process. Normal control participants were told that they were participating in a protocol designed to ex- amine the differences between adolescents with or without social fears.

Semistructured interview

Both social phobic and normal control adolescents and their parents were assessed for the presence of DSM-IV Axis I disorders by a Ph.D.-level clinician, using the Child/Parent version of the Anxiety Disorders Interview Schedule (ADIS- C/P; Silverman & Albano, 1996). The ADIS-C/P is a semistructured interview that includes an 8-point clinician rating (CSR) that quantifies the severity of assigned diag- noses. The clinician interviewed the parent first, then the ado- lescent. Using the information obtained from both sources, the clinician arrived at a final, composite diagnosis. In addi- tion, overall social functioning was rated using the Chil- dren’s Global Assessment Scale (K-GAS; Shaffer et al., 1983). In order to calculate inter-rater reliability, twenty- five percent of the diagnostic interviews of both groups were randomly selected and videotaped by a second rater unaware of the initial diagnosis. Using the kappa coefficient, inter- rater agreement for the diagnosis of social phobia was κ = .79. There were three cases of disagreement, and in those instances, the final diagnosis was determined by the first author based on a review of all assessment data. Other diag- noses were assigned too infrequently for kappa coefficients to be calculated. Inter-rater reliability (Pearson’s correlation coefficient) was r = .84 for the CSR and r = .80 for the K-GAS.

Self-report inventories

Adolescents completed four self-report inventories. The Children’s Depression Inventory (CDI; Kovacs, 1992) is a 27-item assessment of depressive symptomatology. Partic- ipants also completed the 24-item Loneliness Scale (LS; Asher & Wheeler, 1985), which assesses for feelings of so- cial isolation, and the Eysenck Personality Questionnaire- Junior (EPQJ; Eysenck & Eysenck, 1975), an assessment of introversion and neuroticism. Finally, adolescents’ social anxiety across a broad range of situations was assessed using the Social Phobia Anxiety Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1995).

Parent-report inventory

One parent (primarily the mother) completed the Child Be- havior Checklist (CBCL; Achenbach, 1991). The Internaliz- ing and Externalizing subscales were used in this study.

Behavioral assessment

Adolescents’ social skill and anxiety were assessed through participation in two behavioral tasks: role play and read aloud. In each of five role play scenes, participants responded to statements or questions posed by same-aged peers trained to give friendly but neutral (i.e., non-leading) responses. The scene content included starting a conversation with an un- familiar peer, offering to help another peer, giving a com- pliment, receiving a compliment, and responding assertively to a peer’s inappropriate behavior. During the read aloud task, the adolescent read aloud “The Ransom of Red Chief” to an audience comprised of an adult and same-aged peer. Participants’ responses were videotaped and coded for so- cial anxiety and skill on a 4-point Likert scale by raters who were blind to diagnostic status and purpose of the study. Anxiety ratings ranged from 1 = “not at all anxious” to 4 = “severely anxious.” Social skill ratings ranged from 1 = “not effective at all” to 4 = “effective.” Twenty-five percent of all assessments were rated independently by a sec- ond rater, also blind to diagnostic status. Interrater reliability (Pearson’s r) for anxiety during the role play scenarios was r = .87 and during the read aloud task was r = .81. Inter- rater reliability for social skill during the role play scenarios was r = .89 and r = .90 for reading aloud.

Results

Descriptive pathology of adolescents with social phobia

Ratings of fear and avoidance in social situations

With respect to the study’s first aim, ratings of fear and avoid- ance across social and performance situations were exam- ined. Table 1 depicts the percentage of the adolescent sample who indicated at least moderate fear (a rating of 4 or higher on a scale of 1–8) for each ADIS-C/P situation. Interestingly, 6 of the 8 most-feared situations involved unstructured so- cial interactions describing general conversation skills (e.g., “starting or joining a conversation,” or “inviting a friend to get together”). The least frequently feared situation, still endorsed by over half of the sample was “dating” (54.0%).

