Forced choice reaction time paradigm in children with separation anxiety disorder, social phobia, and nonanxious controls

Cognitive distortions refer to cognitive processes that are biased and therefore yield dysfunctional and maladaptive products (e.g., interpretation bias). Automatic aspects of information processing need to be considered and investigating these aspects requires forms of assessment other than self-report. Studies focussing on the specificity of cognitive biases across different types of anxiety disorders in childhood are rare. Thus, a forced choice reaction time paradigm with picture stimuli was used to assess the interpretation bias in anxious children online. The study investigated disorder-specific interpretation bias in 71 children with separation anxiety disorder (SAD), 31 children with social phobia, and 42 children without mental disorders, aged 5–13 years. Results indicated that children with SAD rated ambiguous separation pictures as significantly more unpleasant and more arousing than nonanxious children. However, no support was found that children with SAD and social phobia interpret ambiguous separation or social pictures in a more negative way than nonanxious children. Furthermore, no group differences were found in reaction times to all picture categories.     

Influence of expressed emotion and perceived criticism on cognitive-behavioral therapy for social phobia

This study examined significant others' expressed emotion (EE) and a closely related construct, perceived criticism, as predictors of cognitive-behavioral therapy outcome in a sample of 40 patients with social phobia (social anxiety disorder). Patients enrolled in group therapy for social phobia completed pre- and post-treatment questionnaire measures of perceived criticism and anxious and depressive symptoms. Designated significant others were assessed for the components of high EE (criticism, hostility and emotional overinvolvement) using the Camberwell Family Interview. It was hypothesized that these high-EE components and patients' perceived criticism would be associated with poorer treatment outcome, and results ran counter to these expectations. Controlling for initial social phobia severity, lower levels of perceived criticism predicted treatment dropout. There was also a nonsignificant trend for participants with a significant other rated as high in emotional overinvolvement to show less change on a composite symptom measure. Findings from this study suggest that close relationships impact the outcome of cognitive-behavioral interventions for social phobia.     

Suppressor effects and age differences in the expression of anxious emotion

This study examined the role of suppressor effects on age differences in anxious emotion. Children and adolescents (n = 1099) ages 7–18 years were assessed for separation anxiety, social anxiety, and generalized anxiety. Results of zero-order correlations indicated a significant negative association between age and separation anxiety but no association for social anxiety and generalized anxiety. However, semi-partial correlations indicated the presence of a cooperative suppressor effect such that the associations between age and social anxiety as well as age and generalized anxiety symptoms became significant and positive and the association with separation anxiety became larger in a simultaneous regression analysis of each facet with age. Similar effects occurred when controlling for hyperarousal in an ANCOVA across grade levels. Results suggest that attempts to understand developmental differences in anxious emotion in childhood and adolescence will be facilitated by parsing facets of anxious emotion and attention to potential suppressor effects.     

Threat perception bias in nonreferred, socially anxious children

Investigated whether socially anxious children display a threat perception bias. A sample of 252 primary school children ages 8 to 13 years were exposed to ambiguous stories of social situations and instructed to find out as quickly as possible whether a story was scary. Furthermore, children were invited to tell how each story would end and to judge how they would feel when actually confronted with that situation. The main results can be summarized as follows. First, socially anxious children displayed lower thresholds for threat perception than control children. In other words, compared with control children, socially anxious children needed to hear fewer sentences of a story before deciding it was scary. Furthermore, socially anxious children more frequently perceived threat while listening to the stories than did control children. Finally, socially anxious children more often interpreted the stories as threatening and displayed higher levels of negative feelings and cognitions in relation to these stories compared with control children. These findings fit nicely in current information-processing theories of childhood anxiety. An additional aim of this study was to investigate the convergent validity of the social phobia scales of 2 recently developed self-report questionnaires for measuring anxiety disorder symptoms in children: the Spence Children's Anxiety Scale (Spence, 1998) and the Screen for Child Anxiety Related Emotional Disorders (Birmaher et al., 1997). Results indicated that the social phobia scale of the Spence Children's Anxiety Scale and the extended social phobia scale of the Screen for Child Anxiety Related Emotional Disorders correlated substantially with a specific measure of social anxiety, the Social Anxiety Scale for Children-Revised.     

