Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0888-y
ORIGINAL PAPER
Self-reported social anxiety symptoms and correlates in a clinical (CAP) and a community (Young-HUNT) adolescent sample Ingunn Ranøyen • Thomas Jozefiak • Jan Wallander • Stian Lydersen • Marit S. Indredavik
Received: 3 December 2012 / Accepted: 16 April 2014 Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The frequencies of social anxiety symptoms in a mental health clinical and a community sample of adolescents are compared. Also, we explore if adolescents can be classified in subgroups based on social anxiety symptoms. Associations between social anxiety symptoms and coexisting problems and sociodemographic characteristics are examined. Methods Adolescent participants, aged 13–18, in two large Norwegian studies, consisting of a clinical (n = 694, 42.1 % participation rate, 55 % girls, mean age = 15.6) and a community (n = 7,694, 73.1 % participation rate, 51 % girls, mean age = 15.8) sample completed identical
I. Ranøyen (&) T. Jozefiak S. Lydersen M. S. Indredavik Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU Central Norway), Faculty of Medicine, Norwegian University of Science and Technology, Pb. 8905, MTFS, 7491 Trondheim, Norway e-mail: [email protected] T. Jozefiak e-mail: [email protected] S. Lydersen e-mail: [email protected] M. S. Indredavik e-mail: [email protected] I. Ranøyen T. Jozefiak M. S. Indredavik Department of Child and Adolescent Psychiatry, St. Olavs Hospital, Postboks 6810, Elgeseter, 7433 Trondheim, Norway J. Wallander Psychological Sciences and Health Sciences Research Institute, University of California, Merced, 5200 North Lake Rd, Merced, CA 95343, USA e-mail: [email protected]
self-report questionnaires measuring social anxiety and related variables. Results Median sum scores (interquartile range) of social anxiety symptoms were higher among girls than boys and in the clinical [girls = 16 (12–22); boys = 12 (9–16)] compared to the community sample [girls = 12 (9–15); boys = 10 (7–12)] (p \ 0.001). Latent profile analysis revealed two classes of adolescents based on social anxiety profiles. Adolescents scoring high on social anxiety symptoms, which ranged from 16 % (boys in community sample) to 40 % (girls in clinical sample), had significantly more coexisting problems than those scoring low. Social anxiety symptoms were associated with academic school problems, bullying, eating problems, acne, and general anxiety and depression in both samples. Conclusion Social anxiety symptoms were commonly reported by adolescents, in both clinical and community settings. These symptoms were associated with a broad spectrum of coexisting problems, which can be used to detect adolescents struggling with social anxiety. Adolescent, family, peer, school, and community interventions targeting these associated problems may contribute to prevent and alleviate social anxiety symptoms. Keywords Social anxiety Symptoms Adolescent psychopathology Latent profile analysis Abbreviations HUNT Young-HUNT CAP SPAI-C SCL
The Nord-Trøndelag Health Study The Nord-Trøndelag Health Study part for adolescents ages 13 through 19 Child and adolescent psychiatry Social Phobia and Anxiety Inventory for Children Symptom Check List
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ICD-10 LPA MI RMSEA BIC CR IQR
International Classification of Diseases, 10th Revision Latent profile analysis Multiple imputation Root mean square error of approximation Bayesian information criterion Composite reliability Interquartile range
Introduction In the few existing European community studies of adolescents the lifetime prevalence of social anxiety varies considerably from 1 to 24 % [1–4]. Most studies find social anxiety to be more common in females [5] and older adolescents [2], but one study of Swedish adolescents, ages 11–15, did not find social anxiety to increase with age [3], and a Finnish study found social anxiety to be equally prevalent in female and male adolescents [4]. We have found only two studies examining socioeconomic status in relation to social anxiety in adolescents, one reporting no [6] and the other a negative [2] association. We have been unable to find studies reporting the prevalence of social anxiety in adolescent psychiatric clinical populations. Few studies have examined problems coexisting with social anxiety among adolescents, and then mainly focusing on comorbid diagnosed mental disorders. Depression and general anxiety disorder have consistently been found to co-occur with social anxiety [1, 4]. Eating disorders have been associated with the generalized subtype of social anxiety among adolescents, but not with any social anxiety diagnosis [2]. Also, it is unclear whether this association differs between girls and boys. Bullying is consistently reported to be associated with social anxiety (although with a relatively small effect size) [7, 8]. Some studies have found social anxiety in adolescence to be correlated with impaired school function [3, 4]. However, it is unclear whether these school-related problems are caused by social anxiety or learning difficulties. It is conceivable that problems with acne may be related to social anxiety as adolescents perceive acne to have negative social consequences [9]. Acne has been associated with general anxiety in adolescent girls [10], but associations with social anxiety have not been examined previously. Social anxiety has shown inconsistent associations with drug use [11, 12] and alcohol problems [13, 14]. In addition, suicidal behaviour has been related to social anxiety with comorbid depression among female adolescents [15], but this has not been examined in male adolescents.
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Among individuals developing social anxiety, 95 % do so before the age of 20 [1, 16]. However, most research informing about adolescent social anxiety thus far has examined adults, possibly introducing recall biases. Although social anxiety is a quite persistent disorder, fluctuations of symptom severity are common [17]. Even a high level of symptoms without necessarily fulfilling diagnostic criteria for social phobia leads to considerable problems in functioning and a reduced quality of life [18, 19]. Almost 25 % of patients who meet criteria for social phobia are instead diagnosed with other mental disorders [20], possibly because they have more comorbid problems than individuals with social anxiety who do not seek treatment [21]. This may indicate that important differences exist in social anxiety and related problems between clinical and community samples. Few individuals with ‘‘pure’’ social anxiety seek treatment [22], even though effective treatment exists [23]. This underscores the need for early detection of symptoms and prevention programs. Although some such programs do exist [24], examining coexisting problems associated with social anxiety can point towards important factors to focus prevention on, in addition to facilitate identification of adolescents with social anxiety. It would also be useful to identify a threshold for social anxiety at which severe comorbid problems occur. This has been examined among adults [18], but no threshold was identified in that study. Thus, the authors concluded that impairment increased linearly with the number of social fears. However, such examinations can be conducted in two complementary ways: by applying (1) variable-centred methods, such as imposing arbitrary cut-off points in logistic regression analyses, which was done in the abovementioned study [18]), or (2) person-centred methods to identify subgroups inherent in the data that differ from each other, for example by trying to classify high- and low-scorers in latent profile analyses. In summary, comparisons of symptoms and correlates of social anxiety in clinical and community samples are lacking in previous research. Also, there is a further need to examine at what level of social anxiety the severe coexisting problems occur. The aims of the present study therefore were to (1) compare social anxiety symptoms in a mental health clinical sample and a community sample of adolescent girls and boys, ages 13 through 18; (2) examine whether subgroups with different levels of social anxiety symptoms can be identified, using a person-centred method; (3) examine the linear relationships between social anxiety symptoms and relevant coexisting problems and sociodemographic characteristics in a clinical and a community sample; and (4) examine whether possible identified subgroups exhibit different coexisting problems.
Soc Psychiatry Psychiatr Epidemiol
Community sample
Clinical sample
Excluded due to exclusion criteria N=289
Total population N=2032
Total population N=10490
Excluded due to exclusion criteria N=0
System error (were not invited) N=95
Should have been invited N=1743
Should have been invited N=10490
System error (were not invited) N=0
Did not consent to participation N=931 (56.5%)
Study population N=1648 (100.0%)
Study population N=10490 (100.0%)
Did not consent to participation N=1810 (17.3%)
Did not complete the study N=0 (0.0%)
Willing to participate N=717 (43.5%)
Willing to participate N=8680 (82.7%)
Did not complete the study N=480 (4.6%)
Participants completing the study N=717 (43.5%)
Participants completing the study N=8200 (78%)
Excluded due to low participation rate: 12 years, N=27 (0.3%) 19 years, N=219 (2.1%) 20 years, N=41 (0.4%)
Participants 13-18 years of age N=701 (42.5%)
Participants 13-18 years of age N=7913 (75.4%)
Excluded due to incomplete information on dependent variable: N=244 (2.3%)
Excluded due to low participation rate: 19 years, N=9 (0.5%) 20 years, N=7 (0.4%)
Excluded due to incomplete information on dependent variable: N=7 (0.4%)
Clinical participants in present study N=694 (42.1%)
Community participants in present study N=7669 (73.1%)
Fig. 1 Flowchart of participants in present study
Methods Participants and procedures Clinical sample The clinical sample consisted of all 13- to 18-year-old participants in The Health Survey in Department of Child and Adolescent Psychiatry, St. Olav’s University Hospital in the county of Sør-Trøndelag, Norway (termed the CAP survey). This clinic provides diagnoses and treatment for all psychiatric conditions in referred children and adolescents, ages 0–18. All patients between 13 and 18 years of age with at least one personal attendance at the clinic between February 2009 and 2011 were invited to participate in the survey. Exclusion criteria were major difficulties answering the questionnaire due to psychiatric state, cognitive function, visual impairments, or lack of sufficient language skills. Emergency patients were invited to take part once they entered a stable phase. The adolescent completed electronic questionnaires about his or her mental
health in conjunction with a clinic appointment. From a total population of 2,032, 289 adolescents fulfilled the exclusion criteria and 95 were missing registration data, and hence, were not included in study recruitment, resulting in an eligible population of 1,648. Of these, 694 (42.1 %), including 54.6 % girls (n = 379) and 45.4 % boys (n = 315), contributed data for this study (see Fig. 1). Mean age for girls was 15.8 (SD = 1.53) and boys 15.3 (SD = 1.52). The distributions across family structures were approximately the same for girls and boys; 6.2 and 5.3 % were not living with parents, 46.9 and 48.4 % were living with one parent, and 46.9 and 46.3 % were living with two parents, respectively. To explore the representativeness of the study population, we collected anonymous information about the reference population (n = 1,743) defined as all adolescents at the clinic in the study period (n = 2,032) minus those excluded (n = 289). Age, sex and main reason for referral between participants (n = 717) and non-participants (n = 1,026) were compared. Participants were 0.27 (95 % CI 0.10–0.45) years older than non-participants [mean
