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Social Skills and Social Acceptance in Children with Anxiety Disorders a
b
Lindsay A. Scharfstein & Deborah C. Beidel a
Yale Child Study Center, Yale University
b
Department of Psychology, University of Central Florida Published online: 12 May 2014.
Click for updates To cite this article: Lindsay A. Scharfstein & Deborah C. Beidel (2015) Social Skills and Social Acceptance in Children with Anxiety Disorders, Journal of Clinical Child & Adolescent Psychology, 44:5, 826-838, DOI: 10.1080/15374416.2014.895938 To link to this article: http://dx.doi.org/10.1080/15374416.2014.895938
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Journal of Clinical Child & Adolescent Psychology, 44(5), 826–838, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1537-4416 print=1537-4424 online DOI: 10.1080/15374416.2014.895938
ANXIETY SYMPTOMS
Social Skills and Social Acceptance in Children with Anxiety Disorders Lindsay A. Scharfstein Yale Child Study Center, Yale University
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Deborah C. Beidel Department of Psychology, University of Central Florida
Whereas much is known about the deficits in social behaviors and social competence in youth with social anxiety disorder (SAD), less is known about those characteristics among youth with generalized anxiety disorder (GAD). This study aimed to better elucidate the social repertoire and peer acceptance of youth with SAD and youth with GAD, relative to normal control (NC) youth. The sample consisted of 58 primarily Caucasian children, ages 6 to 13 years: 20 SAD (12 female), 18 GAD (12 female), and 20 NC (9 female). Diagnoses were based on Anxiety Disorders Interview Schedule for DSM-IV: Children and Parent Versions interviews. A multimodal assessment strategy included parent and child reports, observer ratings of social performance, computer-based analysis of vocal qualities of speech, and peer ratings of likeability and friendship potential. Whereas self- and parental report did not differentiate the two diagnostic groups, differences on observable behaviors were apparent. Children with SAD exhibited anxious speech patterns, extended speech latencies, a paucity of speech, few spontaneous vocalizations, and ineffective social responses; they were perceived by peers as less likeable and socially desirable. Children with GAD had typical speech patterns and were well liked by their peers but displayed fewer spontaneous comments and questions than NC children. Parent and child reports are less sensitive to what could be important differences in social skill between youth with SAD and GAD. Direct observations, computer-based measures of speech quality, and peer ratings identify specific group differences, suggesting the need for a comprehensive evaluation to inform treatment planning.
Social anxiety disorder (SAD) is the most common pediatric anxiety disorder, with current prevalence ranging between 3% and 8% of youth (Costello, Egger, & Angold, 2005). SAD has an early onset, characterized by a marked and persistent fear of social situations in which negative evaluation may occur (Beesdo et al., 2007; Beidel, Turner, & Morris, 1999). Feared social situations include reading in front of others, speaking to unfamiliar children or adults, and participating in groups=clubs (Beidel et al., 1999), and social interaction Correspondence should be addressed to Lindsay A. Scharfstein, Yale Child Study Center, Yale University, 230 South Frontage Road, New Haven, CT 06519. E-mail: [email protected]
difficulties are consistently identified among youth with SAD (e.g., Beidel et al., 1999; Beidel et al., 2007; Spence, Donovan, & Brechman-Toussaint, 1999). Children with SAD are less socially competent and less socially skilled than normal control (NC) children according to self (Spence et al., 1999) and parent report (Scharfstein, Alfano, Beidel, & Wong, 2011; Spence et al., 1999). They also are less likely to select assertive responses to social vignettes than NC peers (Spence et al., 1999). During analogue role plays, children with SAD are less skilled interpersonally (Beidel et al., 1999; Rao et al., 2007; Spence et al., 1999) and have longer speech latencies than NC youth (Beidel et al., 1999; Scharfstein, Beidel, Sims, & Rendon Finnel, 2011). In
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SOCIAL SKILLS
the latter study, children with SAD exhibit deficient speech production and difficulty managing the conversational topic relative to NC youth and youth with Asperger’s disorder. Digital vocal analysis revealed that children with SAD speak more softly than NC peers and have higher vocal pitch and more vocal pitch variability (jitteriness) than children with Asperger’s disorder (Scharfstein, Beidel, Sims, et al., 2011). Thus, youth with SAD evidence anxious speech and deficits in many of the basic social skills necessary for successful peer interactions. Whereas deficits in social behaviors and social competence in youth with SAD have been established, much less is known about those characteristics among youth with generalized anxiety disorder (GAD). GAD is characterized by excessive worry (American Psychiatric Association, 2000), and children with this disorder often set exceedingly high standards for their competence in and the quality of their peer relationships (Albano, Chorpita, & Barlow, 2003). Their eagerness to please and their tendency to be perfectionistic, overly conscientious (Bernstein & Layne, 2006), and rule abiding may facilitate friendships. Alternatively, their excessive reassurance seeking and preoccupation with performance (Albano et al., 2003) might annoy and=or eventually alienate other children. Based on parent report alone, children with GAD have relatively fewer friends but are otherwise similar to NC youth in terms of interpersonal functioning, social competence, presence of a best friend, and participation in groups=clubs (Scharfstein, Alfano, et al., 2011). Youth with GAD may possess adequate social skills, but to date, this has only been assessed through questionnaires, and no study has assessed social behaviors in GAD youth through direct observation. The comparison of social abilities between these two diagnostic groups is important for understanding psychopathology and developing optimal remediation efforts. Youth with SAD and GAD often are researched collectively (i.e., as a unitary group), treated using identical treatment protocols, and outcome often is assessed unilaterally across the sample (e.g., Crawley, Beidas, Benjamin, Martin, & Kendall, 2008; Hudson, Rapee, Lyneham, Wuthrich, & Schneiring, 2010; Scharfstein & Beidel, 2011). Yet if differences in clinical functioning exist, clinicians may inappropriately apply less than adequate treatment approaches. Thus, direct observation and comparison of the social relations of youth with SAD and GAD is needed. Another important element of social functioning is peer relations (Hartup, 1996; Hartup & Stevens, 1999), including peer liking, friendships, and participation in social activities. In particular, youth with SAD, but not GAD, may have an increased risk for peer difficulties given their poor skills for social discourse and friendship formation. Thus far, our knowledge regarding peer relations among anxious youth is largely based on early
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studies examining sociometric status. In general, youth with anxiety disorders are found to be neglected by their peers (Diagnostic and Statistical Manual of Mental Disorders [third ed.; DSM–III] or DSM–III–R diagnoses; Strauss, Lahey, Frick, Frame, & Hynd, 1988). Children’s self-ratings are consistent with these sociometric data, wherein clinically anxious youth report having a best friend but fewer friends overall relative to their peers (Chansky & Kendall, 1997). A few studies have examined peer variables specifically among youth with SAD. On the school playground, they receive fewer positive responses and more negative and ignore responses than nonanxious peers (Spence et al., 1999). Although they are just as likely as their peers to have a best friend (Bernstein, Bernat, Davis, & Layne, 2008; Scharfstein, Alfano, et al., 2011), youth with SAD have fewer friends and difficulty making new friends compared to NC youth (Bernstein et al., 2008; Scharfstein, Alfano, et al., 2011; Spence et al., 1999). Most studies of peer functioning have used self- or parent reports, rather than direct report from same-age peers. In the only study to evaluate an immediate impression of liking, based on videotaped speeches, peers like children with anxiety disorders (SAD, GAD, separation anxiety disorder) less than youth without anxiety disorders (Verduin & Kendall, 2008). When likeability ratings are examined by specific anxiety diagnosis, lower scores of peer liking are uniquely associated with SAD. To summarize, impaired social skills are identified consistently among children with SAD, but less is known about those characteristics among children with GAD. Based on available data, children with GAD should be less impaired than those with SAD. In this study, we are examining two major areas of social functioning— social competence and social acceptance. Here, the term social competence comprises social skills=behaviors, social knowledge, and vocal characteristics, whereas the term social acceptance is used to refer to peer liking, friendship, and participation in social activities. The current study utilized direct observation to compare the social abilities and social acceptance of children with SAD to children with GAD and children with no DSM-IV-TR psychological disorder (NC). It was hypothesized that children with SAD would exhibit poorer social skills during a peer play interaction, would exhibit poorer social skills regardless of social context, and would be less socially accepted compared to children with GAD and NC children.
METHOD Participants The sample consisted of 58 children, ranging in age from 6 to 13 years: 20 children meeting DSM-IV-TR criteria
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for primary SAD (12 female), 18 children meeting DSM-IV-TR criteria for primary GAD (12 female), and 20 NC children (9 female) not meeting criteria for any DSM-IV-TR diagnosis. The groups were not different on age, F(2, 55) ¼ 1.804, ns, g2 ¼ 0.062; sex, v2(2) ¼ 1.933, ns, g2 ¼ 0.183; and race=ethnicity, v2(4) ¼ 11.619, ns, g2 ¼ 0.325. Descriptive statistics for demographic and clinical characteristics are presented in Table 1. The study was conducted through the University of Central Florida Anxiety Disorders Clinic, Orlando, Florida. Recruitment was conducted via flyers and mailings to local schools, pediatricians, and mental health providers. Children with SAD and GAD were clinically referred and=or recruited. These youth qualified for free group behavioral treatment at the Anxiety Disorders Clinic after study participation. Exclusion criteria for the anxiety disorder groups included comorbid SAD or GAD (in children diagnosed with primary GAD or SAD, respectively), attentiondeficit=hyperactivity disorder, autism spectrum disorders, bipolar diagnoses, psychosis, suicidal ideation, or intellectual disability. The NC children were recruited for this protocol and were compensated with a $20 gift card for participation. All participants provided written informed consent=assent to the study procedures prior to enrollment.
Procedures Diagnostic Procedure Children and their parent(s) were interviewed independently using the Anxiety Disorders Interview Schedule for DSM-IV: Children and Parent Versions (ADIS-C=P, Silverman & Albano, 1996) by a doctoral student in clinical psychology. Diagnoses were based on information from both sources. For each diagnosis, the clinician assigned the ADIS-C=P Clinician Severity Rating (CSR; a 9-point scale, ranging from 0 to 8). A CSR of 4 (moderate) or higher was required for study inclusion. Based on a random selection of 17% of the interviews, 90% interrater agreement on diagnosis (i.e., presence=absence) and CSRs (i.e., within 1 point) was obtained. Because limited cognitive and language abilities may negatively impact social and peer functioning, the Block Design and Vocabulary subtests of the Wechsler Intelligence Scale for Children–Fourth Edition (Wechsler, 2003) were administered. Block Design scores were average and did not differ significantly (MSAD ¼ 10.30, MGAD ¼ 10.11, MNC ¼ 11.65), F(2, 53) ¼ 1.634, ns, partial g2 ¼ 0.056. Vocabulary scores indicated at least average verbal intelligence and reasoning for all groups, with significantly lower scores in the SAD and GAD groups than the NC group (MSAD ¼ 10.22, MGAD ¼ 12.67,
TABLE 1 Demographic and Clinical Characteristics Generalized Anxiety Disorder Age (M=SD) Sex (n=%) Female Male WISC Standard Scores (M=SD) Block Design Vocabulary Race=Ethnicity (n=%) Caucasian Hispanic Biracial CSR (M=SD) Secondary Disorder (n=%) No Diagnosis OCD Specific Phobia Major Depression Selective Mutism PTSD
8.72 (1.6)
Social Anxiety Disorder 8.70 (2.0)
Normal Control
F=v2=t Value
Partial g2=g2
9.65 (1.8)
1.804 1.933
0.062 0.183
1.634 8.453 11.619
0.056 0.242 0.325
1.027 6.045
0.054
12 (66.7) 6 (33.3)
12 (60.0) 8 (40.0)
9 (45.0) 11 (55.0)
10.11 (3.0) 12.67 (1.5)a
10.30 (2.8) 10.22 (2.8)a
11.65 (2.9) 13.75 (3.3)b
16 2 0 5.56
(88.9) (11.1) (0.0) (1.0)
10 8 2 5.25
(50.0) (40.0) (10.0) (0.8)
14 1 1 1 0 1
(77.8) (5.6) (5.6) (5.0) (0.0) (5.6)
16 0 1 0 3 0
(80.0) (0.0) (5.0) (0.0) (15.0) (0.0)
12 (60.0) 3 (15.0) 5 (25.0)
Note: n ¼ 58. WISC ¼ Wechsler Intelligence Scale for Children; CSR ¼ Clinician Severity Rating; OCD ¼ obsessivecompulsive disorder; PTSD ¼ posttraumatic stress disorder. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 18 for the social anxiety disorder group for the vocabulary variable; n ¼ 20 for the normal control group; n ¼ 18 for the social anxiety disorder group. p .05). All scale scores fell in the nonclinical range, indicating that deficits in the SAD and GAD groups were not clinically problematic.