Anxious Solitude and Clinical Disorder in Middle Childhood: Bridging Developmental and Clinical Approaches to Childhood Social Anxiety

It was hypothesized that children identified by their peers at school as anxious solitary would report more symptoms of social anxiety disorder on a self report questionnaire and, on the basis of child and parent clinical interviews, receive more diagnoses of social anxiety disorder and additional anxiety and mood disorders. Participants were 192 children drawn from a community sample of 688 children attending public elementary schools. Half of these children were selected because they were identified as anxious solitary by peers and the other half were demographically-matched controls. 192 children provided self reports of social anxiety disorder symptoms on a questionnaire, and 76 of these children and their parent participated in clinical interviews. Results indicate that children identified by their peers as anxious solitary in the fall of 4th grade, compared to control children, were significantly more likely to receive diagnoses of social anxiety disorder, specific phobia, and selective mutism based on parent clinical interviews. Additionally, there was a tendency for these children to be diagnosed with generalized anxiety disorder and post traumatic stress disorder based on parent clinical interviews. Furthermore, children who had been identified as anxious solitary at any time in the 3rd or 4th grades were more likely than control children to report symptoms of social anxiety disorder that fell in the clinical range and to receive diagnoses of social anxiety disorder and dysthymia (both trends) and major depression (a significant effect) according to parental clinical interview.     

Impact of anticipatory processing versus distraction on multiple indices of anxiety in socially anxious individuals

In models of social phobia, anticipatory processing before a social-evaluative event is a key maintaining factor for the disorder. This study investigated the impact of anticipatory processing versus distraction before a social-evaluative task on affective (self-reported anxiety), psychophysiological (skin conductance), cognitive (self-reported maladaptive self-beliefs) and behavioural (in-situation performance) responses of participants. High and low socially anxious undergraduates were randomly allocated to either an anticipatory processing or distraction condition, and then completed an impromptu speech task. Relative to distraction, anticipatory processing increased self-reported anxiety in all participants, and increased skin conductance and the strength of conditional and high standard beliefs in the high (but not low) socially anxious participants. Unconditional beliefs were not affected. For high socially anxious individuals, anticipatory processing was also indirectly associated with poorer speech performance by increasing self-reported anxiety. Anticipatory processing appears to have multiple adverse effects in socially anxious individuals.     

Interpersonal Subtypes Within Social Anxiety: The Identification of Distinct Social Features

Although social anxiety disorder is defined by anxiety-related symptoms, little research has focused on the interpersonal features of social anxiety. Prior studies (Cain, Pincus, & Grosse Holtforth, 2010; Kachin, Newman, & Pincus, 2001) identified distinct subgroups of socially anxious individuals' interpersonal circumplex problems that were blends of agency and communion, and yet inconsistencies remain. We predicted 2 distinct interpersonal subtypes would exist for individuals with high social anxiety, and that these social anxiety subtypes would differ on empathetic concern, paranoia, received peer victimization, perspective taking, and emotional suppression. From a sample of 175 undergraduate participants, 51 participants with high social anxiety were selected as above a clinical cutoff on the social phobia scale. Cluster analyses identified 2 interpersonal subtypes of socially anxious individuals: low hostility–high submissiveness (Cluster 1) and high hostility–high submissiveness (Cluster 2). Cluster 1 reported higher levels of empathetic concern, lower paranoia, less peer victimization, and lower emotional suppression compared to Cluster 2. There were no differences between subtypes on perspective taking or cognitive reappraisal. Findings are consistent with an interpersonal conceptualization of social anxiety, and provide evidence of distinct social features between these subtypes. Findings have implications for the etiology, classification, and treatment of social anxiety.     