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(SD): 15.66 (1.65) vs. 15.39 (1.95), p = 0.0015]. There were more girls among participants compared to non-participants (54.8 vs. 49.6 %, p = 0.032). Main reason for referral is a variable with 16 categories coded according to a national classification system of suspected disorders (e.g. suspected anxiety disorder, suspected hyperkinetic disorders). Reason for referral did not differ between participants and non-participants (Pearson’s Exact v2 test p = 0.11). Community sample The community sample contained all adolescents ages 13 through 18 participating in the third Nord-Trøndelag Health Study (termed Young-HUNT3), a population health survey conducted in one county between 2006 and 2008 (a description of the sample is published in a separate paper [25]). This county with 131,000 inhabitants is contiguous to the county where the clinical study was performed. All inhabitants above the age of 12 were invited to the study, and there were no exclusion criteria. The survey was administered during a class at school. Adolescents temporarily away from school on the day of survey completion received the survey about 1 month later during a health exam that was also part of the original study. Adolescents not attending school were invited and received the survey by mail. Teachers read the questions aloud to adolescents with problems answering the questionnaire. From a population of 10,490, 7,669 (73.1 %) contributed data for this study (see Fig. 1). Mean age for girls was 15.8 (SD = 1.66) and for boys 15.7 (SD = 1.62). Approximately the same proportion of girls and boys participated [50.8 % girls (n = 3,898), 49.2 % boys (n = 3,771)]. The distributions across family structures were approximately the same for girls and boys; 6.4 and 5.0 % were not living with parents, 28.2 and 32.9 % were living with one parent, and 65.3 and 62.0 % were living with two parents, respectively. Instruments All scales and questionnaire items were identical for the clinical and the community sample because the clinical study was specifically modelled after the community study to be able to compare the two samples. In the clinical sample, ICD-10 [26] diagnoses of social phobia were set by a child and adolescent psychiatrist or a clinical psychologist. Social anxiety symptoms were measured with a shortened version of The Social Phobia and Anxiety Inventory for Children (SPAI-C) [27] consisting of six items from the original 26-item version. SPAI-C has been shown to be
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valid and reliable for use with adolescents ages 13 through 17 [28]. The HUNT study adapted a shortened version of the scale comprising six items, which is used in the current study with both samples. These items were selected based on factor analyses of the complete SPAI-C scale (T. Aune, personal communication, April 30, 2009). A clinical cutoff point has not been established for this shortened version. Each item was rated on an ordinal scale (1 = never, 5 = always), which were summed (range 6–30) with higher scores indicating more symptoms. Composite reliability (CR) indicated good internal consistency in both samples (CR = 0.918 in clinical sample; CR = 0.891 in community sample). Symptoms of general anxiety and depression in the previous 2 weeks were measured with the Symptom Check List (SCL-5), which consists of five items from the 25-item version of the SCL [29]. Whereas the SCL-5 has shown satisfactory reliability [30], a distinction between anxiety and depressive symptoms is not possible [31]. Each symptom was rated on an ordinal scale (1 = not bothered, 4 = very bothered). The mean across the five ratings was computed, with high scores indicating more symptoms. CR indicated good internal consistency in both samples (CR = 0.936 in clinical sample; CR = 0.899 in community sample). Eating problems were assessed with a seven-item-version of The Eating Attitude Test [32] addressing oral control, bulimia and food preoccupation. Each symptom was rated on an ordinal scale (1 = never, 4 = always), which were summed (range 7–28) with high scores indicating more symptoms. CR indicated good internal consistency in both samples (CR = 0.827 in clinical sample; CR = 0.803 in community sample). Academic school problems were measured by six items (e.g. comprehension, concentration problems) rated on an ordinal scale (1 = never, 4 = very often). Five items comprised the ‘‘academic’’ factor in a scale on school functioning [33]. In addition, a question on current learning problems was included. The mean across the six items was computed, with high scores indicating more problems. CR indicated good internal consistency in both samples (CR = 0.752 in the clinical sample; CR = 0.734 in the community sample). Bullying was assessed by four items. Two items on name-calling and exclusion by peers were rated on an ordinal scale (0 = never, 3 = very often). Another two items on sexual harassment and physical threats by peers were rated on a three-point scale (0 = never, 1 = yes, previously, 2 = yes, in the past year). A sum score for the four items was computed (range 0–10). CR indicated good internal consistency in both samples (CR = 0.814 in the clinical sample; CR = 0.831 in the community sample).
Soc Psychiatry Psychiatr Epidemiol
Suicidal thoughts were measured by one dichotomous item, ‘‘Have you ever thought about ending your own life?’’ (0 = no, 1 = yes). In the community sample, only adolescents above the age of 16 answered this item. Alcohol use was measured by one item, ‘‘Have you ever drunk so much alcohol that you felt intoxicated (drunk)?’’ We recoded the original six-point scale (1 = no, never, 2 = yes, once, 3 = yes, 2–3 times, 4 = yes, 4–10 times, 5 = yes, 11–25 times, 6 = yes, more than 25 times) into three categories (0 = never, 1 = 1–10 times, 2 = 11 or more times), as in previous studies [31, 34]. Individuals who had not tried alcohol were coded as 0 = never. Use of illegal substances was measured by one dichotomous item, ‘‘Have you ever tried hash, marijuana or other drugs?’’ (0 = no, 1 = yes). Acne problems were measured by one item, ‘‘How much has acne bothered you?’’, rated on an ordinal scale (1 = no impact, 4 = a lot of impact). Individuals reporting no acne were coded as 1 = no impact. Sociodemographic items asked about age, sex, and with whom the adolescent lives (0 = living alone, with friends, siblings and/or partner/spouse, 1 = living with one parent/ stepparent/grandparent(s), 2 = living with two parents, one parent and one stepparent, foster parents or adoptive parents). In addition, a question whether the adolescent feels his or her family is better or worse off economically than others was included (0 = worse off, 1 = the same, 2 = better off). Ethics All adolescents participating in the studies, and at least one parent when the adolescent was below 16 years of age, signed a written informed consent to participate. Both studies were approved by the Regional Committee for Medical and Health Research Ethics and the Norwegian Social Science Data Services, and have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Statistics Short forms of measurement scales are often used in epidemiological surveys to reduce respondent fatigue. As recommended [35], confirmatory factor analyses (CFA) were performed to examine the validity of the short forms used in the study. A model where items were made to load on their assumed latent variable had an acceptable-to-good model fit in both samples (e.g. RMSEA B0.065). Thus, the factor structure was retained.1
1
Further details on these analyses are available from the authors.
Due to non-normal distributions of social anxiety symptoms, group differences between the clinical and community samples were analysed by Mann–Whitney U tests. Latent profile analyses (LPA) were performed to empirically identify a division of social anxiety symptoms into groups instead of imposing an arbitrary cut-off point. The goal of LPA was to identify subgroups (latent classes) of adolescents based on how close or distant they were on their scores on the six social anxiety items (e.g. high- and low-scoring adolescents). To examine demographic correlates and coexisting problems, linear regression analyses with the sum score of social anxiety symptoms as the dependent variable were performed. First, the associations between social anxiety and each demographic correlate and coexisting problem were analysed, adjusting only for age, because age was associated with social anxiety. Then multi-adjusted regression analyses were carried out with all covariates entered simultaneously in the model. Multi-adjusted analyses should be interpreted with some caution due to the difficulty of deciding whether variables are mediators, confounders, or colliders [36]. Still, if a variable remains significant in such analyses, the importance of this variable is strengthened. To obtain comparable regression coefficients in both samples, all covariates were divided by the standard deviation of that covariate in the community sample. Also, differences between latent classes on coexisting problems and sociodemographic measures were analysed by v2 tests. These variables were entered as auxiliary to prevent the correlates from changing the class memberships for respondents. Missing values on social anxiety in the community sample ranged from 2.9 to 3.2 % across the six items, and in the clinical sample from 1.1 to 1.4 %. Following the SPAI-C-manual [27], respondents with missing on more than one of the six items were excluded from further analyses (see Fig. 1). The remaining missing values on the dependent variable and all independent variables were substituted by multiple imputation with 100 imputed data sets. All variables used in the analyses were included in the imputation models.2 To approximate normality for the multiple imputation, social anxiety, general anxiety and depression, eating problems, and academic school problems were transformed with the natural logarithm. For
2
With regard to the item on suicidal thoughts, the probability of missing values in the community sample was completely specified by the observed variable ‘‘age’’. Thus, because age was included in the imputation models, it was feasible to impute the missing values on the item on suicidal thoughts.
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LPA, results from complete case analyses are reported because tests of class differences are not readily available for multiple imputation datasets. Two-sided p values \0.05 were considered significant. CFA and LPA were performed using Mplus, version 7.11 [37]. All other analyses were performed in IBM SPSS Statistics 21. All analyses were performed separately for the two samples and each sex.
Results Comparing social anxiety symptoms As shown in Fig. 2, social anxiety symptoms were more frequent in the clinical than in the community sample (p \ 0.001). The median sum score (interquartile range) of social anxiety symptoms (range 6–30) in the clinical sample was higher (p \ 0.001) for girls [Mdn = 16 (12–22)] than boys [Mdn = 12 (9–16)]. This pattern was repeated in the community sample [girls: Mdn = 12 (9–15)]; [boys: Mdn = 10 (7–12)], (p \ 0.001). Both girls and boys in the clinical sample had more social anxiety symptoms than their respective same sex peers in the community sample (p \ 0.001). In the clinical sample, the prevalence of the ICD-10-diagnosis social phobia set by therapists in the clinic was 2.3 % (n = 16). Determining classes Fit statistics indicated that a two- or a three-class solution was appropriate among girls and boys in both samples. The log likelihood and BIC-statistics suggested a better fit to the data with three compared to two classes. However, entropy values decreased for all groups when comparing two against three classes, and the Vuong–Lo–Mendell– Rubin test showed that three classes did not fit the data significantly better than two classes among boys in the clinical sample. Applying the principle of parsimony, we determined that two classes fit the data best.3 The classification of individuals into classes and mean scores on social anxiety symptoms for girls and boys in each sample are shown in the upper panel of Table 1. Girls with a mean score on the six social anxiety items of 3.86 in the clinical sample [40.4 % (n = 153)] and 2.98 in the community sample [26.5 % (n = 1,032)] formed a relatively homogenous subgroup scoring high on social anxiety symptoms. Girls with a mean score of 2.12 in the clinical [59.6 % (n = 226)] and 1.72 in the community sample [73.5 % (n = 2,866)] formed another subgroup scoring low on symptoms. Boys with a mean score of 3.28 in the 3
Further details are available from the authors.