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On the SSRS, there was a significant effect for group on assertion, F(2, 55) ¼ 14.555, p < .001, partial g2 ¼ 0.346; responsibility, F(2, 55) ¼ 8.501, p ¼ .001, partial g2 ¼ 0.236; and social skills standard, F(2, 55) ¼ 8.228, p ¼ .001, partial g2 ¼ 0.230. Post hoc LSD tests revealed that children with SAD and children with GAD exhibit fewer social behaviors necessary for successful social engagement than their NC counterparts (p ¼ .001 and .011, respectively). Specifically, parents rated the SAD and GAD groups as exhibiting fewer assertive behaviors than NC group (p < .001 and p ¼ .001, respectively). Youth with SAD were also rated as exhibiting fewer responsible behaviors than NC children (p < .001). The SAD and GAD groups did not differ significantly on the social skills standard, assertion, and responsibility scores (ps > .05). No significant group differences emerged for self-control, F(2, 55) ¼ 2.203, p ¼ .120, partial g2 ¼ 0.074. No significant group differences emerged for cooperation despite a significant F score, F(2, 55) ¼ 3.645, p ¼ .033, partial g2 ¼ 0.117. Social Anxiety A series of ANOVAs examined the effect of group membership on all social anxiety dependent variables: (a) SPAIC-PV, (b) SPAIC, (c) SAM Baseline, (d) SAM Wii Social Task, (e) SAM Social Vignettes Task. See Table 2 for means and standard deviations. There was a significant group effect on SPAIC-PV, F(2, 55) ¼ 48.381, p < .001, partial g2 ¼ 0.638, and SPAIC, F(2, 53) ¼ 6.236, p ¼ .004, partial g2 ¼ 0.190. LSD tests revealed that children with SAD and GAD were rated as more socially anxious than NC children on the SPAIC-PV (both ps < .001) and SPAIC (ps ¼ .022 and .006, respectively). No significant differences emerged between the SAD and GAD groups on these scores (ps > .05). There were no significant group differences on SAM ratings during the baseline, F(2, 53) ¼ 0.403, ns, partial g2 ¼ 0.015; Wii Social Task, F(2, 53) ¼ 0.366, ns, partial g2 ¼ 0.014; and Social Vignettes Task, F(2, 53) ¼ 0.019, ns, partial g2 ¼ 0.001. Social Effectiveness and Social Knowledge during the Social Vignettes Task A series of ANOVAs examined the effect of group on the social vignette variables: number of prompts unanswered, average number of words per response, total number of words across responses, and appropriateness of responses (see Table 3). There was a significant main effect for group on the number of prompts unanswered, F(2, 55) ¼ 6.034, p ¼ .004, partial g2 ¼ 0.180; number of words across social responses, F(2, 55) ¼ 5.800, p ¼ .005, partial
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TABLE 2 Parent and Child Report of Social Competence and Social Anxiety
Social Skill CBCL Subscale Social Competence Social Problems SSRS Subscale Cooperation Assertion Responsibility Self-Control SSRS Total Score Social Anxiety Parent Report SPAIC-PV Self-Report SPAIC Behavioral Assessment Baseline SAM Wii SAM Social Vignette SAM
Generalized Anxiety Disorder M (SD)
Social Anxiety Disorder M (SD)
Normal Control M (SD)
F Value
Partial g2
39.61 (7.9)a 62.22 (8.3)a
39.85 (8.3)a 57.80 (7.4)a
54.90 (7.8)b 52.05 (4.6)b
23.444 10.404
.460 .274
10.00 11.78 12.11 12.17 86.61
10.35 10.25 10.35 11.55 81.95
3.645 14.555 8.501 2.203 8.228
.117 .346 .236 .074 .230
(3.4) (3.2)a (3.3)a,b (4.1) (15.9)a
(3.5) (2.9)a (1.5)a (3.1) (10.5)a
13.00 16.50 14.55 14.05 107.05
(4.4) (5.0)b (4.3)b (4.5) (30.1)b
28.12 (10.4)a
33.34 (6.2)a
8.11 (8.7)b
48.381
.638
18.23 (9.0)a
19.42 (9.2)a
10.62 (6.9)b
6.236
.190
1.39 (0.7) 1.78 (1.1) 1.33 (0.7)
1.39 (0.5) 1.50 (0.8) 1.33 (0.6)
1.25 (0.4) 1.70 (1.1) 1.30 (0.6)
0.403 0.366 0.019
0.015 0.014 0.001
Note: n ¼ 56. CBCL ¼ Child Behavior Checklist; SSRS ¼ Social Skills Rating System; SPAIC-PV ¼ Social Phobia and Anxiety Inventory for Children–Parent Version; SAM ¼ Self-Assessment Manikin. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 20 for the normal control group. p < .05. p < .01. p < .001. a,b Means sharing superscripts are not significantly different.
g2 ¼ 0.174; and appropriateness of responses, F(2, 55) ¼ 7.145, p ¼ .002, partial g2 ¼ .206. Post hoc LSD tests revealed that children with SAD responded to social prompts with fewer words (ps ¼ .023 and .010, respectively) and left more prompts unanswered (ps ¼ .006 and .029, respectively) than children with GAD and NC children. Further, children with SAD provided less effective responses to peer-initiated social prompts than the GAD and NC groups (p ¼ .018 and .002, respectively). No significant differences emerged between the NC and GAD groups (ps > .05). Social Behavior and Vocal Characteristics during the Wii Social Task A series of ANOVAs examined the effect of group membership on social behavior variables: (a) latency to first utterance, (b) instances of talk, and the frequency of (c) answers to peer questions, (d) spontaneous comments, (e) exclamations, and (f) questions. Because these scores were dependent upon speaking, all statistical analyses were conducted initially excluding children with a comorbid diagnosis of selective mutism (SM). The results were not different when SM was excluded. Therefore to maximize power, the results presented next include children with a comorbid SM diagnosis. Means and standard deviations are reported in Table 3.
There was a significant main effect for group on latency to first vocalization, F(2, 55) ¼ 8.708, p ¼ .001, partial g2 ¼ 0.240; instances of talk, F(2, 55) ¼ 16.769, p < .001, partial g2 ¼ 0.379; and the frequency of spontaneous comments, F(2, 55) ¼ 18.894, p < .001, partial g2 ¼ 0.407; exclamations, F(2, 55) ¼ 4.272, p ¼ .019, partial g2 ¼ 0.134; and questions, F(2, 55) ¼ 1 4.828, p < .001, partial g2 ¼ 0.350. Post hoc LSD tests revealed that children with SAD took longer to make their first prompted or unprompted vocalization (ps ¼ .002 and .003, respectively) and spoke on fewer occasions compared to the GAD and NC children (both ps < .001). The GAD and NC groups did not differ significantly (ps > .05). Children with SAD made fewer spontaneous comments than children with GAD and NC children (p ¼ .004 and p < .001, respectively). In addition, the GAD group made fewer spontaneous comments than children in the NC group (p ¼ .042). Children with SAD made fewer exclamations than NC children (p ¼ .017), whereas the GAD group fell between but was not significantly different (ps > .05). Both children with SAD and children with GAD asked fewer questions than NC children (p < .001 and p ¼ .004, respectively), but were not significantly different (ps > .05). No significant group differences emerged for the number of answers to questions, F(2, 55) ¼ 2.489, ns, partial g2 ¼ 0.083.
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TABLE 3 Vocal Characteristics and Observer Ratings of Social Behavior
Social Vignettes Task No. of Words No. of Unanswered Prompts Appropriateness Wii Social Task Latency to Speech (in seconds) Instances of Talk Comments Exclamations Questions Answers Vocal Features Pitch Minimum Pitch Maximum Pitch Mean Pitch Variability Volume Minimum Volume Maximum Volume Mean Volume Variability
Generalized Anxiety Disorder M (SD)
Social Anxiety Disorder M (SD)
Normal Control M (SD)
45.39 (23.2)a 0.28 (0.8)a 16.22 (2.7)a
24.65 (22.4)b 2.45 (3.3)b 13.40 (3.7)b
47.15 (23.6)a 0.70 (0.9)a 16.80 (2.5)a
5.800 6.034 7.145
0.174 0.180 0.206
34.66 (99.3)a 44.80 (14.9)a 53.4 (26.5)c 14.00 (19.5)b 9.35 (5.4)b 6.50 (4.2)
8.708 16.769 18.894 4.272 14.828 2.489
0.240 0.379 0.407 0.134 0.350 0.083
(8.5)a (33.4)a (20.5) (11.5)b (3.5) (6.0)a (8.2)b (0.8)a,b
5.798 5.430 .177 3.558 .028 5.171 4.864 8.087
0.185 0.176 0.007 0.122 0.001 0.169 0.160 0.241
18.78 40.50 35.61 10.00 4.72 5.28
(25.68)a (17.1)a (22.4)a (10.6)a,b (3.0)a (3.5)
225.30 (274.7)b 16.6 (17.5)b 11.65 (14.0)b 2.15 (3.4)a 2.1 (3.9)a 3.65 (4.3)
185.50 497.64 274.65 56.10 55.71 88.30 69.39 6.68
(9.3)a (48.2)a (20.5) (13.8)a,b (4.0) (6.0)a (6.3)a,b (1.4)a
196.59 444.59 271.01 46.66 55.97 82.14 65.17 4.99
(17.9)b (87.1)b (24.2) (18.0)a (2.3) (8.0)b (3.1)a (1.4)b
183.26 505.17 275.01 59.25 55.89 88.73 71.84 5.95
F Value
Partial g2
Note: n ¼ 58. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 16 for the social anxiety group for all of the vocal feature variables; n ¼ 20 for the normal control group. p < .05. p < .01. p < .001. a,b,c Means sharing superscripts are not significantly different.
