Social Phobia and Overanxious Disorder in School-Age Children DEBORAH C. BEIDEL, PH.D.
Abstract. Epidemiological data indicate that, based on current diagnostic criteria, anxiety disorders are the most common childhood disorders. Furthermore, the comorbidity rate among the various diagnostic categories is quite high, and relatively little attention has been given to delineating the specific and distinct parameters of these disorders. The current study examined the characteristics of overanxious disorder and social phobia by comparing children who have these disorders to matched normal controls. The results indicated that children with social phobia could be differentiated from the other groups, based on self-report inventories, daily diary data, and a psychophysiological assessment. However, there were few variables that distinguished overanxious children. The results provide strong support for the diagnostic validity of social phobia in children but lesser support for overanxious disorder as currently defined. l. Am. Acad. Child Adolesc. Psychiatry. 1991,30,4:545-552. Key Words: overanxious disorder, childhood social phobia, psychophysiological assessment. There has been increased interest in childhood anxiety disorders in the past 10 years. Although diagnostic categories such as separation anxiety disorder and overanxious disorder were described in the DSM-lII, until recently there were few data on even the basic epidemiology of these conditions. Recently, however, a longitudinal study conducted in New Zealand (Anderson et aI., 1987; McGee et al., 1990) indicated that anxiety disorders were very common in cross-sectional samples of children II or 15 years of age. At age II, the population prevalence rate was 3.5% for separation anxiety disorder (SAD), 2.9% for overanxious disorder (OAD), and 0.9% for social phobia (SP) (Anderson et aI., 1987). When the children were reassessed 4 years later (at age 15), anxiety disorders were the most prevalent disorder, affecting approximately 12.6% of the population (McGee et aI., 1990). However, nearly half of the adolescents diagnosed with an anxiety disorder were given the diagnosis of OAD. The overall prevalence rates for the general population were OAD (5.9%), SAD (2%), simple phobia (3.6%; most common was the fear of public speaking, although it was unclear why this was included as a simple phobia rather than a social phobia), and SP (worry about making mistakes-I.I %). Similar epidemiological investigations conducted in the United States (Kashani et aI., 1987; Kashani and Orvaschel, 1988) corroborate the New Zealand findings. Among adolescents aged 14 to 16, anxiety disorders and conduct disorder were most common (each with an 8.7% prevalence rate). Among the children with anxiety disorders, 85% of the diagnoses were OAD. Phobias accounted for the other 15%. Finally, two cross-sectional epidemiological studies (Kashani et aI., 1989; Kashani and Orvaschel, 1990) more Accepted February 27. 1991. Dr. Beidel is with the Department ofPsychiatry. University ofPittsburgh School of Medicine. Western Psychiatric Institute and Clinic. This project was supported by NIMH Grant MH43252. The author would like to thank Karen Trager. M.A .• Amy Lederer. and lonathan Rubin for their assistance in data collection and analysis. Reprint requests to Dr. Beidel. WPIC 3811 O'Hara Street. Pittsburgh. PA 15213. 0890-8567/91/3OO4-0545$03.OO/0© 1991 by the American Academy of Child and Adolescent Psychiatry. l.Am.Acad. Child Adolesc. Psychiatry. 30:4,luly 1991
closely examined children aged 8, 12, or 17. In these samples, based on the child's report of symptoms, 21 % had an anxiety disorder, making it more prevalent than any other disorder. Among the anxiety disorders, SAD and OAD were equally prevalent (12.9% and 12.4%, respectively). Simple phobia accounted for 3.3%, and 1.1% had SP. These data indicated that, based on current diagnostic criteria, anxiety disorders are the most common childhood disorder. Within samples of children referred to an anxiety disorders clinic (Last et aI., 1987a), prevalence data indicated that nearly 33% suffered from a primary diagnosis of SAD, 15% had primary OAD, 15% had primary school phobia (which was social in origin), and 15% had primary major depression. Data from a second, somewhat larger sample (Last et al., 1987b) also highlighted the prevalence of SAD and OAD in clinic samples, where 76% of the clinic referrals had one or both of these conditions. Comparing prevalence rates for epidemiological and clinic-referred samples indicated that although OAD appeared more prevalent in the general population, OAD and SAD were equally prevalent among children referred to a clinic. These data suggest that despite OAD's higher prevalence in the general population, SAD may result in more serious impairment, thus generating a higher proportion of clinic referrals. In addition to their substantial prevalence rates, there