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clinical [26.7 % (n = 84)] and 2.88 in the community sample [16.2 % (n = 611)] constituted a subgroup of highscorers. Boys with a mean score of 1.68 in the clinical [73.3 % (n = 231)] and 1.51 in the community sample [83.8 % (n = 3,160)] constituted low-scorers. Coexisting problems and sociodemographic characteristics among girls The upper panel of Table 2 displays the associations between social anxiety symptoms and coexisting problems and sociodemographic characteristics among girls in the clinical and the community sample (b values are comparable). When the associations between social anxiety and each coexisting problem and sociodemographic variable were analysed adjusting only for age, positive associations were found in both samples for the following correlates (see Table 2): academic school problems, bullying, eating problems, suicidal thoughts, acne problems, symptoms of general anxiety and depression, older age and perception of poorer family economy. In the multi-adjusted models, adjusting for all other variables, academic school problems, eating problems, and anxiety and depression remained associated with social anxiety in both samples. Moreover, in the community sample, being bullied, having suicidal thoughts, acne problems, fewer alcohol intoxications, less drug use, and being older were also associated with social anxiety symptoms. The multi-adjusted models explained 40 % of the variance in the clinical sample and 32 % in the community sample. Coexisting problems and sociodemographic characteristics among boys The lower panel of Table 2 shows associations between social anxiety symptoms and coexisting problems and sociodemographic characteristics among boys in both samples (b values are comparable). When the associations between social anxiety symptoms and each coexisting problem and sociodemographic variable were analysed adjusting only for age, positive associations were found in both samples for the following correlates (see Table 2): academic school problems, bullying, eating problems, suicidal thoughts, acne problems, anxiety/depression, and older age. In the community sample, alcohol intoxications and family economy were negatively associated with social anxiety. When adjusting for all other variables, bullying and anxiety/depression remained associated with social anxiety in both samples. In the community sample, academic school problems, eating problems, acne problems, fewer alcohol intoxications, less drug use, poorer family economy, and being older were also associated with social anxiety. The multi-adjusted models explained 28 % of the variance in both samples.
Soc Psychiatry Psychiatr Epidemiol Fig. 2 Sum scores of social anxiety symptoms in the clinical and community samples
Class comparisons The lower panel of Table 1 shows that compared to adolescents with lower mean scores on each of the social
anxiety items (class 1), adolescents in class 2 had higher mean scores on academic school problems, bullying, acne problems, anxiety/depression, age and a higher probability of ever having had suicidal thoughts in all sex-by-sample
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123 226 59.6 2.357 2.162 2.733 1.541 1.725 2.206 2.121 2.169 1.382 11.188 2.073 2.061 15.57 0.484 0.516 0.897 0.103 0.503 0.281 0.216 0.175 0.639 0.186 0.045 0.455 0.500
153 40.4 3.660 3.915 4.223 3.572 3.825 3.964 3.860 2.521 2.656 14.182 2.341 3.044 16.118 0.176 0.824 0.810 0.190 0.310 0.384 0.306 0.325 0.497 0.178 0.086 0.490 0.424
Class 2
3.045
9.519**
10.172**
4.767*
35.832***
41.941*** 32.005*** 48.848*** 5.943* 173.181*** 12.332***
v2 2,866 73.5 1.917 1.747 2.205 1.308 1.396 1.717 1.715 1.714 0.424 9.875 1.352 1.469 15.712 0.828 0.172 0.977 0.023 0.429 0.318 0.254 0.069 0.762 0.169 0.056 0.279 0.665
1,032 26.5 2.954 3.085 3.587 2.511 2.745 2.983 2.978 2.024 1.213 11.855 1.844 2.104 16.053 0.528 0.472 0.969 0.031 0.354 0.374 0.272 0.190 0.698 0.112 0.089 0.289 0.622
Class 2
Girls community Class 1
10.914**
81.287***
12.693**
1.672
103.640***
377.850*** 189.169*** 327.965*** 111.354*** 799.017*** 32.819***
v2 231 73.3 1.871 1.685 2.057 1.385 1.450 1.627 1.679 2.132 1.009 9.912 1.766 1.454 15.166 0.749 0.251 0.891 0.109 0.580 0.262 0.158 0.111 0.654 0.235 0.044 0.470 0.486
84 26.7 3.209 3.496 3.710 2.782 2.973 3.486 3.276 2.293 2.345 10.551 2.094 2.184 15.613 0.517 0.483 0.915 0.085 0.680 0.194 0.127 0.187 0.668 0.145 0.074 0.521 0.405
Class 2
Boys clinical Class 1
1.677
4.395
1.998
0.366
12.616***
6.086* 29.693*** 3.319 7.858** 63.176*** 5.276*
v2 3,160 83.8 1.685 1.500 1.932 1.230 1.276 1.455 1.513 1.759 0.548 9.001 1.290 1.252 15.713 0.835 0.165 0.963 0.037 0.433 0.293 0.274 0.066 0.724 0.210 0.050 0.324 0.626
611 16.2 2.768 2.934 3.391 2.617 2.745 2.803 2.876 2.017 1.477 10.605 1.644 1.761 15.990 0.615 0.385 0.947 0.053 0.430 0.291 0.278 0.168 0.641 0.191 0.051 0.353 0.595
Class 2
Boys community Class 1
1.713
32.296***
0.033
2.635
31.581***
141.342*** 121.174*** 141.355*** 45.183*** 409.018*** 15.300***
v2
Class 1 Low-scoring class, Class 2 high-scoring class Significant v2 values in bold: * p \ 0.05, ** p \ 0.01, *** p \ 0.001 a Social anxiety item 1 text: ‘‘I feel anxious and do not know what to do in an embarrassing situation’’ b Social anxiety item 2 text: ‘‘I feel anxious when I am with others and have to do something while they watch me do it (for example be in a play, play music, sports)’’ c Social anxiety item 3 text: ‘‘I feel anxious when I have to speak or read aloud in front of a group of people’’ d Social anxiety item 4 text: ‘‘Before I go someplace where I am going to be with people (for example a party, school, football game), I sweat, my heart beats fast and/or I get a headache or stomach ache’’ e Social anxiety item 5 text: ‘‘Before I go to a party or someplace with other people, I think about what could go wrong (for example that I make mistakes, seem dumb and/or…what if they see how frightened I am!)’’ f Social anxiety item 6 text: ‘‘I feel anxious and do not know what to do when I am in a new situation’’
Number of respondents Percent respondents Mean social anxiety item 1 (range 1–5)a Mean social anxiety item 2 (1–5)b Mean social anxiety item 3 (1–5)c Mean social anxiety item 4 (1–5)d Mean social anxiety item 5 (1–5)e Mean social anxiety item 6 (1–5)f Mean all social anxiety items (1–5) Mean academic school problems (range 1–4) Mean bullying (0–10) Mean eating problems (7–28) Mean acne problems (1–4) Mean anxiety and depression (1–4) Mean age (13.0–18.9) Prob. no suicidal thoughts Prob. yes suicidal thoughts Prob. no drug use Prob. yes drug use Prob. never drunk Prob. drunk 1–10 times Prob. drunk [10 times Prob. family economy worse than others Prob. family economy like others Prob. family economy better than others Prob. living without parents Prob. living with one parent Prob. living with two parents
Class 1
Girls clinical
Table 1 Two-class solution of latent profile analyses with social anxiety scores predicting latent class membership (upper panel) and v2 tests of differences in means and probabilities of coexisting problems and sociodemographics between adolescents scoring low (class 1) and high (class 2) on social anxiety (lower panel)
Soc Psychiatry Psychiatr Epidemiol
1–4 1–3 0–2 13–18.9
Anxiety and depression Family economy
Living with number of parents
Age
1.67***
21.02 to 0.23
0–2 13–18.9
Living with number of parents
Age
0.09 to 1.13
0.22
0.08 to 1.26
20.76 to 0.40
0.67*
20.18
1.39 to 2.08 21.04 to 0.03
20.51
1.73***
20.68 to 0.11
20.29
0.28
20.28
20.24
1.36***
20.34
0.08 20.63
0.27 to 1.94
0.10
21.45 to 0.18
0.47 to 1.49
0.49 0.60*
Significant coefficients in bold: * p \ 0.05, ** p \ 0.01, *** p \ 0.001
0.06
0.52***
20.44 to 1.01
20.80 to 0.24
20.70 to 0.23
0.98 to 1.74
20.71 to 0.04
0.34***
20.08
20.38***
1.90***
20.01
20.22*
20.68 to 0.84 21.50 to 0.24
1.17*** 0.70***
20.24 to 0.69 20.39 to 0.60
1.12***
0.14 to 1.05
1.00***
0.45***
20.01 to 0.99
20.23**
20.47 to 0.57
2.21*** 20.71***
0.06
20.01 to 1.46
1.26 to 2.16 20.36 to 0.44
b = Standardized beta values divided by the standard deviation of that covariate in the community sample
1–4 1–3
Anxiety and depression
Family economy
0, 1
Drug use
0.44 to 1.43 0.94 to 1.80
0.05 0.73
-0.63
1.10**
0–4 0–2
Acne problems
0.61* 0.98***
7–28 0, 1
Eating problems
Suicidal thoughts
0.94*** 1.37***
1–4 0–10
0.75 to 2.08
1.71*** 0.04
20.37 to 0.15
21.01 to 0.50
20.25 20.11
20.07 to 1.61 20.11 to 0.47
0.73***
1.24***
20.24 to 0.83 20.64 to 0.64
1.36***
0.30 to 1.04
0.30
0.67***
1.54*** 1.23***
0.42 to 1.28 20.02 to 0.64
20.00
1.32 to 2.43
20.40 1.42***
0.85*** 0.31
0.18 to 1.72
1.13 to 1.93
2.30 to 2.57 21.11 to 20.16
Academic school problems
Alcohol intoxications
1.22 to 2.11 0.88 to 1.56
2.43*** 20.64**
0.18
0.77
0.95*
1.88***
1.53***
1.22***
b
0.21 to 0.47
20.21 to 0.05
20.52 to 20.25
1.79 to 2.02
20.14 to 0.12
20.40 to 20.04
0.39 to 0.65
0.50 to 0.90
1.04 to 1.29
0.98 to 1.26
0.87 to 1.13
0.32 to 0.58
20.37 to 20.10
2.10 to 2.33 20.88 to 20.57
20.08 to 0.20
20.14 to 0.25
0.60 to 0.87
1.03 to 1.45
1.23 to 1.49
1.09 to 1.37
1.41 to 1.67
95 % CI
b
b 95 % CI
Adjusted for age
Adjusted for all variables
Adjusted for age 95 % CI
Community sample
Clinical sample
Bullying
Boys
0–2 0, 1
Alcohol intoxications
Drug use
0, 1 0–4
Suicidal thoughts
7–28
Eating problems
Acne problems
1–4 0–10
Academic school problems
Range
Bullying
Girls
Independent variables
0.68***
0.22***
0.22*
0.48***
0.30***
0.41***
0.04
20.17**
1.51***
20.25***
20.57***
0.12*
0.00
0.56***
0.41***
0.41***
0.42***
0.03
1.53*** 20.35***
20.18**
20.53***
b
0.26 to 0.56
20.07 to 0.15
20.28 to 20.05
1.37 to 1.64
20.37 to 20.14
20.73 to 20.40
0.01 to 0.23
20.19 to 0.20
0.44 to 0.68
0.28 to 0.55
0.28 to 0.55
0.26 to 0.58
20.08 to 0.15
1.38 to 1.68 20.47 to 20.23
20.30 to 20.07
20.70 to 20.36
0.10 to 0.34
0.02 to 0.43
0.35 to 0.60
0.16 to 0.43
0.55 to 0.82
95 % CI
Adjusted for all variables
Table 2 Standardized beta coefficients and 95 % confidence intervals of linear regression analysis with social anxiety symptoms as dependent and coexisting problems and sociodemographic characteristics as independent variables among girls and boys in the clinical and community sample
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groups than adolescents in class 1. In addition, individuals in class 2 in all groups, except boys in the clinical sample, had a higher mean score for eating problems and reported worse family economy. Girls in class 2 in both samples had a higher probability of alcohol intoxications than girls in class 1.
