Avoidant Disorder and Social Phobia in Children and Adolescents GRETA FRANCIS, PH.D., CYNTHIA G. LAST, PH.D.,
AND
CYD C. STRAUSS, PH.D.
Abstract. The diagnoses of avoidant disorder and social phobia in children have received little research attention. Although DSM-IIl-R describes avoidant disorder and social phobia as distinct disorders, no empirical data are available to support this notion. The current study examined characteristics of avoidant disorder and social phobia by comparing outpatient youngsters with avoidant disorder, social phobia, and avoidant disorder plus social phobia on demographic variables and patterns of comorbidity. The psychiatric groups were compared with matched normal controls on symptom measures of depression and fear. Findings indicated that the three psychiatric groups were strikingly similar on all but one variable, age at intake. These findings question the notion of avoidant disorder and social phobia as distinct disorders in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31,6:1086-1089. Key Words: avoidant disorder, social phobia, diagnostic comorbidity. Avoidant disorder of childhood and adolescence first appeared in the psychiatric nomenclature with the publication of the third edition of the Diagnostic and Statistical Manual ofMental Disorders (DSM-III: American Psychiatric Association, 1980). The essential feature of avoidant disorder is persistent and excessive shrinking from contact with strangers of sufficient severity to interfere with social functioning in peer relationships. However, the disturbance is not pervasive and persistent enough to warrant the diagnosis of avoidant personality disorder. Children with avoidant disorder desire acceptance and have satisfactory interpersonal relations with familiar persons, such as family members. In the recent revision of the DSM-III (DSM-III-R: American Psychiatric Association, 1987), the essential features of avoidant disorder have remained the same. There are very few references to avoidant disorder in the literature. A small number of investigators (e.g., Beitchman et aI., 1986; Cantwell and Baker, 1987) have examined the
of avoidant disorder supersedes the diagnosis of social phobia in persons under the age of 18 years. There have been few published studies of social phobia in children. Last and Strauss (1990) described social phobia as the second most common anxiety disorder in their sample of school refusing children and adolescents. Beidel (1991) compared children with social phobia with those with overanxious disorder and with matched normal controls. Findings indicated that social phobic children could be distinguished from the other groups on the basis of selfreport inventories, self-monitoring of anxiety, and psychophysiological variables. Examination of the DSM-III-R criteria for avoidant disorder and social phobia shows there is considerable symptom similarity in that both disorders involve social anxiety. Although they are described nosologically as distinct disorders, there are no empirical data available by which to make such a determination.
prevalence of avoidant disorder in samples of language-
The purpose of the present study was to assess whether
disordered preschool children. For example, Cantwell and Baker (1987) reported that avoidant disorder was the most common psychiatric diagnosis (4.8%) in their sample of 600 language-disordered, primarily preschool-aged children. Similarly, Beitchman et a1. (1986) found that 3.7% of their sample of 142 language-disordered, preschool-aged children received the diagnosis of avoidant disorder. Social phobia also appeared for the fIrst time in DSM-III. The defining feature of social phobia is persistent fear of situations in which the person is exposed to possible scrutiny by others and fears he/she may behave in a way that will be embarrassing or humiliating (American Psychiatric Association, 1987). In addition, DSM-III-R indicates that a diagnosis
avoidant disorder and social phobia are distinct disorders in children and adolescents. As such, the diagnostic groups were compared on demographic variables· and patterns of comorbidity. Psychiatric groups then were compared with a group of never psychiatrically ill children on self-report measures of depression and fear.
Accepted June 17, 1992. Dr. Francis is Assistant Professor ofPsychiatry and Human Development in the Brown University School of Medicine and Director of the Anxiety Disorders Clinic at Emma Pendleton Bradley Hospital. Dr. Last is Professor ofPsychology and Director ofthe School Phobia Program at Nova University. Dr. Strauss is Visiting Assistant Professor of Psychology at the University of Florida. Reprint requests to Dr. Francis, Emma Pendleton Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, R102915. 0890-8567/92/3106-1O86$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry.