When encountering feared situations, adolescents, like children and adults, endorse the use of avoidance strategies to decrease or eliminate their distress. Table 1 also depicts

Springer

50 J Psychopathol Behav Assess (2007) 29:47–54

Table 1 Fear and avoidance of social situations by adolescents with social phobia

Endorsing situation % Endorsing at least moderate distress

% Avoidance

Oral reports or reading aloud 90.5 65.1 Attending dances, parties, or

activity nights 90.5 65.1

Asking the teacher a question or asking for help

87.3 69.8

Starting or joining in on a conversation

87.3 73.0

Musical or athletic performances

87.3 52.4

Speaking to adults 85.7 68.3 Speaking to new or unfamiliar

people 85.7 63.5

Inviting a friend to get together 81.0 57.1 Refusing an unreasonable

request 77.8 51.0

Taking tests 76.2 22.2 Writing on the chalkboard 76.2 49.2 Gym class 76.2 28.6 Walking in the hallway or

standing at a locker 76.2 41.3

Asking someone else to change his/her behavior

76.2 54.0

Answering questions in class 74.6 58.7 Working or playing with a

group 74.6 41.3

Using school or public bathrooms

74.6 22.2

Meetings, such as boy or girl scouts

74.6 42.9

Answering or talking on the telephone

74.6 34.9

Having a picture taken 71.4 20.6 Eating in front of others 68.3 25.4 Dating 54.0 31.7

the percentage of socially phobic adolescents who reported at least some avoidance of social situations. The nine most- feared situations were avoided by over 50% of the adoles- cents. The least-avoided situation (“having a picture taken”) was avoided by 20% of the social phobic adolescents.

Social phobic adolescents also reported substantial im- pairment due to their social fears and avoidance. Forty-eight (76.2%) reported having fewer friends than most other teens, and 20 (31.7%) were not involved in any extra-curricular ac- tivities. Seven adolescents (11.1%) refused to attend school on a regular basis, a number surprisingly high for this age group.

Social phobia subtypes and comorbid diagnoses

Based on this broad pattern of fear and avoidance, it is not surprising that only five adolescents (8% of the social pho-

Table 2 Comorbid diagnoses in social phobic adolescents

Secondary diagnosis %

None 42.9 Generalized anxiety disorder 31.7 Specific phobia 6.3 Attention-deficit/hyperactivity disorder 4.8 Major depression 4.8 Adjustment disorder with depressed mood 1.6 Dysthymic disorder 1.6 Obsessive-compulsive disorder 1.6 Oppositional-defiant disorder 1.6 Separation anxiety disorder 1.6 Selective mutism 1.6

bic sample) met criteria for the nongeneralized subtype. In other words, 92% of the social phobic sample met criteria for the generalized subtype. Thirty-six (57.1%) had a sec- ondary Axis I diagnosis (see Table 2). Among those with a comorbid disorder, 27 (75.0%) had a second anxiety disor- der, the majority of whom (74.1%) had generalized anxiety disorder. Four children were diagnosed with specific pho- bia (11.1%) and one each had obsessive-compulsive disor- der (2.8%), separation anxiety disorder (2.8%), and selec- tive mutism (2.8%). Mood disorders were diagnosed in 11% of this sample. Because the normal control sample was re- cruited specifically for that purpose, none of the children in that group met criteria for any Axis I disorder.

Social and emotional functioning of adolescents with social phobia

Self-report measures

The second aim of the study was to compare the social and emotional functioning of adolescents with social phobia to those with no disorder. Inter-item consistency (Cronbach’s alpha) was calculated for each of the self-report measures used in the investigation. Coefficients were as follows: SPAI- C á = .97; CDI á = .87; LS á = .86; EPQ-J Neuroticism á = .89; EPQ-J Extraversion á = .84.