Discussion In the present study, social anxiety symptoms were frequently reported by adolescents, more so by girls than boys as well as by the clinical compared to the community sample. Two latent classes of adolescents reporting high vs. low levels of social anxiety were identified. The most prominent correlates of social anxiety symptoms were academic school problems, bullying, eating problems, acne problems, general anxiety and depression, and older age. Also, a negative perception of family economy was associated with social anxiety for all groups except boys in the clinical sample. Drug use and number of alcohol intoxications were inconsistently related to social anxiety. The present study expands on existing knowledge by focusing on correlates of social anxiety in clinical and community samples, which provides a richer understanding of the burden faced by adolescents who struggle with social anxiety and factors potentially important for prevention and treatment purposes. Comparing social anxiety symptoms Social anxiety symptoms were more often reported by girls, confirming findings from previous studies [2, 38]. As expected, symptoms were more common in the clinical than in the community sample. Most adolescents in the community are healthy. In the clinical sample, only 2.3 % of the adolescents received a primary ICD-10-diagnosis of social phobia, whereas 40.4 % of girls and 26.7 % of boys were extracted as a latent class reporting high levels of social anxiety symptoms. Thus, many adolescents with such symptoms were referred to the specialist mental health service for treatment, but not for social anxiety. This confirms findings that individuals with social anxiety primarily seek treatment for other disorders [21], and that social anxiety is frequently not recognized by clinicians [20]. Thus, the identification of social anxiety in clinical settings seems suboptimal. The frequency of social anxiety symptoms in the community is consistent with previous findings [2], indicating that social fears are experienced daily by many adolescents. This was also underscored by the results from LPA, in which rather large proportions (16.2–40.4 %) in all sex-by-sample groups were in the high social anxiety class.
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Associated sociodemographic correlates and coexisting problems Older age was associated with social anxiety symptoms in all groups, consistent with most other studies [2, 4]. A subjective perception of worse family economy was also associated with social anxiety, supporting findings from another study also measuring subjective perception [2]. A study measuring exact income did however not find an association with social anxiety [6]. Academic school problems were strongly associated with social anxiety symptoms among girls and boys in both samples, and more school problems were reported in the high than in the low social anxiety class. The scale included items on comprehension and concentration problems, which may confound antecedents and consequences of social anxiety. This makes it unclear whether the scale reflects actual learning difficulties leading to social anxiety or vice versa, which is also a problem in previous studies. Thus, longitudinal research clarifying these issues is necessary. Bullying, another problem often occurring in the school setting, was highly associated with social anxiety in both samples, and more often reported in the high social anxiety class. This is consistent with previous studies, with explanations including deficits in social skills, poorer feedback from peers and traumatization from bullying [7, 39]. Adults working with adolescents need to be aware of the possible associations between social anxiety and both academic and social school problems. Eating problems have been associated with social anxiety previously, but most studies have had only adult female respondents [40]. The present study extends this association to adolescents of both sexes, and healthcare workers should be especially aware that boys with eating problems might experience broader social problems that warrant attention. We have not been able to find studies examining why social anxiety and eating problems are related, although low self-esteem, bullying and a critical family environment may be possible explanations. Acne was modestly but consistently associated with social anxiety in both sexes in both samples, with the high social anxiety class reporting more acne problems. Thus, it seems that the negative psychological effects of acne extend beyond general anxiety and depression to social anxiety. Suicidal thoughts were associated with social anxiety in all groups. Consistent with previous research [15, 41], this association disappeared when controlling for anxiety/ depression, except among girls in the community sample. As girls tend to be more socially oriented than boys [42], girls with social anxiety may experience their anxiety as more burdensome. Because social fears are quite common among adolescents, it is difficult to identify when treatment is indicated.
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One study among adults concluded that social anxiety ‘‘seems to exist on a continuum of severity’’ [18, p 1046]. However, our analyses were able to identify a group of adolescents scoring high on social anxiety symptoms who also had a broad spectrum of additional difficulties and may be at high risk for mental health problems. The findings provide a rough profile on the mean score for each item on the SPAI-C, which can be useful for separating low- and high-risk groups. As indicated by overlapping confidence intervals, there were few differences between the clinical and community samples with regard to problems correlated with social anxiety. Due to the larger number of participants in the community sample, the estimates from this sample may be more precise. Methodological strengths and limitations The advantage of LPA is that data are used empirically to identify subgroups within the samples. Supporting the validity of this analysis, the resulting subgroups consisted of high- and low-scorers on the social anxiety items. Although based on different methodologies, regression analyses and LPA paint a quite similar picture of the correlates of social anxiety. This shows the complementarity of both methods, and their convergence suggests that our findings are valid. In addition, LPA was able to show that girls in the high social anxiety class had a higher probability of alcohol and drug use. Concurrent assessment of adolescents reduces recall biases in our study compared to previous studies that have relied on adults’ retrospective reports. Self-reported social anxiety symptoms and correlates were examined in large samples drawn from clinic and community settings comparable with regard to measures used, age, geographic area, and culture. The response rate in the community sample supports the representativeness of those results whereas the lower response rate in the clinical sample is a limitation. However, there were no substantial differences between participants and non-participants in main reason for referral, suggesting that participants are fairly representative of the clinical population. Previous studies indicate that adolescents’ self-reports of mental health and health-risk behaviours are generally valid [43]. There was a low degree of missing values on most variables, except for alcohol intoxications (15–25 % in the sex-by-sample groups). Multiple imputation was used because it results in less biased estimates than complete case analyses under a missing-at-random assumption [44]. The cross-sectional design of the study makes it impossible to establish causal relationships. The correlated factors may be associated with a range of psychiatric problems, not uniquely with social anxiety. Also, social anxiety may be a consequence of these problems.
Furthermore, the problems may interact and mutually influence each other. More longitudinal and experimental research is needed to clarify whether these problems are antecedents or consequences of social anxiety.