1086
Method SAMPLE
The sample consisted of 61 outpatients and 32 normal controls. Nineteen youngsters with avoidant disorder (AD), 33 youngsters with social phobia (SP), and 12 youngsters with avoidant disorder and social phobia (AD + SP) between the ages of 6.0 and 17.11 years were evaluated in an outpatient clinic specializing in the assessment and treatment of children and adolescents with anxiety disorders. Thirty-two never psychiatrically ill children served as a normal control group (NC). Diagnoses were made on the basis of DSM-III-R criteria using semistructured, symptom-oriented diagnostic interviews. Because of a change in clinic assessment procedures, the first 14 subjects were administered the Interview Schedule for Children ([ISC] Kovacs, unpublished), and the remaining 50 subjects were administered a version of the . J. Am. Acad. Child Adolesc. Psychiatry, 31:6, November 1992
AVOIDANT DISORDER AND SOCIAL PHOBIA
Schedule for Affective Disorders and Schizophrenia for School-Aged Children ([KSADS] Puig-Antich et al., 1978) modified by Last (unpublished) for use with anxiety-disordered populations. All normal control subjects were administered the KSADS. Although different interview schedules were used, the content areas covered by each were identical, and DSM-III-R diagnostic criteria for anxiety and affective disorders were included in both instruments. As such, DSMIII-R diagnoses were made according to identical criteria, regardless of the instrument used. Each parent and child was interviewed individually by a clinical psychologist. The interviewer subsequently provided descriptions of all presenting complaints to a second clinical psychologist and a child psychiatrist to obtain consensus diagnosis. Additional parent and/or child interviews were conducted as needed to resolve any discrepancies in diagnostic formulation. The sample of 32 never psychiatrically ill children, roughly matched for age (within one year) and gender to the psychiatric groups, was recruited from the community via mailings using the Cole's directory. These normal control subjects served as a comparison group for analyses of symptom measures. Control youngsters were evaluated with the KSADS and offered participation in the study only if they did not meet DSM-III-R criteria for any current or past psychiatric disorder and had no history of mental health contact. Because the control children were not initially matched to the psychiatric subjects on socioeconomic status, the groups were compared on this variable using a complex Chi-square analysis. There were no differences in socioeconomic status between AD, SP, AD + SP, and NC groups.
nostic assessments. To obtain a comprehensive picture of comorbidity, the DSM-III-R hierarchical system and exclusionary rules were not adhered to as they pertain to the diagnosis of anxiety and affective disorders. In other words, children were assigned all DSM-III-R anxiety and affective disorders for which they qualified. This procedure has been detailed by Barlow et al., (1986) and used previously by our group (Last et al., 1987b; Last et al., 1987c; Last et al., 1987a).
Results DEMOGRAPHIC CHARACTERISTICS
Demographic characteristics for the three anxiety groups, AD, SP, and AD + SP, are presented in Table 1. Age at Intake
Age at intake ranged from 6 to 17 years. Results of a oneway analysis of variance revealed that the groups differed significantly with respect to age at intake (F = 8.45, df = 2, P < .001). Children in the SP (X = 14.2) and AD + SP (X = 15.0) groups were significantly older at intake than children in the AD group (X = 11.3). Age at intake was not significantly different for SP and AD + SP groups. Gender
Findings of a complex Chi-square analysis indicated that the numbers of males and females in the three groups were not significantly different. Both AD and SP groups consisted of a majority of females (% female = 74 and 58, respectively); there were equal numbers of females and males in the AD + SP group.
PROCEDURE
Before the interviews, the following demographic information was collected: age at intake, gender, and family socioeconomic status. Socioeconomic status was determined using the Hollingshead Four-Factor Index of Social Status (Hollingshead, unpublished). In addition, children completed self-report measures of fear, the revised Fear Survey Schedule for Children (FSSC-R: Ollendick, 1983), and depression, the Children's Depression Inventory ([CDI] Kovacs, unpublished). Complete self-report data were not obtained for the entire sample, because of the failure of some subjects to complete measures correctly. Comorbidity was examined by observing concurrent DSM-III-R diagnoses asssigned to children after their diag-
Race
Almost all of the children in each group were white (AD
= 94%, SP = 82%, AD + SP = 82%). Findings of a complex Chi-square analysis revealed that there were no significant differences among the groups. Socioeconomic Status
Socioeconomic status ratings were combined into two groups: (1) middle-upper, consisting of levels I, II, and III; and (2) lower, consisting of levels IV and V. Findings of a complex Chi-square analysis indicated no significant differences among the groups. Socioeconomic status was roughly evenly distributed in the three groups.
TABLE 1. Demographic Characteristics of Children with AD, SP, or AD + SP AD
Variable Mean age at intake (years) Gender (% female) Socioeconomic status Percent upper-middle Percent lower Race (% white)
N= 19 11.3 74 60 40 94
SP
N
= 33
AD + SP
N = 12
p.