To control for the experiment-wise-error rate, data were initially analyzed using Hotelling’s t2. The results indicated a significant between group effect (t(df = 15,54) = 30.36, p < .001). Therefore, follow-up between-group compar- isons were conducted using independent samples t-tests (see Table 3). Adolescents with social phobia reported sig- nificantly higher levels of social anxiety on the SPAI-C (p < .001) and higher levels of social isolation on the Lone- liness Scale (p < .001). For adolescents with social phobia, scores on both of these measures were in the clinical range when compared to published norms. Adolescents with social phobia also reported significantly more symptoms of depres- sion based upon the CDI (p < .001) and their mean score

Springer

J Psychopathol Behav Assess (2007) 29:47–54 51

Table 3 Scores of adolescents with social phobia or no disorder on measures of psychopathology

Measure Social phobia (n = 63)

Normal controls (n = 43)

Partial η2

Mean SD Mean SD

CDI 11.92 7.70 4.15 4.07∗∗ .258 EPQ-J: extraversion 11.60 5.10 19.88 2.68∗∗ .478 EPQ-J: neuroticism 10.05 5.21 5.43 3.39∗∗ .200 Loneliness scale 41.40 12.14 23.78 5.63∗∗ .426 SPAI-C 26.18 11.70 6.81 5.66∗∗ .497 Role play anxietya 2.59 1.14 1.68 0.77∗∗ .168 Read aloud anxietya 2.72 1.29 2.03 0.97∗∗ .080 CBCL: internalizing 66.40 8.62 48.36 11.62∗∗ .438 CBCL: externalizing 49.43 9.42 49.04 10.05 .000 KGAS 5.61 0.73 8.70 0.46∗∗ .853 Role play anxietya 2.40 0.85 2.02 0.86∗ .049 Role play effectivenessb

2.43 0.95 2.84 0.84∗ .051

Read aloud anxietya 2.02 0.68 1.58 0.71∗∗ .094 Read aloud effectivenessb

2.69 0.81 3.23 0.80∗∗ .101

Role play speech latencyc

2.36 2.35 0.99 0.82∗∗ .124

aLower scores indicate less anxiety. bLower scores indicate less skill. cMean scores are indicated in seconds. ∗p < .05. ∗∗p < .01.

was at the 50th percentile based on published norms. There- fore, although higher than the normal control group, not all of the adolescents scored in the clinically significant range for depression. Finally, social phobic adolescents scored sig- nificantly higher on the EPQ-J neuroticism scale (p < .001) but significantly lower on the extraversion scale (p < .001). Mean scores for adolescents with social phobia were in the clinically significant range according to published norms.

Parents of adolescents with social phobia endorsed sig- nificantly more internalizing behaviors on the CBCL than did the parents of normal control adolescents (p < .001; see Table 3). There was no group difference on the CBCL externalizing subscale scores.

Group differences on self- and parent-reports were cor- roborated by clinicians, who rated social phobic adolescents as significantly more impaired in their overall functioning than normal controls based on K-GAS scores (p < .001). In fact, the overall K-GAS score of 5.61 for adolescents with social phobia indicates that the disorder exerted substantial interference with every day functioning.

Behavioral assessment of social and performance skill

Independent observers blind to group status rated social pho- bic adolescents as significantly more anxious (p < .01) and

significantly less effective in their presentation (p < .01) than normal control adolescents during the read-aloud task. Likewise, social phobic adolescents were significantly more anxious (p < .05) and significantly less skilled during the role play interactions (p < .05). Additionally, social phobic adolescents had significantly longer speech latencies during the role play task (p < .01). Consistently, social phobic ado- lescents rated themselves as more anxious during both the role play scenes (p < .001) and the read aloud performance task (p < .01).

Effects of gender and race

A 2 (race; Caucasian vs. African American) × 2 (gender) multivariate analysis of variance (MANOVA) examining all of the above variables did not reveal significant main effects for gender or race or a significant interaction for race x gender interaction.

Discussion

This study examines the psychopathology of adolescent so- cial phobia using a sample composed entirely of adolescents and including a comparison to adolescents with no disorder. The results indicate that adolescents with social phobia ex- hibit significant psychopathology across various domains of functioning. They not only experience significantly greater social distress, but also higher levels of dysphoria and depres- sion, loneliness, neuroticism and introversion, in comparison to adolescents without disorders. They also exhibit signifi- cant patterns of social avoidance, poor social skills and a range of comorbid conditions.