Conclusion Social anxiety symptoms were frequently reported both in the clinical and the community samples, and were associated with academic school problems, bullying, eating problems, acne, and general anxiety and depression. Adolescents with a high social anxiety score had a broad spectrum of additional difficulties. The results are important for both identification and prevention of social anxiety. The associated problems may be easier to detect than social anxiety symptoms as such, and hence, can be used to identify burdening symptoms. The findings from this study should be communicated to parents, health personnel, and especially mental health professionals so that adolescents who are struggling with social anxiety will be identified and helped. In light of the associations found in the present study, prevention programs targeting bullying, school problems, anxiety/depression, and eating problems could be useful for reducing social anxiety. As recommended in previous research on prevention of mental health problems [45], long-term interventions targeting adolescent, family, peer, school environment, and community settings will probably also increase the likelihood of success in prevention and treatment of social anxiety. Acknowledgments The Health Survey in Department of Child and Adolescent Psychiatry (The CAP study) is a collaboration between Department of Child and Adolescent Psychiatry, St. Olav’s Hospital, Trondheim University Hospital, and The Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Faculty of Medicine, Norwegian University of Science and Technology, Trondheim. The Nord-Trøndelag Health Study (The HUNT Study) is a collaboration between HUNT Research Centre (Faculty of Medicine, Norwegian University of Science and Technology NTNU), Nord-Trøndelag County Council, Central Norway Health Authority, and the Norwegian Institute of Public Health. Financial support was provided by Department of Child and Adolescent Psychiatry, St. Olav’s Hospital, Trondheim University Hospital, and The Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Faculty of Medicine, Norwegian University of Science and Technology, Trondheim. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
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ORIGINAL PAPER
Self-reported social anxiety symptoms and correlates in a clinical (CAP) and a community (Young-HUNT) adolescent sample Ingunn Ranøyen • Thomas Jozefiak • Jan Wallander • Stian Lydersen • Marit S. Indredavik
Received: 3 December 2012 / Accepted: 16 April 2014 Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The frequencies of social anxiety symptoms in a mental health clinical and a community sample of adolescents are compared. Also, we explore if adolescents can be classified in subgroups based on social anxiety symptoms. Associations between social anxiety symptoms and coexisting problems and sociodemographic characteristics are examined. Methods Adolescent participants, aged 13–18, in two large Norwegian studies, consisting of a clinical (n = 694, 42.1 % participation rate, 55 % girls, mean age = 15.6) and a community (n = 7,694, 73.1 % participation rate, 51 % girls, mean age = 15.8) sample completed identical
I. Ranøyen (&) T. Jozefiak S. Lydersen M. S. Indredavik Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU Central Norway), Faculty of Medicine, Norwegian University of Science and Technology, Pb. 8905, MTFS, 7491 Trondheim, Norway e-mail: [email protected] T. Jozefiak e-mail: [email protected] S. Lydersen e-mail: [email protected] M. S. Indredavik e-mail: [email protected] I. Ranøyen T. Jozefiak M. S. Indredavik Department of Child and Adolescent Psychiatry, St. Olavs Hospital, Postboks 6810, Elgeseter, 7433 Trondheim, Norway J. Wallander Psychological Sciences and Health Sciences Research Institute, University of California, Merced, 5200 North Lake Rd, Merced, CA 95343, USA e-mail: [email protected]
self-report questionnaires measuring social anxiety and related variables. Results Median sum scores (interquartile range) of social anxiety symptoms were higher among girls than boys and in the clinical [girls = 16 (12–22); boys = 12 (9–16)] compared to the community sample [girls = 12 (9–15); boys = 10 (7–12)] (p \ 0.001). Latent profile analysis revealed two classes of adolescents based on social anxiety profiles. Adolescents scoring high on social anxiety symptoms, which ranged from 16 % (boys in community sample) to 40 % (girls in clinical sample), had significantly more coexisting problems than those scoring low. Social anxiety symptoms were associated with academic school problems, bullying, eating problems, acne, and general anxiety and depression in both samples. Conclusion Social anxiety symptoms were commonly reported by adolescents, in both clinical and community settings. These symptoms were associated with a broad spectrum of coexisting problems, which can be used to detect adolescents struggling with social anxiety. Adolescent, family, peer, school, and community interventions targeting these associated problems may contribute to prevent and alleviate social anxiety symptoms. Keywords Social anxiety Symptoms Adolescent psychopathology Latent profile analysis Abbreviations HUNT Young-HUNT CAP SPAI-C SCL
The Nord-Trøndelag Health Study The Nord-Trøndelag Health Study part for adolescents ages 13 through 19 Child and adolescent psychiatry Social Phobia and Anxiety Inventory for Children Symptom Check List
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ICD-10 LPA MI RMSEA BIC CR IQR
International Classification of Diseases, 10th Revision Latent profile analysis Multiple imputation Root mean square error of approximation Bayesian information criterion Composite reliability Interquartile range
Introduction In the few existing European community studies of adolescents the lifetime prevalence of social anxiety varies considerably from 1 to 24 % [1–4]. Most studies find social anxiety to be more common in females [5] and older adolescents [2], but one study of Swedish adolescents, ages 11–15, did not find social anxiety to increase with age [3], and a Finnish study found social anxiety to be equally prevalent in female and male adolescents [4]. We have found only two studies examining socioeconomic status in relation to social anxiety in adolescents, one reporting no [6] and the other a negative [2] association. We have been unable to find studies reporting the prevalence of social anxiety in adolescent psychiatric clinical populations. Few studies have examined problems coexisting with social anxiety among adolescents, and then mainly focusing on comorbid diagnosed mental disorders. Depression and general anxiety disorder have consistently been found to co-occur with social anxiety [1, 4]. Eating disorders have been associated with the generalized subtype of social anxiety among adolescents, but not with any social anxiety diagnosis [2]. Also, it is unclear whether this association differs between girls and boys. Bullying is consistently reported to be associated with social anxiety (although with a relatively small effect size) [7, 8]. Some studies have found social anxiety in adolescence to be correlated with impaired school function [3, 4]. However, it is unclear whether these school-related problems are caused by social anxiety or learning difficulties. It is conceivable that problems with acne may be related to social anxiety as adolescents perceive acne to have negative social consequences [9]. Acne has been associated with general anxiety in adolescent girls [10], but associations with social anxiety have not been examined previously. Social anxiety has shown inconsistent associations with drug use [11, 12] and alcohol problems [13, 14]. In addition, suicidal behaviour has been related to social anxiety with comorbid depression among female adolescents [15], but this has not been examined in male adolescents.
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Among individuals developing social anxiety, 95 % do so before the age of 20 [1, 16]. However, most research informing about adolescent social anxiety thus far has examined adults, possibly introducing recall biases. Although social anxiety is a quite persistent disorder, fluctuations of symptom severity are common [17]. Even a high level of symptoms without necessarily fulfilling diagnostic criteria for social phobia leads to considerable problems in functioning and a reduced quality of life [18, 19]. Almost 25 % of patients who meet criteria for social phobia are instead diagnosed with other mental disorders [20], possibly because they have more comorbid problems than individuals with social anxiety who do not seek treatment [21]. This may indicate that important differences exist in social anxiety and related problems between clinical and community samples. Few individuals with ‘‘pure’’ social anxiety seek treatment [22], even though effective treatment exists [23]. This underscores the need for early detection of symptoms and prevention programs. Although some such programs do exist [24], examining coexisting problems associated with social anxiety can point towards important factors to focus prevention on, in addition to facilitate identification of adolescents with social anxiety. It would also be useful to identify a threshold for social anxiety at which severe comorbid problems occur. This has been examined among adults [18], but no threshold was identified in that study. Thus, the authors concluded that impairment increased linearly with the number of social fears. However, such examinations can be conducted in two complementary ways: by applying (1) variable-centred methods, such as imposing arbitrary cut-off points in logistic regression analyses, which was done in the abovementioned study [18]), or (2) person-centred methods to identify subgroups inherent in the data that differ from each other, for example by trying to classify high- and low-scorers in latent profile analyses. In summary, comparisons of symptoms and correlates of social anxiety in clinical and community samples are lacking in previous research. Also, there is a further need to examine at what level of social anxiety the severe coexisting problems occur. The aims of the present study therefore were to (1) compare social anxiety symptoms in a mental health clinical sample and a community sample of adolescent girls and boys, ages 13 through 18; (2) examine whether subgroups with different levels of social anxiety symptoms can be identified, using a person-centred method; (3) examine the linear relationships between social anxiety symptoms and relevant coexisting problems and sociodemographic characteristics in a clinical and a community sample; and (4) examine whether possible identified subgroups exhibit different coexisting problems.
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Community sample
Clinical sample
Excluded due to exclusion criteria N=289
Total population N=2032
Total population N=10490
Excluded due to exclusion criteria N=0
System error (were not invited) N=95
Should have been invited N=1743
Should have been invited N=10490
System error (were not invited) N=0
Did not consent to participation N=931 (56.5%)
Study population N=1648 (100.0%)
Study population N=10490 (100.0%)
Did not consent to participation N=1810 (17.3%)
Did not complete the study N=0 (0.0%)
Willing to participate N=717 (43.5%)
Willing to participate N=8680 (82.7%)
Did not complete the study N=480 (4.6%)
Participants completing the study N=717 (43.5%)
Participants completing the study N=8200 (78%)
Excluded due to low participation rate: 12 years, N=27 (0.3%) 19 years, N=219 (2.1%) 20 years, N=41 (0.4%)
Participants 13-18 years of age N=701 (42.5%)
Participants 13-18 years of age N=7913 (75.4%)
Excluded due to incomplete information on dependent variable: N=244 (2.3%)
Excluded due to low participation rate: 19 years, N=9 (0.5%) 20 years, N=7 (0.4%)
Excluded due to incomplete information on dependent variable: N=7 (0.4%)
Clinical participants in present study N=694 (42.1%)
Community participants in present study N=7669 (73.1%)
Fig. 1 Flowchart of participants in present study
Methods Participants and procedures Clinical sample The clinical sample consisted of all 13- to 18-year-old participants in The Health Survey in Department of Child and Adolescent Psychiatry, St. Olav’s University Hospital in the county of Sør-Trøndelag, Norway (termed the CAP survey). This clinic provides diagnoses and treatment for all psychiatric conditions in referred children and adolescents, ages 0–18. All patients between 13 and 18 years of age with at least one personal attendance at the clinic between February 2009 and 2011 were invited to participate in the survey. Exclusion criteria were major difficulties answering the questionnaire due to psychiatric state, cognitive function, visual impairments, or lack of sufficient language skills. Emergency patients were invited to take part once they entered a stable phase. The adolescent completed electronic questionnaires about his or her mental