Vocal Characteristics A series of ANOVAs examined the effect of group membership on vocal characteristics during the Wii Task: (a) minimum pitch, (b) maximum pitch, (c) mean pitch, and (d) pitch variability, (e) minimum volume, (f) maximum volume, (g) mean volume, and (h) volume variability. Means and standard deviations are reported in Table 3 (see Figure 1 for visual representation of vocal characteristics). Four children’s scores in the SAD group were excluded from data analysis of vocal characteristics due to their refusal to speak during the Wii task. Analysis of the individual variables revealed a significant main effect for group on minimum pitch, F(2, 51) ¼ 5.798, p ¼ .005, partial g2 ¼ 0.185; maximum pitch, F(2, 51) ¼ 5.430, p ¼ .007, partial g2 ¼ 0.176; pitch variability, F(2, 51) ¼ 3.558, p ¼ .036, partial g2 ¼ 0.122; maximum volume, F(2, 51) ¼ 5.171, p ¼ .009, partial g2 ¼ 0.169; mean volume, F(2, 51) ¼ 4.864, p ¼ .012, partial g2 ¼ 0.160; and volume variability, F(2, 51) ¼ 8.087, p ¼ .001, partial g2 ¼ 0.241. Children with SAD exhibited higher minimum pitch (p ¼ .033 and .006, respectively) and lower maximum pitch than GAD and NC children (ps ¼ .033 and .010, respectively), whereas the latter groups were not significantly different (ps > .05). Children with SAD also had significantly less variability in their pitch than NC
children (p ¼ .036). The GAD group fell between the SAD and NC groups but was not significantly different from either group (ps > .05). Pitch findings for the SAD group indicated that these youth had a small range of
FIGURE 1 Visual representation of vocal characteristics. Note: SAD characterized by anxious speech, that is, low volume, low volume variability, low pitch variability (lack inflection); GAD characterized by nonanxious speech, that is, nonsignificant differences between GAD and TD on all vocal characteristics. TD ¼ typically developing children; SAD ¼ children with social anxiety disorder; GAD ¼ children children with generalized anxiety disorder.
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pitch and spoke with little vocal inflection. For volume, children with SAD spoke in a lower mean volume (p ¼ .009) and had less variability in their volume than NC children (p ¼ .001), and again, the mean volume and volume variability for children with GAD was not significantly different from either group (ps > .05). Children with SAD had lower maximum volume than GAD and NC children (ps ¼ .029 and .015, respectively), whereas the latter groups were not significantly different (p > .05). No significant group differences were found on mean pitch, F(2, 51) ¼ 0.177, ns, partial g2 ¼ 0.007, or minimum volume, F(2, 51) ¼ 0.028, p ¼ .973, partial g2 ¼ 0.001.
Peer Acceptance
Interpersonal Functioning
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on Friendship Quality Questionnaire–Revised scores. The means and standard deviations are reported in Table 4. There was a significant main effect for group on friendship Validation scores, F(2, 55) ¼ 4.363, p ¼ .017, partial g2 ¼ 0.137. Children with SAD were less likely to have friends that made them feel good about their ideas, told them they were good at things, and made them feel important and special compared to NC children (p ¼ .022). The GAD group was not significantly different from either group on friendship Validation (ps > .05). For all three groups, no significant differences emerged for friendship Intimacy, F(2, 55) ¼ 1.686, ns, partial g2 ¼ 0.058.
Interpersonal Relationships ANOVAs examined group differences for (a) parent and (b) child report on the Interpersonal Relationships Module of the ADIS-C=P (see Table 4). There was a significant main effect for group on both parental and child report on the Interpersonal Relationships Module: ADIS-P, F(2, 55) ¼ 13.641, p < .001, partial g2 ¼ 0.332, and ADIS-C, F(2, 55) ¼ 10.466, p < .001, partial g2 ¼ 0.276. NC youth had better interpersonal relationships than children with SAD and children with GAD based on parent (ps < .001) and child report (p < .001 and p ¼ .001, respectively). No significant differences were found between the SAD and GAD groups on parent or child report of interpersonal relationships (ps > .025).
ANOVAs examined group differences on (a) peer ratings of target child likeability and (b) target child ratings of peer likability. See Table 4 for the means and standard deviations. There was a significant main effect for group on peer ratings of target child likeability, F(2, 55) ¼ 5.352, p ¼ .008, partial g2 ¼ 0.171. When playing the Wii, youth with GAD were rated by peers as more likeable, fun, and a good friend, and they were more interested in being friends with them or playing with them again than youth with SAD (p ¼ .009). The NC group was not significantly different from either group (ps > .05). No significant differences emerged for the groups on target child ratings of the peer’s likeability, F(2, 55) ¼ 0.106, ns, partial g2 ¼ 0.004.
DISCUSSION
Friendship Validation and Intimacy A series of ANOVAs examined group differences on child ratings of friendship Validation and Intimacy based
The current study examined the social and peer functioning of children with SAD, children with GAD, and
TABLE 4 Peer, Parent, and Self Ratings of Interpersonal Functioning
ADIS Interpersonal Relationships Module Parent Child Friendship Survey Subscale Intimacy Validation Peer Likeability Scale Likeability of Target Child Likeability of Peer
Generalized Anxiety Disorder M (SD)
Social Anxiety Disorder M (SD)
Normal Control M (SD)
F Value
Partial g2
3.39 (1.6)a 4.00 (1.1)a
3.55 (1.7)a 3.95 (1.5)a
5.70 (1.3)b 5.75 (1.6)b
13.641 10.466
0.332 0.276
1.93 (1.4) 3.06 (1.0)a,b
1.53 (1.3) 2.37 (1.1)a
2.28 (1.2) 3.2 (0.8)b
1.686 4.363
.058 .137
14.84 (3.5)b 15.95 (2.8)
17.21 (3.3)a,b 16.30 (2.9)
5.352 0.106
0.171 0.004
18.06 (2.5)a 16.33 (2.93)
Note: n ¼ 58. ADIS ¼ Anxiety Disorders Interview Schedule for DSM-IV. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 20 for the normal control group. p < .05. p < .01. p < .001. a,b Means sharing superscripts are not significantly different.
SOCIAL SKILLS
children with no psychiatric diagnosis (i.e., NC). This is the first study of social competence in children with GAD to use behavioral observations and to compare youth with GAD to those with SAD. The results suggest that parent and child reports may be less sensitive to what are likely to be important differences in social skills between youth with SAD and GAD. Whereas self- and parental reports suggest that children with GAD are just as impaired as those with SAD, direct observations, computer-based measures of speech quality, and peer ratings show that the groups are in fact different. These data suggest that their use is important to provide a comprehensive evaluation and to inform treatment planning.
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Social Skills Among Children with SAD and GAD Parents’ perception of their child’s social problems, social competence, and social skills suggested more similarities than differences in the social functioning of children with SAD or GAD. Consistent with previous research (Scharfstein, Alfano, et al., 2011), CBCL scores indicated that all children had nonclinical levels of social problems, such as being dependent, jealous, lonely, and clumsy and exhibiting speech problems. The SAD and GAD groups had significantly lower CBCL social competence scores than the NC group, but all scores fell within the nonclinical range, indicating that deficits in the SAD and GAD groups were not clinically problematic. All youth displayed appropriate cooperation and selfcontrol skills based on the SSRS. Specific skills deficits in overall social skill and assertiveness were noted for youth with SAD and GAD relative to the NC group. These findings are consistent with other studies of SAD indicating poor social skills and deficient assertiveness (Alfano, Beidel, & Turner, 2006; Beidel et al., 1999; Beidel et al., 2007; Spence et al., 1999). Low assertiveness scores for the GAD group correspond to their clinical presentation, described as rule abiding, concerned with safety, and eager to please (Bernstein et al., 2008; Scharfstein, Alfano, et al., 2011), which are reflected in the items on this scale (reports accidents, accepts friends’ ideas for play). Children with SAD and GAD did not differ on responsible behavior, but SAD responsibility scores fell significantly below the TD group. Examination of the items on the responsibility scale suggests that low scores for SAD might reflect social fears (items such as introduces self, asks clerks for information) rather than a (dis)regard for authority (items such as requests permission before leaving the house, appropriately questions household rules). In summary, parent report data indicated that both youth with SAD and GAD have poor assertiveness and overall social skill difficulties, whereas only children with SAD have impaired responsibility compared to NC peers.
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Whereas many of the aforementioned skills assessed by self and parent report are complex behaviors (cooperation, self-control), which may be related to social functioning, behavioral observation of more molecular social behaviors (speech latency, speech content, vocal tone) allow for a more fine-grained analysis of social behavior. In this study, direct observations of children when playing a video game indicated a distinct pattern of social behavior deficits for children with SAD, who had an initial speech latency of greater than 3 min compared to fewer than 35 s in the other groups. Delayed speech during social engagement is characteristic of behaviorally inhibited toddlers and young children (Kagan, Reznick, & Snidman, 1987) and is one of the earliest markers for the development of SAD during adolescence (Hayward, Killen, Kraemer, & Taylor, 1998; Schwartz, Snidman, & Kagan, 1999). Children with SAD also spoke on nearly 60% fewer occasions, indicating a relative paucity of speech. These deficits did not just occur during in vivo interactions. Even when instructed to write down responses to a series of audio-recorded vocal prompts, children with SAD exhibited a paucity of content, not apparent in their GAD and NC peers. These data suggest a social awkwardness among children with SAD, which could negatively impact spontaneous social interactions. Given that first impressions form quickly, this deficient ability to quickly=spontaneously interact with an unknown peer may negatively impact their ability to establish friendships. Digital analysis of vocal characteristics (pitch, volume) also shed light on group differences. Children with SAD spoke with a lower average and maximum voice volume and exhibited a restricted range of pitch compared to NC children, subjectively heard as soft speech with a lack of vocal inflection. In a previous study, children with SAD responded to social prompts with low volume and high pitch, but with high variability in their vocal pitch (i.e., jitteriness; Scharfstein, Beidel, Sims, et al., 2011). When data from both investigations are considered together, children with SAD consistently evidence anxious speech patterns not found in other groups, with some variation possibly depending on conversational demands. These findings suggest differences in the social skills of youth with SAD and GAD. Attention to the shared and distinctive aspects of their social repertoire may inform differential diagnosis and treatment planning. Youth with GAD may benefit from assertiveness training and guidance in the use of questions to facilitate social conversation. Among youth with SAD, the current study supported and extended previous research documenting their social impairments (Alfano et al., 2006; Beidel et al., 1999, 2007; Scharfstein, Beidel, Sims, et al., 2011; Spence et al., 1999) and illustrated a pattern of overall deficits in social skill, suggesting that treatments that
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do not include social skills as part of the intervention may not yield optimal treatment outcome (Scharfstein, Beidel, Rendon Finnell, Distler, & Carter, 2011). Social skills training programs for SAD youth should therefore be comprehensive and incorporate skills for unstructured and extended interactions with peers (e.g., spontaneous speech, exclamations, latency to speech).