When compared to published results for pre-adolescents with social phobia, there appears to be a more pervasive pat- tern of fear and avoidance and higher social distress (Beidel et al., 1999; Spence et al., 1999). For example, using the same diagnostic interview, only 35% of potentiallly distress- ing social situations were endorsed as at least moderately distressing by at least 50% of preadolescent children (Beidel et al., 1999). However, in this study, 100% of the situations were endorsed as at least moderately distressing by at least 50% of the adolescent sample. Similarly, there is a substan- tial percentage of adolescents who avoid social encounters. Because this study did not include a pre-adolescent group, the comparison should be interpreted cautiously. However, it appears that despite their identical diagnoses, adolescents experience a much more pervasive pattern of distress and avoidance than younger children.

The available figures for the percentage of adolescents with social phobia who met generalized subtype are vari- able; 33–45.5% of those in epidemiological samples met the generalized criteria (Hofmann et al., 1999; Wittchen et al.,

Springer

52 J Psychopathol Behav Assess (2007) 29:47–54

1999), whereas in this investigation, 92% met criteria for the generalized subtype. One obvious reason for these disparate rates is the different populations from which the samples were drawn (community vs. clinical). Additionally, in one investigation (Wittchen et al., 1999), test anxiety was in- cluded as a social phobia, a situation inconsistent with the current DSM-IV criteria. A large number of adolescents in that study endorsed only testing fears and therefore were clas- sified as non-generalized social phobics. Eliminating those adolescents from the sample would undoubtedly change the percentage of those with the generalized subtype. Addition- ally, it is important to note that clinically, many individuals seeking treatment often present with only one specific com- plaint, yet a thorough diagnostic interview reveals a more pervasive pattern of distress (e.g., Beidel & Turner, 1998). Thus, it is likely that among a clinic sample, the percent- age of adolescents with the generalized subtype is higher than that found for epidemiological samples, perhaps reflect- ing the more severe impairment seen in a treatment-seeking sample.

Interestingly, the percentage of adolescents with social phobia who had a comorbid diagnosis (57%) is very similar to that found for other adolescent samples (Clark et al., 1995; DeWit, MacDonald, & Offord, 1999; Essau et al., 1999). The pattern of comorbidity was somewhat different, how- ever. In contrast to other investigations (Clark et al., 1995; DeWit et al., 1999), fewer externalizing disorders were found among this clinic sample. Similarly, externalizing symptoms were not significantly higher among those with social pho- bia when compared to children with no psychiatric disorder based on CBCL scores. These differences may have been due to sampling and/or recruitment strategies.

GAD was the most common secondary (comorbid) dis- order in this sample and the rate (31.7%) was similar to the rate found for adults (e.g., Turner, Beidel, Borden, Stanley, & Jacob, 1991). Generalized anxiety disorder (GAD) is de- fined as excessive worry and anxious apprehension about a number of events or activities and the worry is difficult to control. Worry requires the ability to consider the future, a cognitive skill that may not necessarily be developed in all preadolescent children (see Alfano, Beidel, & Turner, 2002 for a discussion of this issue). Thus, GAD as a comorbid disorder in those with social phobia may emerge in concert with cognitive maturity.

On the other hand, selective mutism (SM) was much less common among adolescents (1.6%) than the rate reported for younger children (8%, Beidel et al., 1999). As noted (Beidel & Turner, 1998; Yeganeh, Beidel, Turner, Pina, & Silverman, 2004), SM may be conceptualized as an avoid- ance strategy used by children and adolescents with social phobia to deal with their high levels of distress. As children mature, they may find different ways to deal with stress. Be- havioral avoidance strategies also evolve and become more

subtle with increasing age. For example, among children undergoing stressful medical procedures, overt fear behav- iors (crying, screaming, expressing verbal anxiety, needing physical restraint) were more common among younger chil- dren. Adolescents were more likely to use subtle expressions of distress such as groaning, flinching, and muscle tension (Katz, Kellerman, & Sigel, 1980; LeBaron & Zeltzer, 1984). Although the youth in that investigation did not necessarily have an anxiety disorder, the data do suggest the emergence of different patterns of anxious behaviors in preadolescent and adolescent children. Data from this investigation suggest that behavioral avoidance, in the form of selective mutism, may be replaced by different behavioral strategies consis- tent with the adolescents’ more sophisticated physical and cognitive maturity.