health in conjunction with a clinic appointment. From a total population of 2,032, 289 adolescents fulfilled the exclusion criteria and 95 were missing registration data, and hence, were not included in study recruitment, resulting in an eligible population of 1,648. Of these, 694 (42.1 %), including 54.6 % girls (n = 379) and 45.4 % boys (n = 315), contributed data for this study (see Fig. 1). Mean age for girls was 15.8 (SD = 1.53) and boys 15.3 (SD = 1.52). The distributions across family structures were approximately the same for girls and boys; 6.2 and 5.3 % were not living with parents, 46.9 and 48.4 % were living with one parent, and 46.9 and 46.3 % were living with two parents, respectively. To explore the representativeness of the study population, we collected anonymous information about the reference population (n = 1,743) defined as all adolescents at the clinic in the study period (n = 2,032) minus those excluded (n = 289). Age, sex and main reason for referral between participants (n = 717) and non-participants (n = 1,026) were compared. Participants were 0.27 (95 % CI 0.10–0.45) years older than non-participants [mean
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(SD): 15.66 (1.65) vs. 15.39 (1.95), p = 0.0015]. There were more girls among participants compared to non-participants (54.8 vs. 49.6 %, p = 0.032). Main reason for referral is a variable with 16 categories coded according to a national classification system of suspected disorders (e.g. suspected anxiety disorder, suspected hyperkinetic disorders). Reason for referral did not differ between participants and non-participants (Pearson’s Exact v2 test p = 0.11). Community sample The community sample contained all adolescents ages 13 through 18 participating in the third Nord-Trøndelag Health Study (termed Young-HUNT3), a population health survey conducted in one county between 2006 and 2008 (a description of the sample is published in a separate paper [25]). This county with 131,000 inhabitants is contiguous to the county where the clinical study was performed. All inhabitants above the age of 12 were invited to the study, and there were no exclusion criteria. The survey was administered during a class at school. Adolescents temporarily away from school on the day of survey completion received the survey about 1 month later during a health exam that was also part of the original study. Adolescents not attending school were invited and received the survey by mail. Teachers read the questions aloud to adolescents with problems answering the questionnaire. From a population of 10,490, 7,669 (73.1 %) contributed data for this study (see Fig. 1). Mean age for girls was 15.8 (SD = 1.66) and for boys 15.7 (SD = 1.62). Approximately the same proportion of girls and boys participated [50.8 % girls (n = 3,898), 49.2 % boys (n = 3,771)]. The distributions across family structures were approximately the same for girls and boys; 6.4 and 5.0 % were not living with parents, 28.2 and 32.9 % were living with one parent, and 65.3 and 62.0 % were living with two parents, respectively. Instruments All scales and questionnaire items were identical for the clinical and the community sample because the clinical study was specifically modelled after the community study to be able to compare the two samples. In the clinical sample, ICD-10 [26] diagnoses of social phobia were set by a child and adolescent psychiatrist or a clinical psychologist. Social anxiety symptoms were measured with a shortened version of The Social Phobia and Anxiety Inventory for Children (SPAI-C) [27] consisting of six items from the original 26-item version. SPAI-C has been shown to be
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valid and reliable for use with adolescents ages 13 through 17 [28]. The HUNT study adapted a shortened version of the scale comprising six items, which is used in the current study with both samples. These items were selected based on factor analyses of the complete SPAI-C scale (T. Aune, personal communication, April 30, 2009). A clinical cutoff point has not been established for this shortened version. Each item was rated on an ordinal scale (1 = never, 5 = always), which were summed (range 6–30) with higher scores indicating more symptoms. Composite reliability (CR) indicated good internal consistency in both samples (CR = 0.918 in clinical sample; CR = 0.891 in community sample). Symptoms of general anxiety and depression in the previous 2 weeks were measured with the Symptom Check List (SCL-5), which consists of five items from the 25-item version of the SCL [29]. Whereas the SCL-5 has shown satisfactory reliability [30], a distinction between anxiety and depressive symptoms is not possible [31]. Each symptom was rated on an ordinal scale (1 = not bothered, 4 = very bothered). The mean across the five ratings was computed, with high scores indicating more symptoms. CR indicated good internal consistency in both samples (CR = 0.936 in clinical sample; CR = 0.899 in community sample). Eating problems were assessed with a seven-item-version of The Eating Attitude Test [32] addressing oral control, bulimia and food preoccupation. Each symptom was rated on an ordinal scale (1 = never, 4 = always), which were summed (range 7–28) with high scores indicating more symptoms. CR indicated good internal consistency in both samples (CR = 0.827 in clinical sample; CR = 0.803 in community sample). Academic school problems were measured by six items (e.g. comprehension, concentration problems) rated on an ordinal scale (1 = never, 4 = very often). Five items comprised the ‘‘academic’’ factor in a scale on school functioning [33]. In addition, a question on current learning problems was included. The mean across the six items was computed, with high scores indicating more problems. CR indicated good internal consistency in both samples (CR = 0.752 in the clinical sample; CR = 0.734 in the community sample). Bullying was assessed by four items. Two items on name-calling and exclusion by peers were rated on an ordinal scale (0 = never, 3 = very often). Another two items on sexual harassment and physical threats by peers were rated on a three-point scale (0 = never, 1 = yes, previously, 2 = yes, in the past year). A sum score for the four items was computed (range 0–10). CR indicated good internal consistency in both samples (CR = 0.814 in the clinical sample; CR = 0.831 in the community sample).
Soc Psychiatry Psychiatr Epidemiol
Suicidal thoughts were measured by one dichotomous item, ‘‘Have you ever thought about ending your own life?’’ (0 = no, 1 = yes). In the community sample, only adolescents above the age of 16 answered this item. Alcohol use was measured by one item, ‘‘Have you ever drunk so much alcohol that you felt intoxicated (drunk)?’’ We recoded the original six-point scale (1 = no, never, 2 = yes, once, 3 = yes, 2–3 times, 4 = yes, 4–10 times, 5 = yes, 11–25 times, 6 = yes, more than 25 times) into three categories (0 = never, 1 = 1–10 times, 2 = 11 or more times), as in previous studies [31, 34]. Individuals who had not tried alcohol were coded as 0 = never. Use of illegal substances was measured by one dichotomous item, ‘‘Have you ever tried hash, marijuana or other drugs?’’ (0 = no, 1 = yes). Acne problems were measured by one item, ‘‘How much has acne bothered you?’’, rated on an ordinal scale (1 = no impact, 4 = a lot of impact). Individuals reporting no acne were coded as 1 = no impact. Sociodemographic items asked about age, sex, and with whom the adolescent lives (0 = living alone, with friends, siblings and/or partner/spouse, 1 = living with one parent/ stepparent/grandparent(s), 2 = living with two parents, one parent and one stepparent, foster parents or adoptive parents). In addition, a question whether the adolescent feels his or her family is better or worse off economically than others was included (0 = worse off, 1 = the same, 2 = better off). Ethics All adolescents participating in the studies, and at least one parent when the adolescent was below 16 years of age, signed a written informed consent to participate. Both studies were approved by the Regional Committee for Medical and Health Research Ethics and the Norwegian Social Science Data Services, and have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Statistics Short forms of measurement scales are often used in epidemiological surveys to reduce respondent fatigue. As recommended [35], confirmatory factor analyses (CFA) were performed to examine the validity of the short forms used in the study. A model where items were made to load on their assumed latent variable had an acceptable-to-good model fit in both samples (e.g. RMSEA B0.065). Thus, the factor structure was retained.1
1
Further details on these analyses are available from the authors.
Due to non-normal distributions of social anxiety symptoms, group differences between the clinical and community samples were analysed by Mann–Whitney U tests. Latent profile analyses (LPA) were performed to empirically identify a division of social anxiety symptoms into groups instead of imposing an arbitrary cut-off point. The goal of LPA was to identify subgroups (latent classes) of adolescents based on how close or distant they were on their scores on the six social anxiety items (e.g. high- and low-scoring adolescents). To examine demographic correlates and coexisting problems, linear regression analyses with the sum score of social anxiety symptoms as the dependent variable were performed. First, the associations between social anxiety and each demographic correlate and coexisting problem were analysed, adjusting only for age, because age was associated with social anxiety. Then multi-adjusted regression analyses were carried out with all covariates entered simultaneously in the model. Multi-adjusted analyses should be interpreted with some caution due to the difficulty of deciding whether variables are mediators, confounders, or colliders [36]. Still, if a variable remains significant in such analyses, the importance of this variable is strengthened. To obtain comparable regression coefficients in both samples, all covariates were divided by the standard deviation of that covariate in the community sample. Also, differences between latent classes on coexisting problems and sociodemographic measures were analysed by v2 tests. These variables were entered as auxiliary to prevent the correlates from changing the class memberships for respondents. Missing values on social anxiety in the community sample ranged from 2.9 to 3.2 % across the six items, and in the clinical sample from 1.1 to 1.4 %. Following the SPAI-C-manual [27], respondents with missing on more than one of the six items were excluded from further analyses (see Fig. 1). The remaining missing values on the dependent variable and all independent variables were substituted by multiple imputation with 100 imputed data sets. All variables used in the analyses were included in the imputation models.2 To approximate normality for the multiple imputation, social anxiety, general anxiety and depression, eating problems, and academic school problems were transformed with the natural logarithm. For
2
With regard to the item on suicidal thoughts, the probability of missing values in the community sample was completely specified by the observed variable ‘‘age’’. Thus, because age was included in the imputation models, it was feasible to impute the missing values on the item on suicidal thoughts.
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LPA, results from complete case analyses are reported because tests of class differences are not readily available for multiple imputation datasets. Two-sided p values \0.05 were considered significant. CFA and LPA were performed using Mplus, version 7.11 [37]. All other analyses were performed in IBM SPSS Statistics 21. All analyses were performed separately for the two samples and each sex.
Results Comparing social anxiety symptoms As shown in Fig. 2, social anxiety symptoms were more frequent in the clinical than in the community sample (p \ 0.001). The median sum score (interquartile range) of social anxiety symptoms (range 6–30) in the clinical sample was higher (p \ 0.001) for girls [Mdn = 16 (12–22)] than boys [Mdn = 12 (9–16)]. This pattern was repeated in the community sample [girls: Mdn = 12 (9–15)]; [boys: Mdn = 10 (7–12)], (p \ 0.001). Both girls and boys in the clinical sample had more social anxiety symptoms than their respective same sex peers in the community sample (p \ 0.001). In the clinical sample, the prevalence of the ICD-10-diagnosis social phobia set by therapists in the clinic was 2.3 % (n = 16). Determining classes Fit statistics indicated that a two- or a three-class solution was appropriate among girls and boys in both samples. The log likelihood and BIC-statistics suggested a better fit to the data with three compared to two classes. However, entropy values decreased for all groups when comparing two against three classes, and the Vuong–Lo–Mendell– Rubin test showed that three classes did not fit the data significantly better than two classes among boys in the clinical sample. Applying the principle of parsimony, we determined that two classes fit the data best.3 The classification of individuals into classes and mean scores on social anxiety symptoms for girls and boys in each sample are shown in the upper panel of Table 1. Girls with a mean score on the six social anxiety items of 3.86 in the clinical sample [40.4 % (n = 153)] and 2.98 in the community sample [26.5 % (n = 1,032)] formed a relatively homogenous subgroup scoring high on social anxiety symptoms. Girls with a mean score of 2.12 in the clinical [59.6 % (n = 226)] and 1.72 in the community sample [73.5 % (n = 2,866)] formed another subgroup scoring low on symptoms. Boys with a mean score of 3.28 in the 3
Further details are available from the authors.