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Social Acceptance Parent and child ratings of social acceptance indicated that youth with SAD and GAD experienced greater difficulties in interpersonal relationships than NC youth, but there were no group differences on reported feelings of intimacy within their friendships. Low reported friendship intimacy for all groups might be representative of the age range examined. During adolescence, but not childhood, friendships are described as intimate, and friends commonly partake in personal disclosure, shared activities, and sticking up for one another (Berndt, 2002; Hartup & Stevens, 1999). With respect to friendship validation, children with SAD perceived less validation in their relationship with their best friend than their GAD and NC counterparts. Consistent with Festa and Ginsburg (2011), children with SAD were less likely to report that their best friend made them feel good about their ideas, told them they were good at things, and made them feel important and special. Children with SAD and GAD therefore have greater difficulties in their interpersonal relationships overall compared to NC youth, but only children with SAD feel invalidated within their closest friendship. Evaluation of peers’ immediate impression of children’s social acceptance and likeability revealed that in comparison to the other groups, children with SAD were rated by peers as less likeable, less fun, and less likely to be a good friend, and peers were less interested in being friends or playing with them again. Children with SAD, characterized by fear of negative evaluation, are actually perceived as less likeable and less socially desirable by their peers. Children with GAD reported impaired interpersonal relationships and elevated social anxiety, yet peers positively rated them on likability and friendship potential. The possible influence of the unique clinical features associated with this disorder may help to explain the incongruence between self-report and peer report of social acceptance among these youth. Youth with GAD often worry in the absence of objective concern and such worries persist despite reassurance from others (Albano et al., 2003). Youth with GAD may therefore worry about or perceive social failure due to their tendency to overestimate the likelihood of negative outcomes and=or because they have not met their own self-imposed standards of performance. Although these possibilities remain speculative at present, findings that children with GAD are
well liked by their peers suggest important differences in peer functioning compared to youth with SAD. Limitations Some limitations of this study are noted. First, the children in the SAD and GAD groups were not comorbid for SAD and GAD, a comorbidity sometimes reported in the literature, and thus do not represent all children who have one or both of these disorders. However, the use of semistructured interview schedules often leads to the reporting of multiple diagnoses without sufficient reflection as to whether one disorder may be uniquely accounting for the positive symptoms endorsed in a different diagnostic category. In DSM-IV-TR, concerns about social interactions are found in both disorders, contributing to the high rates of comorbidity. Second, direct observation of children’s behavior in social settings such as school and group activities were not used but may provide additional data regarding social functioning. Third, because the social and peer variables included in the current study do not represent all possible aspects of social and peer relations during childhood, nonsignificant differences in observer and peer ratings between the GAD and NC groups should not be interpreted to suggest overall equivalence in the social functioning of these two groups. Fourth, the sample was primarily Caucasian; therefore, replication among children of various ethnic=racial affiliations is warranted. Summary The most important finding in this study is that parent and child reports are insensitive to what could be important differences in social skills between youth with SAD and GAD. Such reports suggest that those with GAD are just as impaired as those with SAD and that those with SAD are no more impaired than those with GAD. But the direct observations, computer-based measures of speech quality, and peer ratings show that the groups are, in fact, different. More research is necessary to determine the relationship among observed social skills deficits and impaired social knowledge in the SAD group and peer ratings of poor likeability. Future studies should also investigate what factors contributed to the peers’ low ratings of likeability for children with SAD and adequate likeability ratings in the GAD and NC groups. REFERENCES Achenbach, T., & Edelbrock, C. (1991). Manual for the child behavior checklist. Burlington, VT: Queen City Printers. Achenbach, T., & Rescorla, L. (2001). Manual for the ASEBA school-age forms and profiles. Burlington: University of Vermont Research Center for Children, Youth, & Families.
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SOCIAL SKILLS Albano, A., Chorpita, B., & Barlow, D. (2003). Childhood anxiety disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (pp. 279–329). New York, NY: Guilford. Alfano, C., Beidel, D., & Turner, S. (2006). Cognitive correlates of social phobia among children and adolescents. Journal of Abnormal Child Psychology, 34, 182–194. American Psychiatric Association (2000). Diagnostic and statistical manual for mental disorders (4th ed., text rev.). Washington, DC: Author. Beesdo, K., Bittner, A., Pine, D., Stein, M., Hofler, M., Lieb, R., & Wittchen, H. (2007). Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Archives of General Psychiatry, 64, 903–912. Beidel, D., Turner, S., & Morris, T. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 73–79. Beidel, D., Turner, S., & Morris, T. (1999). Psychopathology of childhood social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 643–650. Beidel, D., Turner, S., & Morris, T. (2000). Behavioral treatment of childhood social phobia. Journal of Consulting and Clinical Psychology, 68, 1072–1080. Beidel, D., Turner, S., Young, B., Ammerman, R., Sallee, F., & Crosby, L. (2007). Psychopathology of adolescent social phobia. Journal of Psychopathology and Behavioral Assessment, 29, 47–54. Berndt, T. (2002). Friendship quality and social development. Current Directions in Psychological Science, 11, 7–10. Bernstein, G., Bernat, D., Davis, A., & Layne, A. (2008). Functioning in a nonclinical sample of children with social phobia. Depression and Anxiety, 25, 752–760. Bernstein, G., & Layne, A. (2006). Separation anxiety disorder and generalized anxiety disorder. In M. K. Dulcan & J. M. Wiener (Eds.), Essentials of child and adolescent psychiatry (pp. 415–439). Washington, DC: American Psychiatric Publishing. Boersma, P., & Weenink, D. (2005). Praat: Doing phonetics by computer (Version 4.3.14) [Computer software]. Available from http://praat.org/ Bradley, M., & Lang, P. (1994). Measuring emotion: The SelfAssessment Manikin and the semantic differential. Journal of Behavior Therapy and Experimental Psychiatry, 25, 49–59. Chansky, T., & Kendall, P. (1997). Social expectancies and selfperceptions in anxiety-disordered children. Journal of Anxiety Disorders, 11, 347–363. Chung, T., & Asher, S. (1996). Children’s goals and strategies in peer conflict situations. Merrill Palmer Quarterly, 42, 125–147. Costello, E., Egger, H., & Angold, A. (2005). The developmental epidemiology of anxiety disorders: Phenomenology, prevalence, and comorbidity. Child and Adolescent Psychiatric Clinics of North America, 14, 631–648. Crawley, S., Beidas, R., Benjamin, C., Martin, E., & Kendall, P. (2008). Treating socially phobic youth with CBT: Differential outcomes and treatment considerations. Behavioural & Cognitive Psychotherapy, 36, 379–389. Erdley, C., & Asher, S. (1996). Children’s social goals and self efficacy perceptions as influences on their responses to ambiguous provocation. Child Development, 67, 1329–1344. Festa, C., & Ginsburg, G. (2011). Parental and peer predictors of social anxiety in youth. Child Psychiatry and Human Development, 42, 291–306. Fuller, B., Horii, Y., & Conner, D. (1992). Validity and reliability of nonverbal voice measures as indicators of stressor-provoked anxiety. Research in Nursing and Health, 15, 379–389. Gresham, F., & Elliot, S. (1990). The social skills rating system. Circle Pines, MN: American Guidance.
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Hartup, W. (1996). The company they keep: Friendships and their developmental significance. Child Development, 67, 1–13. Hartup, W., & Stevens, N. (1999). Friendships and adaptation across the life span. Current Directions in Psychological Science, 8, 76–79. Hayward, C., Killen, J., Kraemer, H., & Taylor, C. (1998). Linking self-reported childhood behavioral inhibition to adolescent social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1308–1316. Higa, C., Fernandez, S., Nakamura, B., Chorpita, B., & Daleiden, E. (2006). Parental assessment of childhood social phobia: Psychometric properties of the Social Phobia and Anxiety Inventory for Children–Parent Report. Journal of Clinical Child and Adolescent Psychology, 35, 590–597. Hudson, J., Rapee, R., Lyneham, H., Wuthrich, V., & Schneiring, C. (2010, June). Paper presented at The World Congress of Behavioral and Cognitive Therapies, Boston, MA. Kagan, J., Reznick, S., & Snidman, N. (1987). The physiology and psychology of behavioral inhibition in children. Child Development, 58, 1459–1473. Kimble, C., & Seidel, S. (1973). Vocal signs of confidence. Behavioral Assessment, 15, 99–105. Ladd, G., Kochenderfer, B. J., & Coleman, C. (1996). Friendship quality as a predictor of young children’s early school adjustment. Child Development, 67, 1103–1118. Laukka, P., Linnman, C., Ahs, F., Pissiota, A., Frans, O., Faria, V., & . . . Furmark, T. (2008). In a nervous voice: Acoustic analysis and perception of anxiety in social phobics’ speech. Journal of Nonverbal Behavior, 32, 195–214. Parker, J., & Asher, S. (1993). Friendship and friendship quality in middle childhood: Links with peer group acceptance and feelings of loneliness and social dissatisfaction. Developmental Psychology, 29, 611–621. Rao, P., Beidel, D., Turner, S., Ammerman, R., Crosby, L., & Sallee, F. (2007). Social anxiety disorder in childhood and adolescence: Descriptive psychopathology. Behaviour Research and Therapy, 45, 1181–1191. Scharfstein, L., Alfano, C., Beidel, D., & Wong, N. (2011). Children with generalized anxiety disorder do not have peer problems, just fewer friends. Child Psychiatry and Human Development, 41(1), 712–723. Scharfstein, L., & Beidel, D. (2011). Behavioral and cognitivebehavioral treatments for youth with social phobia. Journal of Experimental Psychopathology, 2, 615–628. Scharfstein, L., Beidel, D., Rendon Finnell, L., Distler, A., & Carter, N. (2011). Do pharmacological and behavioral interventions differentially affect treatment outcome for children with social phobia? Behavior Modification, 35, 451–467. Scharfstein, L., Beidel, D., Sims, V., & Rendon Finnel, L. (2011). Social skills deficits and vocal characteristics of children with social phobia or Asperger’s Disorder: A comparative study. Journal of Abnormal Child Psychology, 39, 865–875. Schwartz, C., Snidman, N., & Kagan, J. (1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1008–1015. Silverman, W., & Albano, A. (1996). The anxiety disorders interview schedule for DSM–IV–child and parent versions. San Antonio, TX: Psychological Corporation. Spence, S., Donovan, C., & Brechman-Toussaint, M. (1999). Social skills, social outcomes, and cognitive features of childhood social phobia. Journal of Abnormal Psychology, 108, 211–221. Strauss, C., Lahey, B., Frick, P., Frame, C., & Hynd, G. (1988). Peer social status of children with anxiety disorders. Journal of Consulting and Clinical Psychology, 56, 137–141.
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Verduin, T., & Kendall, P. (2008). Peer perceptions and liking of children with anxiety disorders. Journal of Abnormal Child Psychology, 36, 459–469. Wechsler, D. (2003). Wechsler intelligence scale for children–fourth edition. San Antonio, TX: Psychological Corporation.
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APPENDIX Social Vignettes Task Scenarios and Confederate Prompts Practice Scene: Imagine that you are at the movies and you are buying some popcorn. You pay the cashier and receive the popcorn. There is a boy=girl standing behind you and he=she says: (a) Actor: How’s the popcorn? (b) Actor: I think I’m going to get some! Scene 1: You are riding your bike in front of your house with another boy=girl. The boy=girl stops after he=she almost crashes. It looks as though he=she has a flat tire. You approach him=her. He=she looks at you, and with a sad voice, he=she says: (a) Actor: How am I going to get my bike home? (b) Actor: I guess I ought to call my parent. Scene 2: In gym class, you are learning how to play basketball and how to shoot free throws. You are
having trouble making some shots from the free throw line. Another boy=girl who is a good basketball player says: (a) Actor: Would you like for me to help you with your free throws? (b) Actor: Well, it was hard for me to learn at first. Would you like for me to give you some pointers? Scene 3: A boy=girl who sits next to you in math class is having some trouble with his=her math test. He=she’s been working hard to get his=her grade up. The class gets back the most recent test with grades on them. He=she gets a big smile on his=her face and says: (a) Actor: I finally got an A! (b) Actor: I’ve been studying so hard. Scene 4: You’ve been working hard to memorize a poem to recite in English class. You finish reciting the poem in front of the class and return to your seat. The boy=girl sitting next to you says: (a) Actor: You did a great job. (b) Actor: You remembered every word and you looked so calm and cool. Scene 5: You are playing with a ball during recess. All of a sudden another kid takes the ball from you and says: (a) Actor: This is my ball now! (b) Actor: Go find another one.