14.2 58
15.0 50
AND
CYD C. STRAUSS, PH.D.
Abstract. The diagnoses of avoidant disorder and social phobia in children have received little research attention. Although DSM-IIl-R describes avoidant disorder and social phobia as distinct disorders, no empirical data are available to support this notion. The current study examined characteristics of avoidant disorder and social phobia by comparing outpatient youngsters with avoidant disorder, social phobia, and avoidant disorder plus social phobia on demographic variables and patterns of comorbidity. The psychiatric groups were compared with matched normal controls on symptom measures of depression and fear. Findings indicated that the three psychiatric groups were strikingly similar on all but one variable, age at intake. These findings question the notion of avoidant disorder and social phobia as distinct disorders in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31,6:1086-1089. Key Words: avoidant disorder, social phobia, diagnostic comorbidity. Avoidant disorder of childhood and adolescence first appeared in the psychiatric nomenclature with the publication of the third edition of the Diagnostic and Statistical Manual ofMental Disorders (DSM-III: American Psychiatric Association, 1980). The essential feature of avoidant disorder is persistent and excessive shrinking from contact with strangers of sufficient severity to interfere with social functioning in peer relationships. However, the disturbance is not pervasive and persistent enough to warrant the diagnosis of avoidant personality disorder. Children with avoidant disorder desire acceptance and have satisfactory interpersonal relations with familiar persons, such as family members. In the recent revision of the DSM-III (DSM-III-R: American Psychiatric Association, 1987), the essential features of avoidant disorder have remained the same. There are very few references to avoidant disorder in the literature. A small number of investigators (e.g., Beitchman et aI., 1986; Cantwell and Baker, 1987) have examined the
of avoidant disorder supersedes the diagnosis of social phobia in persons under the age of 18 years. There have been few published studies of social phobia in children. Last and Strauss (1990) described social phobia as the second most common anxiety disorder in their sample of school refusing children and adolescents. Beidel (1991) compared children with social phobia with those with overanxious disorder and with matched normal controls. Findings indicated that social phobic children could be distinguished from the other groups on the basis of selfreport inventories, self-monitoring of anxiety, and psychophysiological variables. Examination of the DSM-III-R criteria for avoidant disorder and social phobia shows there is considerable symptom similarity in that both disorders involve social anxiety. Although they are described nosologically as distinct disorders, there are no empirical data available by which to make such a determination.
prevalence of avoidant disorder in samples of language-
The purpose of the present study was to assess whether
disordered preschool children. For example, Cantwell and Baker (1987) reported that avoidant disorder was the most common psychiatric diagnosis (4.8%) in their sample of 600 language-disordered, primarily preschool-aged children. Similarly, Beitchman et a1. (1986) found that 3.7% of their sample of 142 language-disordered, preschool-aged children received the diagnosis of avoidant disorder. Social phobia also appeared for the fIrst time in DSM-III. The defining feature of social phobia is persistent fear of situations in which the person is exposed to possible scrutiny by others and fears he/she may behave in a way that will be embarrassing or humiliating (American Psychiatric Association, 1987). In addition, DSM-III-R indicates that a diagnosis
avoidant disorder and social phobia are distinct disorders in children and adolescents. As such, the diagnostic groups were compared on demographic variables· and patterns of comorbidity. Psychiatric groups then were compared with a group of never psychiatrically ill children on self-report measures of depression and fear.
Accepted June 17, 1992. Dr. Francis is Assistant Professor ofPsychiatry and Human Development in the Brown University School of Medicine and Director of the Anxiety Disorders Clinic at Emma Pendleton Bradley Hospital. Dr. Last is Professor ofPsychology and Director ofthe School Phobia Program at Nova University. Dr. Strauss is Visiting Assistant Professor of Psychology at the University of Florida. Reprint requests to Dr. Francis, Emma Pendleton Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, R102915. 0890-8567/92/3106-1O86$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry.