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clinical [26.7 % (n = 84)] and 2.88 in the community sample [16.2 % (n = 611)] constituted a subgroup of highscorers. Boys with a mean score of 1.68 in the clinical [73.3 % (n = 231)] and 1.51 in the community sample [83.8 % (n = 3,160)] constituted low-scorers. Coexisting problems and sociodemographic characteristics among girls The upper panel of Table 2 displays the associations between social anxiety symptoms and coexisting problems and sociodemographic characteristics among girls in the clinical and the community sample (b values are comparable). When the associations between social anxiety and each coexisting problem and sociodemographic variable were analysed adjusting only for age, positive associations were found in both samples for the following correlates (see Table 2): academic school problems, bullying, eating problems, suicidal thoughts, acne problems, symptoms of general anxiety and depression, older age and perception of poorer family economy. In the multi-adjusted models, adjusting for all other variables, academic school problems, eating problems, and anxiety and depression remained associated with social anxiety in both samples. Moreover, in the community sample, being bullied, having suicidal thoughts, acne problems, fewer alcohol intoxications, less drug use, and being older were also associated with social anxiety symptoms. The multi-adjusted models explained 40 % of the variance in the clinical sample and 32 % in the community sample. Coexisting problems and sociodemographic characteristics among boys The lower panel of Table 2 shows associations between social anxiety symptoms and coexisting problems and sociodemographic characteristics among boys in both samples (b values are comparable). When the associations between social anxiety symptoms and each coexisting problem and sociodemographic variable were analysed adjusting only for age, positive associations were found in both samples for the following correlates (see Table 2): academic school problems, bullying, eating problems, suicidal thoughts, acne problems, anxiety/depression, and older age. In the community sample, alcohol intoxications and family economy were negatively associated with social anxiety. When adjusting for all other variables, bullying and anxiety/depression remained associated with social anxiety in both samples. In the community sample, academic school problems, eating problems, acne problems, fewer alcohol intoxications, less drug use, poorer family economy, and being older were also associated with social anxiety. The multi-adjusted models explained 28 % of the variance in both samples.
Soc Psychiatry Psychiatr Epidemiol Fig. 2 Sum scores of social anxiety symptoms in the clinical and community samples
Class comparisons The lower panel of Table 1 shows that compared to adolescents with lower mean scores on each of the social
anxiety items (class 1), adolescents in class 2 had higher mean scores on academic school problems, bullying, acne problems, anxiety/depression, age and a higher probability of ever having had suicidal thoughts in all sex-by-sample
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123 226 59.6 2.357 2.162 2.733 1.541 1.725 2.206 2.121 2.169 1.382 11.188 2.073 2.061 15.57 0.484 0.516 0.897 0.103 0.503 0.281 0.216 0.175 0.639 0.186 0.045 0.455 0.500
153 40.4 3.660 3.915 4.223 3.572 3.825 3.964 3.860 2.521 2.656 14.182 2.341 3.044 16.118 0.176 0.824 0.810 0.190 0.310 0.384 0.306 0.325 0.497 0.178 0.086 0.490 0.424
Class 2
3.045
9.519**
10.172**
4.767*
35.832***
41.941*** 32.005*** 48.848*** 5.943* 173.181*** 12.332***
v2 2,866 73.5 1.917 1.747 2.205 1.308 1.396 1.717 1.715 1.714 0.424 9.875 1.352 1.469 15.712 0.828 0.172 0.977 0.023 0.429 0.318 0.254 0.069 0.762 0.169 0.056 0.279 0.665
1,032 26.5 2.954 3.085 3.587 2.511 2.745 2.983 2.978 2.024 1.213 11.855 1.844 2.104 16.053 0.528 0.472 0.969 0.031 0.354 0.374 0.272 0.190 0.698 0.112 0.089 0.289 0.622
Class 2
Girls community Class 1
10.914**
81.287***
12.693**
1.672
103.640***
377.850*** 189.169*** 327.965*** 111.354*** 799.017*** 32.819***
v2 231 73.3 1.871 1.685 2.057 1.385 1.450 1.627 1.679 2.132 1.009 9.912 1.766 1.454 15.166 0.749 0.251 0.891 0.109 0.580 0.262 0.158 0.111 0.654 0.235 0.044 0.470 0.486
84 26.7 3.209 3.496 3.710 2.782 2.973 3.486 3.276 2.293 2.345 10.551 2.094 2.184 15.613 0.517 0.483 0.915 0.085 0.680 0.194 0.127 0.187 0.668 0.145 0.074 0.521 0.405
Class 2
Boys clinical Class 1
1.677
4.395
1.998
0.366
12.616***
6.086* 29.693*** 3.319 7.858** 63.176*** 5.276*
v2 3,160 83.8 1.685 1.500 1.932 1.230 1.276 1.455 1.513 1.759 0.548 9.001 1.290 1.252 15.713 0.835 0.165 0.963 0.037 0.433 0.293 0.274 0.066 0.724 0.210 0.050 0.324 0.626
611 16.2 2.768 2.934 3.391 2.617 2.745 2.803 2.876 2.017 1.477 10.605 1.644 1.761 15.990 0.615 0.385 0.947 0.053 0.430 0.291 0.278 0.168 0.641 0.191 0.051 0.353 0.595
Class 2
Boys community Class 1
1.713
32.296***
0.033
2.635
31.581***
141.342*** 121.174*** 141.355*** 45.183*** 409.018*** 15.300***
v2
Class 1 Low-scoring class, Class 2 high-scoring class Significant v2 values in bold: * p \ 0.05, ** p \ 0.01, *** p \ 0.001 a Social anxiety item 1 text: ‘‘I feel anxious and do not know what to do in an embarrassing situation’’ b Social anxiety item 2 text: ‘‘I feel anxious when I am with others and have to do something while they watch me do it (for example be in a play, play music, sports)’’ c Social anxiety item 3 text: ‘‘I feel anxious when I have to speak or read aloud in front of a group of people’’ d Social anxiety item 4 text: ‘‘Before I go someplace where I am going to be with people (for example a party, school, football game), I sweat, my heart beats fast and/or I get a headache or stomach ache’’ e Social anxiety item 5 text: ‘‘Before I go to a party or someplace with other people, I think about what could go wrong (for example that I make mistakes, seem dumb and/or…what if they see how frightened I am!)’’ f Social anxiety item 6 text: ‘‘I feel anxious and do not know what to do when I am in a new situation’’
Number of respondents Percent respondents Mean social anxiety item 1 (range 1–5)a Mean social anxiety item 2 (1–5)b Mean social anxiety item 3 (1–5)c Mean social anxiety item 4 (1–5)d Mean social anxiety item 5 (1–5)e Mean social anxiety item 6 (1–5)f Mean all social anxiety items (1–5) Mean academic school problems (range 1–4) Mean bullying (0–10) Mean eating problems (7–28) Mean acne problems (1–4) Mean anxiety and depression (1–4) Mean age (13.0–18.9) Prob. no suicidal thoughts Prob. yes suicidal thoughts Prob. no drug use Prob. yes drug use Prob. never drunk Prob. drunk 1–10 times Prob. drunk [10 times Prob. family economy worse than others Prob. family economy like others Prob. family economy better than others Prob. living without parents Prob. living with one parent Prob. living with two parents
Class 1
Girls clinical
Table 1 Two-class solution of latent profile analyses with social anxiety scores predicting latent class membership (upper panel) and v2 tests of differences in means and probabilities of coexisting problems and sociodemographics between adolescents scoring low (class 1) and high (class 2) on social anxiety (lower panel)
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1–4 1–3 0–2 13–18.9
Anxiety and depression Family economy
Living with number of parents
Age
1.67***
21.02 to 0.23
0–2 13–18.9
Living with number of parents
Age
0.09 to 1.13
0.22
0.08 to 1.26
20.76 to 0.40
0.67*
20.18
1.39 to 2.08 21.04 to 0.03
20.51
1.73***
20.68 to 0.11
20.29
0.28
20.28
20.24
1.36***
20.34
0.08 20.63
0.27 to 1.94
0.10
21.45 to 0.18
0.47 to 1.49
0.49 0.60*
Significant coefficients in bold: * p \ 0.05, ** p \ 0.01, *** p \ 0.001
0.06
0.52***
20.44 to 1.01
20.80 to 0.24
20.70 to 0.23
0.98 to 1.74
20.71 to 0.04
0.34***
20.08
20.38***
1.90***
20.01
20.22*
20.68 to 0.84 21.50 to 0.24
1.17*** 0.70***
20.24 to 0.69 20.39 to 0.60
1.12***
0.14 to 1.05
1.00***
0.45***
20.01 to 0.99
20.23**
20.47 to 0.57
2.21*** 20.71***
0.06
20.01 to 1.46
1.26 to 2.16 20.36 to 0.44
b = Standardized beta values divided by the standard deviation of that covariate in the community sample
1–4 1–3
Anxiety and depression
Family economy
0, 1
Drug use
0.44 to 1.43 0.94 to 1.80
0.05 0.73
-0.63
1.10**
0–4 0–2
Acne problems
0.61* 0.98***
7–28 0, 1
Eating problems
Suicidal thoughts
0.94*** 1.37***
1–4 0–10
0.75 to 2.08
1.71*** 0.04
20.37 to 0.15
21.01 to 0.50
20.25 20.11
20.07 to 1.61 20.11 to 0.47
0.73***
1.24***
20.24 to 0.83 20.64 to 0.64
1.36***
0.30 to 1.04
0.30
0.67***
1.54*** 1.23***
0.42 to 1.28 20.02 to 0.64
20.00
1.32 to 2.43
20.40 1.42***
0.85*** 0.31
0.18 to 1.72
1.13 to 1.93
2.30 to 2.57 21.11 to 20.16
Academic school problems
Alcohol intoxications
1.22 to 2.11 0.88 to 1.56
2.43*** 20.64**
0.18
0.77
0.95*
1.88***
1.53***
1.22***
b
0.21 to 0.47
20.21 to 0.05
20.52 to 20.25
1.79 to 2.02
20.14 to 0.12
20.40 to 20.04
0.39 to 0.65
0.50 to 0.90
1.04 to 1.29
0.98 to 1.26
0.87 to 1.13
0.32 to 0.58
20.37 to 20.10
2.10 to 2.33 20.88 to 20.57
20.08 to 0.20
20.14 to 0.25
0.60 to 0.87
1.03 to 1.45
1.23 to 1.49
1.09 to 1.37
1.41 to 1.67
95 % CI
b
b 95 % CI
Adjusted for age
Adjusted for all variables
Adjusted for age 95 % CI
Community sample
Clinical sample
Bullying
Boys
0–2 0, 1
Alcohol intoxications
Drug use
0, 1 0–4
Suicidal thoughts
7–28
Eating problems
Acne problems
1–4 0–10
Academic school problems
Range
Bullying
Girls
Independent variables
0.68***
0.22***
0.22*
0.48***
0.30***
0.41***
0.04
20.17**
1.51***
20.25***
20.57***
0.12*
0.00
0.56***
0.41***
0.41***
0.42***
0.03
1.53*** 20.35***
20.18**
20.53***
b
0.26 to 0.56
20.07 to 0.15
20.28 to 20.05
1.37 to 1.64
20.37 to 20.14
20.73 to 20.40
0.01 to 0.23
20.19 to 0.20
0.44 to 0.68
0.28 to 0.55
0.28 to 0.55
0.26 to 0.58
20.08 to 0.15
1.38 to 1.68 20.47 to 20.23
20.30 to 20.07
20.70 to 20.36
0.10 to 0.34
0.02 to 0.43
0.35 to 0.60
0.16 to 0.43
0.55 to 0.82
95 % CI
Adjusted for all variables
Table 2 Standardized beta coefficients and 95 % confidence intervals of linear regression analysis with social anxiety symptoms as dependent and coexisting problems and sociodemographic characteristics as independent variables among girls and boys in the clinical and community sample
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groups than adolescents in class 1. In addition, individuals in class 2 in all groups, except boys in the clinical sample, had a higher mean score for eating problems and reported worse family economy. Girls in class 2 in both samples had a higher probability of alcohol intoxications than girls in class 1.