Journal of Clinical Child & Adolescent Psychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hcap20
Social Skills and Social Acceptance in Children with Anxiety Disorders a
b
Lindsay A. Scharfstein & Deborah C. Beidel a
Yale Child Study Center, Yale University
b
Department of Psychology, University of Central Florida Published online: 12 May 2014.
Click for updates To cite this article: Lindsay A. Scharfstein & Deborah C. Beidel (2015) Social Skills and Social Acceptance in Children with Anxiety Disorders, Journal of Clinical Child & Adolescent Psychology, 44:5, 826-838, DOI: 10.1080/15374416.2014.895938 To link to this article: http://dx.doi.org/10.1080/15374416.2014.895938
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Journal of Clinical Child & Adolescent Psychology, 44(5), 826–838, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1537-4416 print=1537-4424 online DOI: 10.1080/15374416.2014.895938
ANXIETY SYMPTOMS
Social Skills and Social Acceptance in Children with Anxiety Disorders Lindsay A. Scharfstein Yale Child Study Center, Yale University
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Deborah C. Beidel Department of Psychology, University of Central Florida
Whereas much is known about the deficits in social behaviors and social competence in youth with social anxiety disorder (SAD), less is known about those characteristics among youth with generalized anxiety disorder (GAD). This study aimed to better elucidate the social repertoire and peer acceptance of youth with SAD and youth with GAD, relative to normal control (NC) youth. The sample consisted of 58 primarily Caucasian children, ages 6 to 13 years: 20 SAD (12 female), 18 GAD (12 female), and 20 NC (9 female). Diagnoses were based on Anxiety Disorders Interview Schedule for DSM-IV: Children and Parent Versions interviews. A multimodal assessment strategy included parent and child reports, observer ratings of social performance, computer-based analysis of vocal qualities of speech, and peer ratings of likeability and friendship potential. Whereas self- and parental report did not differentiate the two diagnostic groups, differences on observable behaviors were apparent. Children with SAD exhibited anxious speech patterns, extended speech latencies, a paucity of speech, few spontaneous vocalizations, and ineffective social responses; they were perceived by peers as less likeable and socially desirable. Children with GAD had typical speech patterns and were well liked by their peers but displayed fewer spontaneous comments and questions than NC children. Parent and child reports are less sensitive to what could be important differences in social skill between youth with SAD and GAD. Direct observations, computer-based measures of speech quality, and peer ratings identify specific group differences, suggesting the need for a comprehensive evaluation to inform treatment planning.
Social anxiety disorder (SAD) is the most common pediatric anxiety disorder, with current prevalence ranging between 3% and 8% of youth (Costello, Egger, & Angold, 2005). SAD has an early onset, characterized by a marked and persistent fear of social situations in which negative evaluation may occur (Beesdo et al., 2007; Beidel, Turner, & Morris, 1999). Feared social situations include reading in front of others, speaking to unfamiliar children or adults, and participating in groups=clubs (Beidel et al., 1999), and social interaction Correspondence should be addressed to Lindsay A. Scharfstein, Yale Child Study Center, Yale University, 230 South Frontage Road, New Haven, CT 06519. E-mail: [email protected]
difficulties are consistently identified among youth with SAD (e.g., Beidel et al., 1999; Beidel et al., 2007; Spence, Donovan, & Brechman-Toussaint, 1999). Children with SAD are less socially competent and less socially skilled than normal control (NC) children according to self (Spence et al., 1999) and parent report (Scharfstein, Alfano, Beidel, & Wong, 2011; Spence et al., 1999). They also are less likely to select assertive responses to social vignettes than NC peers (Spence et al., 1999). During analogue role plays, children with SAD are less skilled interpersonally (Beidel et al., 1999; Rao et al., 2007; Spence et al., 1999) and have longer speech latencies than NC youth (Beidel et al., 1999; Scharfstein, Beidel, Sims, & Rendon Finnel, 2011). In
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SOCIAL SKILLS
the latter study, children with SAD exhibit deficient speech production and difficulty managing the conversational topic relative to NC youth and youth with Asperger’s disorder. Digital vocal analysis revealed that children with SAD speak more softly than NC peers and have higher vocal pitch and more vocal pitch variability (jitteriness) than children with Asperger’s disorder (Scharfstein, Beidel, Sims, et al., 2011). Thus, youth with SAD evidence anxious speech and deficits in many of the basic social skills necessary for successful peer interactions. Whereas deficits in social behaviors and social competence in youth with SAD have been established, much less is known about those characteristics among youth with generalized anxiety disorder (GAD). GAD is characterized by excessive worry (American Psychiatric Association, 2000), and children with this disorder often set exceedingly high standards for their competence in and the quality of their peer relationships (Albano, Chorpita, & Barlow, 2003). Their eagerness to please and their tendency to be perfectionistic, overly conscientious (Bernstein & Layne, 2006), and rule abiding may facilitate friendships. Alternatively, their excessive reassurance seeking and preoccupation with performance (Albano et al., 2003) might annoy and=or eventually alienate other children. Based on parent report alone, children with GAD have relatively fewer friends but are otherwise similar to NC youth in terms of interpersonal functioning, social competence, presence of a best friend, and participation in groups=clubs (Scharfstein, Alfano, et al., 2011). Youth with GAD may possess adequate social skills, but to date, this has only been assessed through questionnaires, and no study has assessed social behaviors in GAD youth through direct observation. The comparison of social abilities between these two diagnostic groups is important for understanding psychopathology and developing optimal remediation efforts. Youth with SAD and GAD often are researched collectively (i.e., as a unitary group), treated using identical treatment protocols, and outcome often is assessed unilaterally across the sample (e.g., Crawley, Beidas, Benjamin, Martin, & Kendall, 2008; Hudson, Rapee, Lyneham, Wuthrich, & Schneiring, 2010; Scharfstein & Beidel, 2011). Yet if differences in clinical functioning exist, clinicians may inappropriately apply less than adequate treatment approaches. Thus, direct observation and comparison of the social relations of youth with SAD and GAD is needed. Another important element of social functioning is peer relations (Hartup, 1996; Hartup & Stevens, 1999), including peer liking, friendships, and participation in social activities. In particular, youth with SAD, but not GAD, may have an increased risk for peer difficulties given their poor skills for social discourse and friendship formation. Thus far, our knowledge regarding peer relations among anxious youth is largely based on early
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studies examining sociometric status. In general, youth with anxiety disorders are found to be neglected by their peers (Diagnostic and Statistical Manual of Mental Disorders [third ed.; DSM–III] or DSM–III–R diagnoses; Strauss, Lahey, Frick, Frame, & Hynd, 1988). Children’s self-ratings are consistent with these sociometric data, wherein clinically anxious youth report having a best friend but fewer friends overall relative to their peers (Chansky & Kendall, 1997). A few studies have examined peer variables specifically among youth with SAD. On the school playground, they receive fewer positive responses and more negative and ignore responses than nonanxious peers (Spence et al., 1999). Although they are just as likely as their peers to have a best friend (Bernstein, Bernat, Davis, & Layne, 2008; Scharfstein, Alfano, et al., 2011), youth with SAD have fewer friends and difficulty making new friends compared to NC youth (Bernstein et al., 2008; Scharfstein, Alfano, et al., 2011; Spence et al., 1999). Most studies of peer functioning have used self- or parent reports, rather than direct report from same-age peers. In the only study to evaluate an immediate impression of liking, based on videotaped speeches, peers like children with anxiety disorders (SAD, GAD, separation anxiety disorder) less than youth without anxiety disorders (Verduin & Kendall, 2008). When likeability ratings are examined by specific anxiety diagnosis, lower scores of peer liking are uniquely associated with SAD. To summarize, impaired social skills are identified consistently among children with SAD, but less is known about those characteristics among children with GAD. Based on available data, children with GAD should be less impaired than those with SAD. In this study, we are examining two major areas of social functioning— social competence and social acceptance. Here, the term social competence comprises social skills=behaviors, social knowledge, and vocal characteristics, whereas the term social acceptance is used to refer to peer liking, friendship, and participation in social activities. The current study utilized direct observation to compare the social abilities and social acceptance of children with SAD to children with GAD and children with no DSM-IV-TR psychological disorder (NC). It was hypothesized that children with SAD would exhibit poorer social skills during a peer play interaction, would exhibit poorer social skills regardless of social context, and would be less socially accepted compared to children with GAD and NC children.
METHOD Participants The sample consisted of 58 children, ranging in age from 6 to 13 years: 20 children meeting DSM-IV-TR criteria
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for primary SAD (12 female), 18 children meeting DSM-IV-TR criteria for primary GAD (12 female), and 20 NC children (9 female) not meeting criteria for any DSM-IV-TR diagnosis. The groups were not different on age, F(2, 55) ¼ 1.804, ns, g2 ¼ 0.062; sex, v2(2) ¼ 1.933, ns, g2 ¼ 0.183; and race=ethnicity, v2(4) ¼ 11.619, ns, g2 ¼ 0.325. Descriptive statistics for demographic and clinical characteristics are presented in Table 1. The study was conducted through the University of Central Florida Anxiety Disorders Clinic, Orlando, Florida. Recruitment was conducted via flyers and mailings to local schools, pediatricians, and mental health providers. Children with SAD and GAD were clinically referred and=or recruited. These youth qualified for free group behavioral treatment at the Anxiety Disorders Clinic after study participation. Exclusion criteria for the anxiety disorder groups included comorbid SAD or GAD (in children diagnosed with primary GAD or SAD, respectively), attentiondeficit=hyperactivity disorder, autism spectrum disorders, bipolar diagnoses, psychosis, suicidal ideation, or intellectual disability. The NC children were recruited for this protocol and were compensated with a $20 gift card for participation. All participants provided written informed consent=assent to the study procedures prior to enrollment.
Procedures Diagnostic Procedure Children and their parent(s) were interviewed independently using the Anxiety Disorders Interview Schedule for DSM-IV: Children and Parent Versions (ADIS-C=P, Silverman & Albano, 1996) by a doctoral student in clinical psychology. Diagnoses were based on information from both sources. For each diagnosis, the clinician assigned the ADIS-C=P Clinician Severity Rating (CSR; a 9-point scale, ranging from 0 to 8). A CSR of 4 (moderate) or higher was required for study inclusion. Based on a random selection of 17% of the interviews, 90% interrater agreement on diagnosis (i.e., presence=absence) and CSRs (i.e., within 1 point) was obtained. Because limited cognitive and language abilities may negatively impact social and peer functioning, the Block Design and Vocabulary subtests of the Wechsler Intelligence Scale for Children–Fourth Edition (Wechsler, 2003) were administered. Block Design scores were average and did not differ significantly (MSAD ¼ 10.30, MGAD ¼ 10.11, MNC ¼ 11.65), F(2, 53) ¼ 1.634, ns, partial g2 ¼ 0.056. Vocabulary scores indicated at least average verbal intelligence and reasoning for all groups, with significantly lower scores in the SAD and GAD groups than the NC group (MSAD ¼ 10.22, MGAD ¼ 12.67,
TABLE 1 Demographic and Clinical Characteristics Generalized Anxiety Disorder Age (M=SD) Sex (n=%) Female Male WISC Standard Scores (M=SD) Block Design Vocabulary Race=Ethnicity (n=%) Caucasian Hispanic Biracial CSR (M=SD) Secondary Disorder (n=%) No Diagnosis OCD Specific Phobia Major Depression Selective Mutism PTSD
8.72 (1.6)
Social Anxiety Disorder 8.70 (2.0)
Normal Control
F=v2=t Value
Partial g2=g2
9.65 (1.8)
1.804 1.933
0.062 0.183
1.634 8.453 11.619
0.056 0.242 0.325
1.027 6.045
0.054
12 (66.7) 6 (33.3)
12 (60.0) 8 (40.0)
9 (45.0) 11 (55.0)
10.11 (3.0) 12.67 (1.5)a
10.30 (2.8) 10.22 (2.8)a
11.65 (2.9) 13.75 (3.3)b
16 2 0 5.56
(88.9) (11.1) (0.0) (1.0)
10 8 2 5.25
(50.0) (40.0) (10.0) (0.8)
14 1 1 1 0 1
(77.8) (5.6) (5.6) (5.0) (0.0) (5.6)
16 0 1 0 3 0
(80.0) (0.0) (5.0) (0.0) (15.0) (0.0)
12 (60.0) 3 (15.0) 5 (25.0)
Note: n ¼ 58. WISC ¼ Wechsler Intelligence Scale for Children; CSR ¼ Clinician Severity Rating; OCD ¼ obsessivecompulsive disorder; PTSD ¼ posttraumatic stress disorder. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 18 for the social anxiety disorder group for the vocabulary variable; n ¼ 20 for the normal control group; n ¼ 18 for the social anxiety disorder group. p .05). All scale scores fell in the nonclinical range, indicating that deficits in the SAD and GAD groups were not clinically problematic.