There were no differences in clinical presentation based on gender or race (Caucasian vs. African American adoles- cents). Thus, consistent with previous investigations (Beidel et al., 1999; Spence et al., 1999), the clinical presentation of adolescent social phobia is consistent across these demo- graphic variables, although further investigations including adolescents from other racial and ethnic groups are needed.

As is consistent with the extant child and adult literature, adolescents with social phobia exhibit substantial social skill deficits when compared to age-matched peers with no psy- chiatric disorder. These deficits were evident to individuals blind to diagnostic group and existed in both one-on-one social interactions and a read-aloud task. In addition to rat- ings of high anxiety and low skill, adolescents with social phobia also had longer speech latencies. Delayed speech in response to comments from others is characteristic of be- haviorally inhibited children (Kagan, Reznick, & Snidman, 1987), a temperamental style evident at a very early age. The current study does not make a determination of whether these speech latencies preceded the development of social phobia, but several recent investigations have reported that childhood behavioral inhibition is associated with adolescent general- ized social anxiety (Schwartz, Snidman, & Kagan, 1999) and adolescent social phobia (Hayward et al., 1998). Higher rates of behavioral inhibition were not related to more spe- cific fears, separation anxiety disorder, or performance anxi- ety (Schwartz et al., 1999), suggesting some predispositional specificity of behavioral inhibition for social phobia.

This investigation is not without limitations. This is one of the largest reported clinical samples for a study of the psychopathology of adolescents with social phobia. How- ever, this was a treatment-seeking sample and thus might not be representative of all adolescents with this disorder. Sec- ond, although the associated treatment protocol allowed for a wide-range of comorbid diagnoses, children with behav- iors suggesting the existence of comorbid conduct disorder, oppositional disorder, primary attention deficit-hyperactivity disorder or significant depression were screened out during

Springer

J Psychopathol Behav Assess (2007) 29:47–54 53

an initial telephone interview. Thus, comorbidity rates for those disorders may be an underestimate of those found in the general population. Third, the sample of African-American adolescents with social phobia is low and children repre- senting other racial or ethnic minority groups were virtually non-existent. Thus, conclusions regarding clinical presenta- tions in non-Caucasian groups require further investigation. Finally, there may be some concern that the study design did not include a psychiatric control group. However, the purpose of this study was to determine the impact of adoles- cent social phobia upon social and emotional functioning, a subject that heretofore has not been adequately addressed. There is no attempt to draw any unique conclusions about the impact of social phobia upon adolescent behavior or to state that social phobia is the only precipitant of impaired adolescent functioning. In short, the study design is appro- priate for the purpose of the investigation: to investigate the psychopathology of adolescent social phobia.

Despite these limitations, this is the first investigation specifically to (a) examine the psychopathology of adoles- cent social phobia using a broad-based assessment strategy, (b) include a comparison to a normal control group, and (c) include a behavioral assessment. This latter component ap- pears particularly important inasmuch as it revealed deficits in the area of social skill, deficits that would be less eas- ily identified based solely on self-report of emotional state. The identification of these deficits has implications for the comprehensive treatment of this disorder. Specifically, inter- ventions that focus solely on decreasing social anxiety may not address these skill deficits. Without increasing social skills, attempts to decrease social anxiety ultimately might be ineffective inasmuch as adolescents still will not “know what to say” (i.e., they will not possess the skills neces- sary for effective social interaction). Such multi-component interventions, combining social skills training and anxiety reduction procedures (e.g., Beidel, Turner, & Morris, 2000; Spence, Donovan, & Brechman-Touissant, 2000) have been demonstrated to be efficacious for children and adolescents up to age 14. Currently, a randomized controlled trial exam- ining the utility of one such multi-component intervention for adolescents ages 13–17 is underway (Beidel, Turner, Sallee, & Ammerman, 2004).