Delineating components of emotion and its dysregulation in anxiety and mood psychopathology

Two studies sought to elucidate the components of emotion and its dysregulation and examine their role in both the overlap and distinctness of the symptoms of 3 highly comorbid anxiety and mood disorders (i.e., generalized anxiety disorder, major depression, and social anxiety disorder). In Study 1, exploratory factor analyses demonstrated that 4 factors--heightened intensity of emotions, poor understanding of emotions, negative reactivity to emotions, and maladaptive management of emotions--best reflected the structure of 4 commonly used measures of emotion function and dysregulation. In Study 2, a separate sample provided support for this 4-factor model of emotion dysregulation. Poor understanding, negative reactivity, and maladaptive management were found to relate to a latent factor of emotion dysregulation. In contrast, heightened intensity of emotions was better characterized separately, suggesting it may relate more strongly to dispositional emotion generation or emotionality. Finally, the 4 components demonstrated both common and specific relationships to self-reported symptoms of generalized anxiety disorder, major depression, and social anxiety disorder.     

Patterns of Emotional Reactivity and Regulation in Children with Anxiety Disorders

Emotion dysregulation is believed to be a key factor in anxiety disorders. However, the empirical basis for this view is limited, particularly in children and adolescents. This study aimed to examine whether anxious children display negative emotional hyper-reactivity and deficits in emotion regulation, using a new task that presents ambiguous situations with potentially threatening meanings. Forty-nine children diagnosed with either generalized anxiety disorder, social anxiety, or separation anxiety disorder, were compared with 42 non-anxious controls. Relative to controls, anxious children demonstrated (a) greater intensity and frequency of negative emotional responses, (b) deficits in using reappraisal in negative emotional situations and corresponding deficits in reappraisal self-efficacy, and (c) greater reliance on emotion regulation strategies that increase the risk of functional impairment, intense negative emotion, and low emotion regulation self-efficacy. Implications for the assessment and treatment of childhood anxiety are discussed.     

Homotypic Versus Heterotypic Continuity of Anxiety Symptoms in Young Adolescents: Evidence for Distinctions Between DSM-IV Subtypes

Objective: to investigate homotypic and heterotypic longitudinal patterns of symptoms of separation anxiety disorder (SAD), generalized anxiety disorder (GAD), social phobia (SoPh), panic disorder (PD), and obsessive compulsive disorder (OCD) in young adolescents from the Dutch general population. Method: 2,067 individuals (51.4% girls) from a Dutch community sample, who were assessed for the first time when they were aged 10 to 12 years, were followed up across a period of two years. At both assessments, anxiety symptoms were assessed with the RCADS, a self-report questionnaire. Results: Regression analyses indicated that homotypic continuity was relatively high for SAD, GAD, and SoPh symptoms, and for PD in girls. Conclusions: In many studies, anxiety disorders are treated as one group of disorders, and some widely used assessment instruments, such as the Child Behavior Checklist, do not even contain scales that tap different anxiety dimensions. In the present study, evidence for homotypic continuity was found, especially for symptoms of separation, social, and generalized anxiety, and for symptoms of panic disorder in girls, underscoring the usefulness of making distinctions between different anxiety constructs. An erratum to this article can be found at     

Changes in maternal expressed emotion toward clinically anxious children following cognitive behavioral therapy

The aim of this study was to determine whether maternal expressed emotion (criticism and emotional overinvolvement) decreased across treatment for childhood anxiety. Mothers of 48 clinically anxious children (aged 6-14 years) were rated on levels of criticism (CRIT) and emotional overinvolvement (EOI), as measured by a Five Minute Speech Sample (FMSS) from mothers, prior to and following cognitive behavioral therapy (CBT) for their children’s anxiety. Results showed a significant decrease in the proportion of mothers who expressed high levels of criticism and emotional overinvolvement from pretreatment to posttreatment. This finding suggests that interventions aimed at reducing symptoms of child anxiety can also result in a decrease of maternal expressed emotion (criticism and emotional overinvolvement).     