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On the SSRS, there was a significant effect for group on assertion, F(2, 55) ¼ 14.555, p < .001, partial g2 ¼ 0.346; responsibility, F(2, 55) ¼ 8.501, p ¼ .001, partial g2 ¼ 0.236; and social skills standard, F(2, 55) ¼ 8.228, p ¼ .001, partial g2 ¼ 0.230. Post hoc LSD tests revealed that children with SAD and children with GAD exhibit fewer social behaviors necessary for successful social engagement than their NC counterparts (p ¼ .001 and .011, respectively). Specifically, parents rated the SAD and GAD groups as exhibiting fewer assertive behaviors than NC group (p < .001 and p ¼ .001, respectively). Youth with SAD were also rated as exhibiting fewer responsible behaviors than NC children (p < .001). The SAD and GAD groups did not differ significantly on the social skills standard, assertion, and responsibility scores (ps > .05). No significant group differences emerged for self-control, F(2, 55) ¼ 2.203, p ¼ .120, partial g2 ¼ 0.074. No significant group differences emerged for cooperation despite a significant F score, F(2, 55) ¼ 3.645, p ¼ .033, partial g2 ¼ 0.117. Social Anxiety A series of ANOVAs examined the effect of group membership on all social anxiety dependent variables: (a) SPAIC-PV, (b) SPAIC, (c) SAM Baseline, (d) SAM Wii Social Task, (e) SAM Social Vignettes Task. See Table 2 for means and standard deviations. There was a significant group effect on SPAIC-PV, F(2, 55) ¼ 48.381, p < .001, partial g2 ¼ 0.638, and SPAIC, F(2, 53) ¼ 6.236, p ¼ .004, partial g2 ¼ 0.190. LSD tests revealed that children with SAD and GAD were rated as more socially anxious than NC children on the SPAIC-PV (both ps < .001) and SPAIC (ps ¼ .022 and .006, respectively). No significant differences emerged between the SAD and GAD groups on these scores (ps > .05). There were no significant group differences on SAM ratings during the baseline, F(2, 53) ¼ 0.403, ns, partial g2 ¼ 0.015; Wii Social Task, F(2, 53) ¼ 0.366, ns, partial g2 ¼ 0.014; and Social Vignettes Task, F(2, 53) ¼ 0.019, ns, partial g2 ¼ 0.001. Social Effectiveness and Social Knowledge during the Social Vignettes Task A series of ANOVAs examined the effect of group on the social vignette variables: number of prompts unanswered, average number of words per response, total number of words across responses, and appropriateness of responses (see Table 3). There was a significant main effect for group on the number of prompts unanswered, F(2, 55) ¼ 6.034, p ¼ .004, partial g2 ¼ 0.180; number of words across social responses, F(2, 55) ¼ 5.800, p ¼ .005, partial
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TABLE 2 Parent and Child Report of Social Competence and Social Anxiety
Social Skill CBCL Subscale Social Competence Social Problems SSRS Subscale Cooperation Assertion Responsibility Self-Control SSRS Total Score Social Anxiety Parent Report SPAIC-PV Self-Report SPAIC Behavioral Assessment Baseline SAM Wii SAM Social Vignette SAM
Generalized Anxiety Disorder M (SD)
Social Anxiety Disorder M (SD)
Normal Control M (SD)
F Value
Partial g2
39.61 (7.9)a 62.22 (8.3)a
39.85 (8.3)a 57.80 (7.4)a
54.90 (7.8)b 52.05 (4.6)b
23.444 10.404
.460 .274
10.00 11.78 12.11 12.17 86.61
10.35 10.25 10.35 11.55 81.95
3.645 14.555 8.501 2.203 8.228
.117 .346 .236 .074 .230
(3.4) (3.2)a (3.3)a,b (4.1) (15.9)a
(3.5) (2.9)a (1.5)a (3.1) (10.5)a
13.00 16.50 14.55 14.05 107.05
(4.4) (5.0)b (4.3)b (4.5) (30.1)b
28.12 (10.4)a
33.34 (6.2)a
8.11 (8.7)b
48.381
.638
18.23 (9.0)a
19.42 (9.2)a
10.62 (6.9)b
6.236
.190
1.39 (0.7) 1.78 (1.1) 1.33 (0.7)
1.39 (0.5) 1.50 (0.8) 1.33 (0.6)
1.25 (0.4) 1.70 (1.1) 1.30 (0.6)
0.403 0.366 0.019
0.015 0.014 0.001
Note: n ¼ 56. CBCL ¼ Child Behavior Checklist; SSRS ¼ Social Skills Rating System; SPAIC-PV ¼ Social Phobia and Anxiety Inventory for Children–Parent Version; SAM ¼ Self-Assessment Manikin. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 20 for the normal control group. p < .05. p < .01. p < .001. a,b Means sharing superscripts are not significantly different.
g2 ¼ 0.174; and appropriateness of responses, F(2, 55) ¼ 7.145, p ¼ .002, partial g2 ¼ .206. Post hoc LSD tests revealed that children with SAD responded to social prompts with fewer words (ps ¼ .023 and .010, respectively) and left more prompts unanswered (ps ¼ .006 and .029, respectively) than children with GAD and NC children. Further, children with SAD provided less effective responses to peer-initiated social prompts than the GAD and NC groups (p ¼ .018 and .002, respectively). No significant differences emerged between the NC and GAD groups (ps > .05). Social Behavior and Vocal Characteristics during the Wii Social Task A series of ANOVAs examined the effect of group membership on social behavior variables: (a) latency to first utterance, (b) instances of talk, and the frequency of (c) answers to peer questions, (d) spontaneous comments, (e) exclamations, and (f) questions. Because these scores were dependent upon speaking, all statistical analyses were conducted initially excluding children with a comorbid diagnosis of selective mutism (SM). The results were not different when SM was excluded. Therefore to maximize power, the results presented next include children with a comorbid SM diagnosis. Means and standard deviations are reported in Table 3.
There was a significant main effect for group on latency to first vocalization, F(2, 55) ¼ 8.708, p ¼ .001, partial g2 ¼ 0.240; instances of talk, F(2, 55) ¼ 16.769, p < .001, partial g2 ¼ 0.379; and the frequency of spontaneous comments, F(2, 55) ¼ 18.894, p < .001, partial g2 ¼ 0.407; exclamations, F(2, 55) ¼ 4.272, p ¼ .019, partial g2 ¼ 0.134; and questions, F(2, 55) ¼ 1 4.828, p < .001, partial g2 ¼ 0.350. Post hoc LSD tests revealed that children with SAD took longer to make their first prompted or unprompted vocalization (ps ¼ .002 and .003, respectively) and spoke on fewer occasions compared to the GAD and NC children (both ps < .001). The GAD and NC groups did not differ significantly (ps > .05). Children with SAD made fewer spontaneous comments than children with GAD and NC children (p ¼ .004 and p < .001, respectively). In addition, the GAD group made fewer spontaneous comments than children in the NC group (p ¼ .042). Children with SAD made fewer exclamations than NC children (p ¼ .017), whereas the GAD group fell between but was not significantly different (ps > .05). Both children with SAD and children with GAD asked fewer questions than NC children (p < .001 and p ¼ .004, respectively), but were not significantly different (ps > .05). No significant group differences emerged for the number of answers to questions, F(2, 55) ¼ 2.489, ns, partial g2 ¼ 0.083.
SOCIAL SKILLS
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TABLE 3 Vocal Characteristics and Observer Ratings of Social Behavior
Social Vignettes Task No. of Words No. of Unanswered Prompts Appropriateness Wii Social Task Latency to Speech (in seconds) Instances of Talk Comments Exclamations Questions Answers Vocal Features Pitch Minimum Pitch Maximum Pitch Mean Pitch Variability Volume Minimum Volume Maximum Volume Mean Volume Variability
Generalized Anxiety Disorder M (SD)
Social Anxiety Disorder M (SD)
Normal Control M (SD)
45.39 (23.2)a 0.28 (0.8)a 16.22 (2.7)a
24.65 (22.4)b 2.45 (3.3)b 13.40 (3.7)b
47.15 (23.6)a 0.70 (0.9)a 16.80 (2.5)a
5.800 6.034 7.145
0.174 0.180 0.206
34.66 (99.3)a 44.80 (14.9)a 53.4 (26.5)c 14.00 (19.5)b 9.35 (5.4)b 6.50 (4.2)
8.708 16.769 18.894 4.272 14.828 2.489
0.240 0.379 0.407 0.134 0.350 0.083
(8.5)a (33.4)a (20.5) (11.5)b (3.5) (6.0)a (8.2)b (0.8)a,b
5.798 5.430 .177 3.558 .028 5.171 4.864 8.087
0.185 0.176 0.007 0.122 0.001 0.169 0.160 0.241
18.78 40.50 35.61 10.00 4.72 5.28
(25.68)a (17.1)a (22.4)a (10.6)a,b (3.0)a (3.5)
225.30 (274.7)b 16.6 (17.5)b 11.65 (14.0)b 2.15 (3.4)a 2.1 (3.9)a 3.65 (4.3)
185.50 497.64 274.65 56.10 55.71 88.30 69.39 6.68
(9.3)a (48.2)a (20.5) (13.8)a,b (4.0) (6.0)a (6.3)a,b (1.4)a
196.59 444.59 271.01 46.66 55.97 82.14 65.17 4.99
(17.9)b (87.1)b (24.2) (18.0)a (2.3) (8.0)b (3.1)a (1.4)b
183.26 505.17 275.01 59.25 55.89 88.73 71.84 5.95
F Value
Partial g2
Note: n ¼ 58. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 16 for the social anxiety group for all of the vocal feature variables; n ¼ 20 for the normal control group. p < .05. p < .01. p < .001. a,b,c Means sharing superscripts are not significantly different.