Acknowledgement This research report was supported by funding from NIMH grant #MH60332 to the first, second, and fourth author.

References

Achenbach, T. (1991). Manual for the Child Behavioral Checklists/4– 18 and 1991 Profile. Burlington: University of Vermont.

Alfano, C., Beidel, D. C., & Turner, S. M. (2002). Considering cognition in childhood anxiety disorders: Conceptual, methodological and

developmental considerations. Clinical Psychology Review, 22, 1209–1238.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, (4th ed.) (DSM-IV). Washington, DC: American Psychiatric Association.

Asher, S., & Wheeler, V. (1985). Children’s loneliness: A comparison of rejected and neglected peer status. Journal of Consulting and Clinical Psychology, 53, 500–505.

Ballenger, J. C., Davidson, J., Lecrubrier, Y., Nutt, D., Bobes, J., Beidel, D. C., Ono, Y., & Westenberg, H. (1998). Consensus statement on social anxiety disorder from the international consensus group on depression and anxiety. Journal of Clinical Psychiatry, 59, 54– 60.

Beidel, D. C., & Turner, S. M. (1998). Shy children, phobic adults: The nature and treatment of social phobia. Washington, DC: American Psychological Association Books.

Beidel, D. C., Turner, S. M., & Morris, T. L. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 73–79.

Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology of childhood social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 643–650.

Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treat- ment of childhood social phobia. Journal of Consulting and Clin- ical Psychology, 68, 1072–1080.

Beidel, D. C., Turner, S. M., Sallee, F. R., & Ammerman, R. T. (2004). Treatment of childhood social phobia. Unpublished manuscript, University of Maryland.

Clark, D. B., Bukstein, O., Smith, M., Kaczynski, N., Mezzich, J. A., & Donovan, J. (1995). Identifying anxiety disorders in adoles- cents hospitalized for alcohol abuse or dependence. Psychiatric Services, 46, 618–620.

DeWit, D., MacDonald, K., & Offord, D. (1999). Childhood stress and symptoms of drug dependence in adolescence and early adulthood: Social phobia as a mediator. American Journal of Orthopsychiatry, 69, 61–72.

Essau, C., Conradt, J., & Petermann, F. (1999). Frequency and comor- bidity of social phobia and social fears in adolescents. Behaviour Research and Therapy, 37, 831–843.

Eysenck, H. J., & Eysenck, S. (1975). Eysenck Personality Question- naire (Junior & Adult) Manual. San Diego, CA: Educational and Industrial Testing Service.

Francis, G., Last, C. G., & Strauss, C. C. (1992). Avoidant disorder and social phobia in children and adolescents. Journal of the Amer- ican Academy of Child and Adolescent Psychiatry, 31, 1086– 1089.

Hayward, C., Killen, J., Kraemer, H. C., & Taylor, C. (1998). Linking self-reported childhood behavioral inhibition to adolescent social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1308–1316.

Hofmann, S., Albano, A. M., Heimberg, R. G., Tracey, S., Chorpita, B., & Barlow, D. H. (1999). Subtypes of social phobia in adolescents. Depression and Anxiety, 9, 15–18.

Hollingshead, A. (1957). Two factor index of social position. New Haven, CT: Yale Station.

Inderbitzen, H., Walters, K., & Bukowski, A. (1997). The role of social anxiety in adolescent peer relations: Differences among sociomet- ric status groups and rejected subgroups. Journal of Clinical Child Psychology, 26, 338–348.

Kagan, J., Reznick, J., & Snidman, N. (1987). The physiology and psy- chology of behavioral inhibition in children. Child Development, 58, 1459–1473.

Kashdan, T., & Herbert, J. (2001). Social anxiety disorder in childhood and adolescence: Current status and future

Springer

54 J Psychopathol Behav Assess (2007) 29:47–54

directions. Clinical Child and Family Psychology Review, 4, 37– 62.