Emotion-focused cognitive-behavioral therapy for anxious youth: A multiple-baseline evaluation

Examined the efficacy of an Emotion-focused Cognitive-Behavioral Therapy (ECBT) for six anxious youths ages 7–13 years. All participants had a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia) based on the Anxiety Disorder Interview Schedule for Children—Child and Parent versions. Children and parents reported on anxious symptomatology using the Multidimensional Anxiety Scale for Children (MASC). To assess emotion-related competencies, children were administered the Kusche Affective Interview—Revised and children and parents completed the Emotion Expression Scale for Children (EESC) and Emotion Regulation Checklist (ERC), respectively. Cases began treatment after baselines of 0, 2, or 3 weeks. At posttreatment, the majority of children demonstrated improvements in anxious symptomatology, emotion understanding and regulation skills, and overall functioning. Such improvements in emotion-related skills, in addition to anxiety, are significant given that emotional competence is a crucial component in children's adaptive social functioning and psychological adjustment. These findings provide initial support for ECBT.     

Impact of rumination versus distraction on anxiety and maladaptive self-beliefs in socially anxious individuals

A large body of experimental evidence has demonstrated the adverse effects of rumination on depressive mood and cognitions. In contrast, while prominent models of social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997) have proposed rumination as a key maintaining factor, the effects of rumination in social anxiety have not been extensively explored. In a sample of (N = 93) undergraduates, this study investigated the impact of rumination versus distraction following a social-evaluative task on anxiety and another key component of social phobia: maladaptive self-beliefs. Relative to distraction, rumination maintained anxiety in both high and low socially anxious individuals, and maintained unconditional beliefs in high socially anxious individuals. The results support models of social phobia and also suggest important theoretical extensions. Implications for the treatment of social anxiety are discussed.     

Interpretation and Expectation in Childhood Anxiety Disorders: Age Effects and Social Specificity

Theory and treatment for childhood anxiety disorders typically implicates children’s negative cognitions, yet little is known about the characteristics of thinking styles of clinically anxious children. In particular, it is unclear whether differences in thinking styles between children with anxiety disorders and non-anxious children vary as a function of child age, whether particular cognitive distortions are associated with childhood anxiety disorders at different child ages, and whether cognitive content is disorder-specific. The current study addressed these questions among 120 7–12 year old children (53% female) who met diagnostic criteria for social anxiety disorder, other anxiety disorder, or who were not currently anxious. Contrary to expectations, threat interpretation was not inflated amongst anxious compared to non-anxious children at any age, although older (10–12 year old) anxious children did differ from non-anxious children on measures of perceived coping. The notion of cognitive-content specificity was not supported across the age-range. The findings challenge current treatment models of childhood anxiety, and suggest that a focus on changing anxious children’s cognitions is not warranted in mid-childhood, and in late childhood cognitive approaches may be better focussed on promoting children’s perceptions of control rather than challenging threat interpretations.     

Social phobics do not misinterpret facial expression of emotion

Attentional biases in the processing of threatening facial expressions in social anxiety are well documented. It is generally assumed that these attentional biases originate in an evaluative bias: socially threatening information would be evaluated more negatively by socially anxious individuals. However, three studies have failed to evidence a negative evaluative bias in the processing of emotional facial expression (EFE) in socially anxious individuals. These studies however suffer from several methodological limitations that the present study has attempted to overcome. Twenty-one out-patients diagnosed with generalized social phobia have been compared to 20 out-patients diagnosed with another anxiety disorder and with 39 normal controls matched for gender, age and level of education. They had to decode on seven emotion intensity scales a set of 40 EFE whose intensity and emotional nature were manipulated. Although sufficient statistical power was ensured, no differences among groups could be found in terms of decoding accuracy, attributed emotion intensity, or reported difficulty of the task. Based on these findings as well as on other evidences, we propose that, if they exist, evaluative biases in social anxiety should be implicit and automatic and that they might be determined by the relevance of the stimulus to the person's concern rather than by the stimulus valence. The implications of these findings for the interpersonal processes involved in social phobia are discussed.     