1086
Method SAMPLE
The sample consisted of 61 outpatients and 32 normal controls. Nineteen youngsters with avoidant disorder (AD), 33 youngsters with social phobia (SP), and 12 youngsters with avoidant disorder and social phobia (AD + SP) between the ages of 6.0 and 17.11 years were evaluated in an outpatient clinic specializing in the assessment and treatment of children and adolescents with anxiety disorders. Thirty-two never psychiatrically ill children served as a normal control group (NC). Diagnoses were made on the basis of DSM-III-R criteria using semistructured, symptom-oriented diagnostic interviews. Because of a change in clinic assessment procedures, the first 14 subjects were administered the Interview Schedule for Children ([ISC] Kovacs, unpublished), and the remaining 50 subjects were administered a version of the . J. Am. Acad. Child Adolesc. Psychiatry, 31:6, November 1992
AVOIDANT DISORDER AND SOCIAL PHOBIA
Schedule for Affective Disorders and Schizophrenia for School-Aged Children ([KSADS] Puig-Antich et al., 1978) modified by Last (unpublished) for use with anxiety-disordered populations. All normal control subjects were administered the KSADS. Although different interview schedules were used, the content areas covered by each were identical, and DSM-III-R diagnostic criteria for anxiety and affective disorders were included in both instruments. As such, DSMIII-R diagnoses were made according to identical criteria, regardless of the instrument used. Each parent and child was interviewed individually by a clinical psychologist. The interviewer subsequently provided descriptions of all presenting complaints to a second clinical psychologist and a child psychiatrist to obtain consensus diagnosis. Additional parent and/or child interviews were conducted as needed to resolve any discrepancies in diagnostic formulation. The sample of 32 never psychiatrically ill children, roughly matched for age (within one year) and gender to the psychiatric groups, was recruited from the community via mailings using the Cole's directory. These normal control subjects served as a comparison group for analyses of symptom measures. Control youngsters were evaluated with the KSADS and offered participation in the study only if they did not meet DSM-III-R criteria for any current or past psychiatric disorder and had no history of mental health contact. Because the control children were not initially matched to the psychiatric subjects on socioeconomic status, the groups were compared on this variable using a complex Chi-square analysis. There were no differences in socioeconomic status between AD, SP, AD + SP, and NC groups.
nostic assessments. To obtain a comprehensive picture of comorbidity, the DSM-III-R hierarchical system and exclusionary rules were not adhered to as they pertain to the diagnosis of anxiety and affective disorders. In other words, children were assigned all DSM-III-R anxiety and affective disorders for which they qualified. This procedure has been detailed by Barlow et al., (1986) and used previously by our group (Last et al., 1987b; Last et al., 1987c; Last et al., 1987a).
Results DEMOGRAPHIC CHARACTERISTICS
Demographic characteristics for the three anxiety groups, AD, SP, and AD + SP, are presented in Table 1. Age at Intake
Age at intake ranged from 6 to 17 years. Results of a oneway analysis of variance revealed that the groups differed significantly with respect to age at intake (F = 8.45, df = 2, P < .001). Children in the SP (X = 14.2) and AD + SP (X = 15.0) groups were significantly older at intake than children in the AD group (X = 11.3). Age at intake was not significantly different for SP and AD + SP groups. Gender
Findings of a complex Chi-square analysis indicated that the numbers of males and females in the three groups were not significantly different. Both AD and SP groups consisted of a majority of females (% female = 74 and 58, respectively); there were equal numbers of females and males in the AD + SP group.
PROCEDURE
Before the interviews, the following demographic information was collected: age at intake, gender, and family socioeconomic status. Socioeconomic status was determined using the Hollingshead Four-Factor Index of Social Status (Hollingshead, unpublished). In addition, children completed self-report measures of fear, the revised Fear Survey Schedule for Children (FSSC-R: Ollendick, 1983), and depression, the Children's Depression Inventory ([CDI] Kovacs, unpublished). Complete self-report data were not obtained for the entire sample, because of the failure of some subjects to complete measures correctly. Comorbidity was examined by observing concurrent DSM-III-R diagnoses asssigned to children after their diag-
Race
Almost all of the children in each group were white (AD
= 94%, SP = 82%, AD + SP = 82%). Findings of a complex Chi-square analysis revealed that there were no significant differences among the groups. Socioeconomic Status
Socioeconomic status ratings were combined into two groups: (1) middle-upper, consisting of levels I, II, and III; and (2) lower, consisting of levels IV and V. Findings of a complex Chi-square analysis indicated no significant differences among the groups. Socioeconomic status was roughly evenly distributed in the three groups.
TABLE 1. Demographic Characteristics of Children with AD, SP, or AD + SP AD
Variable Mean age at intake (years) Gender (% female) Socioeconomic status Percent upper-middle Percent lower Race (% white)
N= 19 11.3 74 60 40 94
SP
N
= 33
AD + SP
N = 12
p.
14.2 58
15.0 50