Katz, E., Kellerman, J., & Siegel, S. (1980). Behavioral distress in chil- dren with cancer undergoing medical procedures: Developmental considerations. Journal of Consulting and Clinical Psychology, 48, 356–365.

Kovacs, M. (1992). Children’s Depression Inventory Manual. Toronto, Ontario, Canada: Multi-Health Systems, Inc.

La Greca, A., & Lopez, N. (1998). Social anxiety among adolescents: Linkages with peer relations and friendships. Journal of Abnormal Child Psychology, 26, 83–94.

Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1992). DSM-III- R anxiety disorders in children: Sociodemographic and clinical characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1070–1076.

LeBaron, S., & Zeltzer, L. (1984). Assessment of acute pain and anx- iety in children and adolescents by self-reports, observer reports, and a behavioral checklist. Journal of Consulting and Clinical Psychology, 52, 729–738.

Lewinsohn, P., Hops, H., Roberts, R., Seeley, J., & Andrews, J. (1993). Adolescent psychopathology: I. Prevalence and incidence of de- pression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 10, 133–144.

Liebowitz, M., Gorman, J., Fyer, A., & Klein, D. (1985). Social Pho- bia: Review of a neglected anxiety disorder. Archives of General Psychiatry, 42, 729–736.

Ollendick, T., & King, N. (1998). Empirically supported treatments for children with phobic and anxiety disorders: Current status. Journal of Clinical Child Psychology, 27, 156–167.

Regier, D., Rae, D., Narrow, W., Kaelber, C., & Schatzberg, A. (1998). Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry, 173, 24–28.

Schwartz, C., Snidman, N., & Kagan, J. (1999). Adolescent social anxi- ety as an outcome of inhibited temperament in childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1008–1015.

Shaffer, D., Gould, M., Brasic, J., Abrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983). A Children’s Global Assessment

Scale (K-GAS). Archives of General Psychiatry, 40, 1228– 1231.

Silverman, W. K., & Albano, A. M. (1996). The anxiety disorders interview schedule for children (ADIS-C/P). San Antonio, TX: Psychological Corporation.

Spence, S., Donovan, C., & Brechman-Toussaint, M. (1999). Social skills, social outcomes, and cognitive features of childhood social phobia. Journal of Abnormal Psychology, 108, 211–221.

Spence, S., Donovan, C., & Brechman-Toussaint, M. (2000). The treat- ment of childhood social phobia: The effectiveness of a social skills training-based, cognitive-behavioural intervention, with and without parental involvement. Journal of Child Psychology and Psychiatry, 41, 713–726.

Strauss, C. C., & Last, C. (1993). Social and simple phobias in children. Journal of Anxiety Disorders, 7, 141–152.

Turk, C., Heimberg, R. G., & Hope, D. A. (2001). Social anxiety dis- order. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders, (3rd ed.). New York, NY: Guilford, pp 114–153.

Turner, S. M., & Beidel, D. C. (1989). Social phobia: Clinical syndrome, diagnosis, and comorbidity. Clinical Psychology Review, 9, 3–18.

Turner, S. M., Beidel, D. C., Borden, J. W., Stanley, M. A., & Jacob, R. G. (1991). Social phobia: Axis I and Axis II correlates. Journal of Abnormal Psychology, 100, 102–106.

Velting, O., & Albano, A. M. (2001). Current trends in the under- standing and treatment of social phobia in youth. Journal of Child Psychology & Psychiatry & Allied Disciplines, 42, 127–140.

Vernberg, E., Abwender, D., Ewell, K., & Beery, S. (1992). Social anxiety and peer relationships in early adolescence: A prospective analysis. Journal of Clinical Child Psychology, 21, 189–196.

Wittchen, H., Stein, M., & Kessler, R. (1999). Social fears and so- cial phobia in a community sample of adolescents and young adults: Prevalence, risk factors and co-morbidity. Psychological Medicine, 29, 309–323.

Yeganeh, R., Beidel, D. C., Turner, S. M., Pina, A., & Silverman, W. (2003). Clinical distinctions between selective mutism and social phobia: An investigation of childhood psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1069–1075.

Springer