Discussion In the present study, social anxiety symptoms were frequently reported by adolescents, more so by girls than boys as well as by the clinical compared to the community sample. Two latent classes of adolescents reporting high vs. low levels of social anxiety were identified. The most prominent correlates of social anxiety symptoms were academic school problems, bullying, eating problems, acne problems, general anxiety and depression, and older age. Also, a negative perception of family economy was associated with social anxiety for all groups except boys in the clinical sample. Drug use and number of alcohol intoxications were inconsistently related to social anxiety. The present study expands on existing knowledge by focusing on correlates of social anxiety in clinical and community samples, which provides a richer understanding of the burden faced by adolescents who struggle with social anxiety and factors potentially important for prevention and treatment purposes. Comparing social anxiety symptoms Social anxiety symptoms were more often reported by girls, confirming findings from previous studies [2, 38]. As expected, symptoms were more common in the clinical than in the community sample. Most adolescents in the community are healthy. In the clinical sample, only 2.3 % of the adolescents received a primary ICD-10-diagnosis of social phobia, whereas 40.4 % of girls and 26.7 % of boys were extracted as a latent class reporting high levels of social anxiety symptoms. Thus, many adolescents with such symptoms were referred to the specialist mental health service for treatment, but not for social anxiety. This confirms findings that individuals with social anxiety primarily seek treatment for other disorders [21], and that social anxiety is frequently not recognized by clinicians [20]. Thus, the identification of social anxiety in clinical settings seems suboptimal. The frequency of social anxiety symptoms in the community is consistent with previous findings [2], indicating that social fears are experienced daily by many adolescents. This was also underscored by the results from LPA, in which rather large proportions (16.2–40.4 %) in all sex-by-sample groups were in the high social anxiety class.
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Associated sociodemographic correlates and coexisting problems Older age was associated with social anxiety symptoms in all groups, consistent with most other studies [2, 4]. A subjective perception of worse family economy was also associated with social anxiety, supporting findings from another study also measuring subjective perception [2]. A study measuring exact income did however not find an association with social anxiety [6]. Academic school problems were strongly associated with social anxiety symptoms among girls and boys in both samples, and more school problems were reported in the high than in the low social anxiety class. The scale included items on comprehension and concentration problems, which may confound antecedents and consequences of social anxiety. This makes it unclear whether the scale reflects actual learning difficulties leading to social anxiety or vice versa, which is also a problem in previous studies. Thus, longitudinal research clarifying these issues is necessary. Bullying, another problem often occurring in the school setting, was highly associated with social anxiety in both samples, and more often reported in the high social anxiety class. This is consistent with previous studies, with explanations including deficits in social skills, poorer feedback from peers and traumatization from bullying [7, 39]. Adults working with adolescents need to be aware of the possible associations between social anxiety and both academic and social school problems. Eating problems have been associated with social anxiety previously, but most studies have had only adult female respondents [40]. The present study extends this association to adolescents of both sexes, and healthcare workers should be especially aware that boys with eating problems might experience broader social problems that warrant attention. We have not been able to find studies examining why social anxiety and eating problems are related, although low self-esteem, bullying and a critical family environment may be possible explanations. Acne was modestly but consistently associated with social anxiety in both sexes in both samples, with the high social anxiety class reporting more acne problems. Thus, it seems that the negative psychological effects of acne extend beyond general anxiety and depression to social anxiety. Suicidal thoughts were associated with social anxiety in all groups. Consistent with previous research [15, 41], this association disappeared when controlling for anxiety/ depression, except among girls in the community sample. As girls tend to be more socially oriented than boys [42], girls with social anxiety may experience their anxiety as more burdensome. Because social fears are quite common among adolescents, it is difficult to identify when treatment is indicated.
Soc Psychiatry Psychiatr Epidemiol
One study among adults concluded that social anxiety ‘‘seems to exist on a continuum of severity’’ [18, p 1046]. However, our analyses were able to identify a group of adolescents scoring high on social anxiety symptoms who also had a broad spectrum of additional difficulties and may be at high risk for mental health problems. The findings provide a rough profile on the mean score for each item on the SPAI-C, which can be useful for separating low- and high-risk groups. As indicated by overlapping confidence intervals, there were few differences between the clinical and community samples with regard to problems correlated with social anxiety. Due to the larger number of participants in the community sample, the estimates from this sample may be more precise. Methodological strengths and limitations The advantage of LPA is that data are used empirically to identify subgroups within the samples. Supporting the validity of this analysis, the resulting subgroups consisted of high- and low-scorers on the social anxiety items. Although based on different methodologies, regression analyses and LPA paint a quite similar picture of the correlates of social anxiety. This shows the complementarity of both methods, and their convergence suggests that our findings are valid. In addition, LPA was able to show that girls in the high social anxiety class had a higher probability of alcohol and drug use. Concurrent assessment of adolescents reduces recall biases in our study compared to previous studies that have relied on adults’ retrospective reports. Self-reported social anxiety symptoms and correlates were examined in large samples drawn from clinic and community settings comparable with regard to measures used, age, geographic area, and culture. The response rate in the community sample supports the representativeness of those results whereas the lower response rate in the clinical sample is a limitation. However, there were no substantial differences between participants and non-participants in main reason for referral, suggesting that participants are fairly representative of the clinical population. Previous studies indicate that adolescents’ self-reports of mental health and health-risk behaviours are generally valid [43]. There was a low degree of missing values on most variables, except for alcohol intoxications (15–25 % in the sex-by-sample groups). Multiple imputation was used because it results in less biased estimates than complete case analyses under a missing-at-random assumption [44]. The cross-sectional design of the study makes it impossible to establish causal relationships. The correlated factors may be associated with a range of psychiatric problems, not uniquely with social anxiety. Also, social anxiety may be a consequence of these problems.
Furthermore, the problems may interact and mutually influence each other. More longitudinal and experimental research is needed to clarify whether these problems are antecedents or consequences of social anxiety.
Conclusion Social anxiety symptoms were frequently reported both in the clinical and the community samples, and were associated with academic school problems, bullying, eating problems, acne, and general anxiety and depression. Adolescents with a high social anxiety score had a broad spectrum of additional difficulties. The results are important for both identification and prevention of social anxiety. The associated problems may be easier to detect than social anxiety symptoms as such, and hence, can be used to identify burdening symptoms. The findings from this study should be communicated to parents, health personnel, and especially mental health professionals so that adolescents who are struggling with social anxiety will be identified and helped. In light of the associations found in the present study, prevention programs targeting bullying, school problems, anxiety/depression, and eating problems could be useful for reducing social anxiety. As recommended in previous research on prevention of mental health problems [45], long-term interventions targeting adolescent, family, peer, school environment, and community settings will probably also increase the likelihood of success in prevention and treatment of social anxiety. Acknowledgments The Health Survey in Department of Child and Adolescent Psychiatry (The CAP study) is a collaboration between Department of Child and Adolescent Psychiatry, St. Olav’s Hospital, Trondheim University Hospital, and The Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Faculty of Medicine, Norwegian University of Science and Technology, Trondheim. The Nord-Trøndelag Health Study (The HUNT Study) is a collaboration between HUNT Research Centre (Faculty of Medicine, Norwegian University of Science and Technology NTNU), Nord-Trøndelag County Council, Central Norway Health Authority, and the Norwegian Institute of Public Health. Financial support was provided by Department of Child and Adolescent Psychiatry, St. Olav’s Hospital, Trondheim University Hospital, and The Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Faculty of Medicine, Norwegian University of Science and Technology, Trondheim. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
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