Vocal Characteristics A series of ANOVAs examined the effect of group membership on vocal characteristics during the Wii Task: (a) minimum pitch, (b) maximum pitch, (c) mean pitch, and (d) pitch variability, (e) minimum volume, (f) maximum volume, (g) mean volume, and (h) volume variability. Means and standard deviations are reported in Table 3 (see Figure 1 for visual representation of vocal characteristics). Four children’s scores in the SAD group were excluded from data analysis of vocal characteristics due to their refusal to speak during the Wii task. Analysis of the individual variables revealed a significant main effect for group on minimum pitch, F(2, 51) ¼ 5.798, p ¼ .005, partial g2 ¼ 0.185; maximum pitch, F(2, 51) ¼ 5.430, p ¼ .007, partial g2 ¼ 0.176; pitch variability, F(2, 51) ¼ 3.558, p ¼ .036, partial g2 ¼ 0.122; maximum volume, F(2, 51) ¼ 5.171, p ¼ .009, partial g2 ¼ 0.169; mean volume, F(2, 51) ¼ 4.864, p ¼ .012, partial g2 ¼ 0.160; and volume variability, F(2, 51) ¼ 8.087, p ¼ .001, partial g2 ¼ 0.241. Children with SAD exhibited higher minimum pitch (p ¼ .033 and .006, respectively) and lower maximum pitch than GAD and NC children (ps ¼ .033 and .010, respectively), whereas the latter groups were not significantly different (ps > .05). Children with SAD also had significantly less variability in their pitch than NC
children (p ¼ .036). The GAD group fell between the SAD and NC groups but was not significantly different from either group (ps > .05). Pitch findings for the SAD group indicated that these youth had a small range of
FIGURE 1 Visual representation of vocal characteristics. Note: SAD characterized by anxious speech, that is, low volume, low volume variability, low pitch variability (lack inflection); GAD characterized by nonanxious speech, that is, nonsignificant differences between GAD and TD on all vocal characteristics. TD ¼ typically developing children; SAD ¼ children with social anxiety disorder; GAD ¼ children children with generalized anxiety disorder.
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SCHARFSTEIN AND BEIDEL
pitch and spoke with little vocal inflection. For volume, children with SAD spoke in a lower mean volume (p ¼ .009) and had less variability in their volume than NC children (p ¼ .001), and again, the mean volume and volume variability for children with GAD was not significantly different from either group (ps > .05). Children with SAD had lower maximum volume than GAD and NC children (ps ¼ .029 and .015, respectively), whereas the latter groups were not significantly different (p > .05). No significant group differences were found on mean pitch, F(2, 51) ¼ 0.177, ns, partial g2 ¼ 0.007, or minimum volume, F(2, 51) ¼ 0.028, p ¼ .973, partial g2 ¼ 0.001.
Peer Acceptance
Interpersonal Functioning
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on Friendship Quality Questionnaire–Revised scores. The means and standard deviations are reported in Table 4. There was a significant main effect for group on friendship Validation scores, F(2, 55) ¼ 4.363, p ¼ .017, partial g2 ¼ 0.137. Children with SAD were less likely to have friends that made them feel good about their ideas, told them they were good at things, and made them feel important and special compared to NC children (p ¼ .022). The GAD group was not significantly different from either group on friendship Validation (ps > .05). For all three groups, no significant differences emerged for friendship Intimacy, F(2, 55) ¼ 1.686, ns, partial g2 ¼ 0.058.
Interpersonal Relationships ANOVAs examined group differences for (a) parent and (b) child report on the Interpersonal Relationships Module of the ADIS-C=P (see Table 4). There was a significant main effect for group on both parental and child report on the Interpersonal Relationships Module: ADIS-P, F(2, 55) ¼ 13.641, p < .001, partial g2 ¼ 0.332, and ADIS-C, F(2, 55) ¼ 10.466, p < .001, partial g2 ¼ 0.276. NC youth had better interpersonal relationships than children with SAD and children with GAD based on parent (ps < .001) and child report (p < .001 and p ¼ .001, respectively). No significant differences were found between the SAD and GAD groups on parent or child report of interpersonal relationships (ps > .025).
ANOVAs examined group differences on (a) peer ratings of target child likeability and (b) target child ratings of peer likability. See Table 4 for the means and standard deviations. There was a significant main effect for group on peer ratings of target child likeability, F(2, 55) ¼ 5.352, p ¼ .008, partial g2 ¼ 0.171. When playing the Wii, youth with GAD were rated by peers as more likeable, fun, and a good friend, and they were more interested in being friends with them or playing with them again than youth with SAD (p ¼ .009). The NC group was not significantly different from either group (ps > .05). No significant differences emerged for the groups on target child ratings of the peer’s likeability, F(2, 55) ¼ 0.106, ns, partial g2 ¼ 0.004.
DISCUSSION
Friendship Validation and Intimacy A series of ANOVAs examined group differences on child ratings of friendship Validation and Intimacy based
The current study examined the social and peer functioning of children with SAD, children with GAD, and
TABLE 4 Peer, Parent, and Self Ratings of Interpersonal Functioning
ADIS Interpersonal Relationships Module Parent Child Friendship Survey Subscale Intimacy Validation Peer Likeability Scale Likeability of Target Child Likeability of Peer
Generalized Anxiety Disorder M (SD)
Social Anxiety Disorder M (SD)
Normal Control M (SD)
F Value
Partial g2
3.39 (1.6)a 4.00 (1.1)a
3.55 (1.7)a 3.95 (1.5)a
5.70 (1.3)b 5.75 (1.6)b
13.641 10.466
0.332 0.276
1.93 (1.4) 3.06 (1.0)a,b
1.53 (1.3) 2.37 (1.1)a
2.28 (1.2) 3.2 (0.8)b
1.686 4.363
.058 .137
14.84 (3.5)b 15.95 (2.8)
17.21 (3.3)a,b 16.30 (2.9)
5.352 0.106
0.171 0.004
18.06 (2.5)a 16.33 (2.93)
Note: n ¼ 58. ADIS ¼ Anxiety Disorders Interview Schedule for DSM-IV. n ¼ 18 for the generalized anxiety disorder group; n ¼ 20 for the social anxiety disorder group; n ¼ 20 for the normal control group. p < .05. p < .01. p < .001. a,b Means sharing superscripts are not significantly different.
SOCIAL SKILLS
children with no psychiatric diagnosis (i.e., NC). This is the first study of social competence in children with GAD to use behavioral observations and to compare youth with GAD to those with SAD. The results suggest that parent and child reports may be less sensitive to what are likely to be important differences in social skills between youth with SAD and GAD. Whereas self- and parental reports suggest that children with GAD are just as impaired as those with SAD, direct observations, computer-based measures of speech quality, and peer ratings show that the groups are in fact different. These data suggest that their use is important to provide a comprehensive evaluation and to inform treatment planning.
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Social Skills Among Children with SAD and GAD Parents’ perception of their child’s social problems, social competence, and social skills suggested more similarities than differences in the social functioning of children with SAD or GAD. Consistent with previous research (Scharfstein, Alfano, et al., 2011), CBCL scores indicated that all children had nonclinical levels of social problems, such as being dependent, jealous, lonely, and clumsy and exhibiting speech problems. The SAD and GAD groups had significantly lower CBCL social competence scores than the NC group, but all scores fell within the nonclinical range, indicating that deficits in the SAD and GAD groups were not clinically problematic. All youth displayed appropriate cooperation and selfcontrol skills based on the SSRS. Specific skills deficits in overall social skill and assertiveness were noted for youth with SAD and GAD relative to the NC group. These findings are consistent with other studies of SAD indicating poor social skills and deficient assertiveness (Alfano, Beidel, & Turner, 2006; Beidel et al., 1999; Beidel et al., 2007; Spence et al., 1999). Low assertiveness scores for the GAD group correspond to their clinical presentation, described as rule abiding, concerned with safety, and eager to please (Bernstein et al., 2008; Scharfstein, Alfano, et al., 2011), which are reflected in the items on this scale (reports accidents, accepts friends’ ideas for play). Children with SAD and GAD did not differ on responsible behavior, but SAD responsibility scores fell significantly below the TD group. Examination of the items on the responsibility scale suggests that low scores for SAD might reflect social fears (items such as introduces self, asks clerks for information) rather than a (dis)regard for authority (items such as requests permission before leaving the house, appropriately questions household rules). In summary, parent report data indicated that both youth with SAD and GAD have poor assertiveness and overall social skill difficulties, whereas only children with SAD have impaired responsibility compared to NC peers.
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Whereas many of the aforementioned skills assessed by self and parent report are complex behaviors (cooperation, self-control), which may be related to social functioning, behavioral observation of more molecular social behaviors (speech latency, speech content, vocal tone) allow for a more fine-grained analysis of social behavior. In this study, direct observations of children when playing a video game indicated a distinct pattern of social behavior deficits for children with SAD, who had an initial speech latency of greater than 3 min compared to fewer than 35 s in the other groups. Delayed speech during social engagement is characteristic of behaviorally inhibited toddlers and young children (Kagan, Reznick, & Snidman, 1987) and is one of the earliest markers for the development of SAD during adolescence (Hayward, Killen, Kraemer, & Taylor, 1998; Schwartz, Snidman, & Kagan, 1999). Children with SAD also spoke on nearly 60% fewer occasions, indicating a relative paucity of speech. These deficits did not just occur during in vivo interactions. Even when instructed to write down responses to a series of audio-recorded vocal prompts, children with SAD exhibited a paucity of content, not apparent in their GAD and NC peers. These data suggest a social awkwardness among children with SAD, which could negatively impact spontaneous social interactions. Given that first impressions form quickly, this deficient ability to quickly=spontaneously interact with an unknown peer may negatively impact their ability to establish friendships. Digital analysis of vocal characteristics (pitch, volume) also shed light on group differences. Children with SAD spoke with a lower average and maximum voice volume and exhibited a restricted range of pitch compared to NC children, subjectively heard as soft speech with a lack of vocal inflection. In a previous study, children with SAD responded to social prompts with low volume and high pitch, but with high variability in their vocal pitch (i.e., jitteriness; Scharfstein, Beidel, Sims, et al., 2011). When data from both investigations are considered together, children with SAD consistently evidence anxious speech patterns not found in other groups, with some variation possibly depending on conversational demands. These findings suggest differences in the social skills of youth with SAD and GAD. Attention to the shared and distinctive aspects of their social repertoire may inform differential diagnosis and treatment planning. Youth with GAD may benefit from assertiveness training and guidance in the use of questions to facilitate social conversation. Among youth with SAD, the current study supported and extended previous research documenting their social impairments (Alfano et al., 2006; Beidel et al., 1999, 2007; Scharfstein, Beidel, Sims, et al., 2011; Spence et al., 1999) and illustrated a pattern of overall deficits in social skill, suggesting that treatments that
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do not include social skills as part of the intervention may not yield optimal treatment outcome (Scharfstein, Beidel, Rendon Finnell, Distler, & Carter, 2011). Social skills training programs for SAD youth should therefore be comprehensive and incorporate skills for unstructured and extended interactions with peers (e.g., spontaneous speech, exclamations, latency to speech).