Perceived parental rearing behaviour and anxiety disorders symptoms in normal children

The present study examined the relationship between perceptions of parental rearing behaviours and anxiety disorders symptomatology in a sample of normal school children. 45 children, aged 8 to 12 years, completed the EMBU for children, a questionnaire that measures perceptions of parental rearing practices. Additionally, they filled in the Screen of Child Anxiety Related Emotional Disorders (SCARED), an index of DSM-defined anxiety disorders symptoms. Significant and positive relationships were found between anxious rearing behaviours and parental control, on the one hand, and anxiety disorders symptomatology, in particular symptoms of generalized anxiety disorder, separation anxiety disorder and environmental–situational phobia, on the other hand.     

Emotional, behavioral, and cognitive factors that differentiate obsessive-compulsive disorder and other anxiety disorders in youth

Abstract The current study examined specific emotional, behavioral, and cognitive variables that may distinguish obsessive-compulsive disorder (OCD) from generalized anxiety disorder (GAD), social phobia (SoP), and separation anxiety disorder (SAD) in youth. Youth with OCD (n=26) and other anxiety disorders (ADs; n=31), aged 7-12 years (56.1% males), and their parents participated. The study compared the two anxious groups on levels of emotional, behavioral, and cognitive functioning, as well as impairment associated with the disorder. Results indicated that in comparison to youth with GAD, SoP, or SAD, youth with OCD were found to have poorer emotion regulation skills, as well as greater oppositionality, cognitive problems/inattention, and parent impairment associated with the disorder. The findings suggest that there are unique characteristics of OCD that may differentiate this disorder from other ADs in youth. Potential clinical implications and directions for future research are discussed.     

Emotion-Focused Cognitive-Behavioral Therapy for Youth with Anxiety Disorders: A Randomized Trial

Difficulties with emotion regulation are a core feature of anxiety disorders (ADs) in children and adults. Interventions with a specific focus on emotion regulation are gaining empirical support. Yet, no studies to date have compared the relative efficacy of such interventions to existing evidence-based treatments. Such comparisons are necessary to determine whether emotion-focused treatments might be more effective for youth exhibiting broad emotion-regulation difficulties at pretreatment. This study examined an emotion-focused cognitive-behavioral therapy (ECBT) protocol in comparison to traditional cognitive-behavioral therapy (CBT) in a sample of children with a primary anxiety disorder diagnosis. Moderation analyses examined whether children with higher levels of emotion dysregulation at pretreatment would show greater levels of improvement in ECBT than CBT. Ninety-two youth ages 7 to 12 years (58% male) with a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia were included. Participants were randomly assigned to ECBT or CBT. Results showed that youth in both conditions demonstrated similar improvements in emotion regulation and that pretreatment levels of emotion dysregulation did not moderate treatment outcomes. Additional analyses showed that ECBT and CBT were similarly effective on diagnostic, severity, and improvement measures. Future work is needed to further explore the ways that emotion regulation is related to treatment outcome for anxious youth.     

Perception of control over anxiety mediates the relation between catastrophic thinking and social anxiety in social phobia

Cognitive models of social phobia (social anxiety disorder) assume that individuals with social phobia experience anxiety in social situations in part because they overestimate the social cost associated with a potentially negative outcome of a social interaction. Some emotion theorists, on the other hand, point to the perception of control over anxiety-related symptoms as a determinant of social anxiety. In order to examine the relationship between perceived emotional control (PEC), estimated social cost (ESC), and subjective anxiety, we compared three alternative structural equation models: Model 1 assumes that PEC and ESC independently predict social anxiety; Model 2 assumes that ESC partially mediates the relationship between PEC and anxiety, and Model 3 assumes that PEC partially mediates the relationship between ESC and anxiety. We recruited 144 participants with social phobia and administered self-report measures of estimated social cost, perceived anxiety control, and social anxiety. The results support Model 3 and suggest that "costly" social situations are anxiety provoking in part because social phobic individuals perceive their anxiety symptoms as being out of control.