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Social Acceptance Parent and child ratings of social acceptance indicated that youth with SAD and GAD experienced greater difficulties in interpersonal relationships than NC youth, but there were no group differences on reported feelings of intimacy within their friendships. Low reported friendship intimacy for all groups might be representative of the age range examined. During adolescence, but not childhood, friendships are described as intimate, and friends commonly partake in personal disclosure, shared activities, and sticking up for one another (Berndt, 2002; Hartup & Stevens, 1999). With respect to friendship validation, children with SAD perceived less validation in their relationship with their best friend than their GAD and NC counterparts. Consistent with Festa and Ginsburg (2011), children with SAD were less likely to report that their best friend made them feel good about their ideas, told them they were good at things, and made them feel important and special. Children with SAD and GAD therefore have greater difficulties in their interpersonal relationships overall compared to NC youth, but only children with SAD feel invalidated within their closest friendship. Evaluation of peers’ immediate impression of children’s social acceptance and likeability revealed that in comparison to the other groups, children with SAD were rated by peers as less likeable, less fun, and less likely to be a good friend, and peers were less interested in being friends or playing with them again. Children with SAD, characterized by fear of negative evaluation, are actually perceived as less likeable and less socially desirable by their peers. Children with GAD reported impaired interpersonal relationships and elevated social anxiety, yet peers positively rated them on likability and friendship potential. The possible influence of the unique clinical features associated with this disorder may help to explain the incongruence between self-report and peer report of social acceptance among these youth. Youth with GAD often worry in the absence of objective concern and such worries persist despite reassurance from others (Albano et al., 2003). Youth with GAD may therefore worry about or perceive social failure due to their tendency to overestimate the likelihood of negative outcomes and=or because they have not met their own self-imposed standards of performance. Although these possibilities remain speculative at present, findings that children with GAD are
well liked by their peers suggest important differences in peer functioning compared to youth with SAD. Limitations Some limitations of this study are noted. First, the children in the SAD and GAD groups were not comorbid for SAD and GAD, a comorbidity sometimes reported in the literature, and thus do not represent all children who have one or both of these disorders. However, the use of semistructured interview schedules often leads to the reporting of multiple diagnoses without sufficient reflection as to whether one disorder may be uniquely accounting for the positive symptoms endorsed in a different diagnostic category. In DSM-IV-TR, concerns about social interactions are found in both disorders, contributing to the high rates of comorbidity. Second, direct observation of children’s behavior in social settings such as school and group activities were not used but may provide additional data regarding social functioning. Third, because the social and peer variables included in the current study do not represent all possible aspects of social and peer relations during childhood, nonsignificant differences in observer and peer ratings between the GAD and NC groups should not be interpreted to suggest overall equivalence in the social functioning of these two groups. Fourth, the sample was primarily Caucasian; therefore, replication among children of various ethnic=racial affiliations is warranted. Summary The most important finding in this study is that parent and child reports are insensitive to what could be important differences in social skills between youth with SAD and GAD. Such reports suggest that those with GAD are just as impaired as those with SAD and that those with SAD are no more impaired than those with GAD. But the direct observations, computer-based measures of speech quality, and peer ratings show that the groups are, in fact, different. More research is necessary to determine the relationship among observed social skills deficits and impaired social knowledge in the SAD group and peer ratings of poor likeability. Future studies should also investigate what factors contributed to the peers’ low ratings of likeability for children with SAD and adequate likeability ratings in the GAD and NC groups. REFERENCES Achenbach, T., & Edelbrock, C. (1991). Manual for the child behavior checklist. Burlington, VT: Queen City Printers. Achenbach, T., & Rescorla, L. (2001). Manual for the ASEBA school-age forms and profiles. Burlington: University of Vermont Research Center for Children, Youth, & Families.
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SOCIAL SKILLS Albano, A., Chorpita, B., & Barlow, D. (2003). Childhood anxiety disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (pp. 279–329). New York, NY: Guilford. Alfano, C., Beidel, D., & Turner, S. (2006). Cognitive correlates of social phobia among children and adolescents. Journal of Abnormal Child Psychology, 34, 182–194. American Psychiatric Association (2000). Diagnostic and statistical manual for mental disorders (4th ed., text rev.). Washington, DC: Author. Beesdo, K., Bittner, A., Pine, D., Stein, M., Hofler, M., Lieb, R., & Wittchen, H. (2007). Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Archives of General Psychiatry, 64, 903–912. Beidel, D., Turner, S., & Morris, T. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 73–79. Beidel, D., Turner, S., & Morris, T. (1999). Psychopathology of childhood social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 643–650. Beidel, D., Turner, S., & Morris, T. (2000). Behavioral treatment of childhood social phobia. Journal of Consulting and Clinical Psychology, 68, 1072–1080. Beidel, D., Turner, S., Young, B., Ammerman, R., Sallee, F., & Crosby, L. (2007). Psychopathology of adolescent social phobia. Journal of Psychopathology and Behavioral Assessment, 29, 47–54. Berndt, T. (2002). Friendship quality and social development. Current Directions in Psychological Science, 11, 7–10. Bernstein, G., Bernat, D., Davis, A., & Layne, A. (2008). Functioning in a nonclinical sample of children with social phobia. Depression and Anxiety, 25, 752–760. Bernstein, G., & Layne, A. (2006). Separation anxiety disorder and generalized anxiety disorder. In M. K. Dulcan & J. M. Wiener (Eds.), Essentials of child and adolescent psychiatry (pp. 415–439). Washington, DC: American Psychiatric Publishing. Boersma, P., & Weenink, D. (2005). Praat: Doing phonetics by computer (Version 4.3.14) [Computer software]. Available from http://praat.org/ Bradley, M., & Lang, P. (1994). Measuring emotion: The SelfAssessment Manikin and the semantic differential. Journal of Behavior Therapy and Experimental Psychiatry, 25, 49–59. Chansky, T., & Kendall, P. (1997). Social expectancies and selfperceptions in anxiety-disordered children. Journal of Anxiety Disorders, 11, 347–363. Chung, T., & Asher, S. (1996). Children’s goals and strategies in peer conflict situations. Merrill Palmer Quarterly, 42, 125–147. Costello, E., Egger, H., & Angold, A. (2005). The developmental epidemiology of anxiety disorders: Phenomenology, prevalence, and comorbidity. Child and Adolescent Psychiatric Clinics of North America, 14, 631–648. Crawley, S., Beidas, R., Benjamin, C., Martin, E., & Kendall, P. (2008). Treating socially phobic youth with CBT: Differential outcomes and treatment considerations. Behavioural & Cognitive Psychotherapy, 36, 379–389. Erdley, C., & Asher, S. (1996). Children’s social goals and self efficacy perceptions as influences on their responses to ambiguous provocation. Child Development, 67, 1329–1344. Festa, C., & Ginsburg, G. (2011). Parental and peer predictors of social anxiety in youth. Child Psychiatry and Human Development, 42, 291–306. Fuller, B., Horii, Y., & Conner, D. (1992). Validity and reliability of nonverbal voice measures as indicators of stressor-provoked anxiety. Research in Nursing and Health, 15, 379–389. Gresham, F., & Elliot, S. (1990). The social skills rating system. Circle Pines, MN: American Guidance.
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Hartup, W. (1996). The company they keep: Friendships and their developmental significance. Child Development, 67, 1–13. Hartup, W., & Stevens, N. (1999). Friendships and adaptation across the life span. Current Directions in Psychological Science, 8, 76–79. Hayward, C., Killen, J., Kraemer, H., & Taylor, C. (1998). Linking self-reported childhood behavioral inhibition to adolescent social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1308–1316. Higa, C., Fernandez, S., Nakamura, B., Chorpita, B., & Daleiden, E. (2006). Parental assessment of childhood social phobia: Psychometric properties of the Social Phobia and Anxiety Inventory for Children–Parent Report. Journal of Clinical Child and Adolescent Psychology, 35, 590–597. Hudson, J., Rapee, R., Lyneham, H., Wuthrich, V., & Schneiring, C. (2010, June). Paper presented at The World Congress of Behavioral and Cognitive Therapies, Boston, MA. Kagan, J., Reznick, S., & Snidman, N. (1987). The physiology and psychology of behavioral inhibition in children. Child Development, 58, 1459–1473. Kimble, C., & Seidel, S. (1973). Vocal signs of confidence. Behavioral Assessment, 15, 99–105. Ladd, G., Kochenderfer, B. J., & Coleman, C. (1996). Friendship quality as a predictor of young children’s early school adjustment. Child Development, 67, 1103–1118. Laukka, P., Linnman, C., Ahs, F., Pissiota, A., Frans, O., Faria, V., & . . . Furmark, T. (2008). In a nervous voice: Acoustic analysis and perception of anxiety in social phobics’ speech. Journal of Nonverbal Behavior, 32, 195–214. Parker, J., & Asher, S. (1993). Friendship and friendship quality in middle childhood: Links with peer group acceptance and feelings of loneliness and social dissatisfaction. Developmental Psychology, 29, 611–621. Rao, P., Beidel, D., Turner, S., Ammerman, R., Crosby, L., & Sallee, F. (2007). Social anxiety disorder in childhood and adolescence: Descriptive psychopathology. Behaviour Research and Therapy, 45, 1181–1191. Scharfstein, L., Alfano, C., Beidel, D., & Wong, N. (2011). Children with generalized anxiety disorder do not have peer problems, just fewer friends. Child Psychiatry and Human Development, 41(1), 712–723. Scharfstein, L., & Beidel, D. (2011). Behavioral and cognitivebehavioral treatments for youth with social phobia. Journal of Experimental Psychopathology, 2, 615–628. Scharfstein, L., Beidel, D., Rendon Finnell, L., Distler, A., & Carter, N. (2011). Do pharmacological and behavioral interventions differentially affect treatment outcome for children with social phobia? Behavior Modification, 35, 451–467. Scharfstein, L., Beidel, D., Sims, V., & Rendon Finnel, L. (2011). Social skills deficits and vocal characteristics of children with social phobia or Asperger’s Disorder: A comparative study. Journal of Abnormal Child Psychology, 39, 865–875. Schwartz, C., Snidman, N., & Kagan, J. (1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1008–1015. Silverman, W., & Albano, A. (1996). The anxiety disorders interview schedule for DSM–IV–child and parent versions. San Antonio, TX: Psychological Corporation. Spence, S., Donovan, C., & Brechman-Toussaint, M. (1999). Social skills, social outcomes, and cognitive features of childhood social phobia. Journal of Abnormal Psychology, 108, 211–221. Strauss, C., Lahey, B., Frick, P., Frame, C., & Hynd, G. (1988). Peer social status of children with anxiety disorders. Journal of Consulting and Clinical Psychology, 56, 137–141.
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Verduin, T., & Kendall, P. (2008). Peer perceptions and liking of children with anxiety disorders. Journal of Abnormal Child Psychology, 36, 459–469. Wechsler, D. (2003). Wechsler intelligence scale for children–fourth edition. San Antonio, TX: Psychological Corporation.
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APPENDIX Social Vignettes Task Scenarios and Confederate Prompts Practice Scene: Imagine that you are at the movies and you are buying some popcorn. You pay the cashier and receive the popcorn. There is a boy=girl standing behind you and he=she says: (a) Actor: How’s the popcorn? (b) Actor: I think I’m going to get some! Scene 1: You are riding your bike in front of your house with another boy=girl. The boy=girl stops after he=she almost crashes. It looks as though he=she has a flat tire. You approach him=her. He=she looks at you, and with a sad voice, he=she says: (a) Actor: How am I going to get my bike home? (b) Actor: I guess I ought to call my parent. Scene 2: In gym class, you are learning how to play basketball and how to shoot free throws. You are
having trouble making some shots from the free throw line. Another boy=girl who is a good basketball player says: (a) Actor: Would you like for me to help you with your free throws? (b) Actor: Well, it was hard for me to learn at first. Would you like for me to give you some pointers? Scene 3: A boy=girl who sits next to you in math class is having some trouble with his=her math test. He=she’s been working hard to get his=her grade up. The class gets back the most recent test with grades on them. He=she gets a big smile on his=her face and says: (a) Actor: I finally got an A! (b) Actor: I’ve been studying so hard. Scene 4: You’ve been working hard to memorize a poem to recite in English class. You finish reciting the poem in front of the class and return to your seat. The boy=girl sitting next to you says: (a) Actor: You did a great job. (b) Actor: You remembered every word and you looked so calm and cool. Scene 5: You are playing with a ball during recess. All of a sudden another kid takes the ball from you and says: (a) Actor: This is my ball now! (b) Actor: Go find another one.
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