appears to be a high comorbidity rate among the anxiety disorders. Last et al. (I987b) reported that 41 % of children with primary SAD, 56% of children with primary OAD, and 63% of children with a school (social) phobia had one or more concurrent anxiety disorders. This high degree of cooccurrence may simply reflect the severity of a clinic population. Nonetheless, nearly 46% of the OAD children in the McGee et al. (1990) study cited above also had a concurrent disorder (usually another anxiety or depressive disorder). Thus, these findings seem to parallel those of the adult literature where there is a high probability of having a second anxiety disorder if there is a primary Axis I anxiety disorder. Similarly, there is considerable overlap with depression. Few studies have investigated the distinctive features of the various childhood disorders, as currently defined in the DSM-lII-R. Last and her colleagues (1987a) reported dif-
545
BEIDEL
ferences between SAD and OAD patients, based on demographic characteristics (sex and age of onset). In a second study (Last et al., 1989), scores on the Fear Survey Schedule for Children-Revised (FSSC-R) were compared for SAD, OAD, and SP children. Notwithstanding the different responses of the groups on several specific items describing their "most severe" fears, there was no significant differentiation on the FSSC-R total score or various factor scores. Although the lack of group differences on the total score was not surprising, the fact that the groups were not different on factor scores theoretically related to the children's "main fears" indicates that there may be significant overlap among the various conditions. Surprisingly, there have been few comparisons between these diagnostic groups and normal controls on relevant measures of psychopathology. Without the use of a control group, the differentiation of SAD and OAD based on demographic or self-report data, for example, documents that the two conditions are different from each other but not necessarily that both are disorders. For example, it is unclear if children with overanxious disorder have restrictions in their daily activities or suffer significant distress when compared with normal controls. Currently, functional impairment is not necessary for the diagnosis, although such a revision is under consideration by the DSM-IV subcommittee (Shaffer et aI., 1989). Furthermore, a recent study by Bell-Dolan et al. (1990) reported that overconcern about competence and excessive need for reassurance (two of the criteria for OAD) are present in about 33% of children who did not meet diagnostic criteria for any psychiatric disorder. The substantial prevalence of these symptoms in normal children questions the distinctiveness of OAD as a discrete syndrome, or at the least suggests that DSM-III-R criteria are far too liberal.
Fears of poor performance and negative evaluation by others are common among children with OAD as well as SP (Beidel and Turner, 1988). Understanding of the nature of SP in children mirrors our knowledge of OAD. That is, although all of the prevalence studies report that there are children who meet diagnostic criteria for SP, there are few data detailing how this disorder is expressed in children, and if, in fact these diagnostic criteria characterize a different group of children than OAD. In summary, although childhood anxiety states were formally introduced a decade ago, basic questions regarding the psychopathology and the validity of these disorders remain unanswered. Furthermore, with respect to OAD, convergent data from several studies raise questions abut the validity of this diagnostic condition as currently defined. First, it appears to have an inordinately high prevalence in epidemiological investigations. Second, several of its key diagnostic features are common among children without psychiatric disorders. Finally, there are no current data that document that these children are functionally impaired as a consequence of meeting criteria for the disorder. The purpose of this study was twofold. First, it was designed to compare the characteristics of children with OAD or SP with matched normal controls in order to characterize the nature of these conditions and the degree to which the children suffer impairment. The second objective
546
was to directly compare matched samples of social phobic and overanxious children to determine areas of similarities and differences. Method SUBJECTS
The 47 children who participated in this project were part of a larger investigation aimed at examining the relationship of test anxiety to DSM-III-R anxiety disorders. Children were initially screened for test anxiety using the Test Anxiety Scale for Children (TASC) (Sarason et aI., 1958). Previous research had validated scores of 16 or above for girls and 12 or above for boys as indicative of significant test anxiety (Beidel and Turner, 1988). Children scoring above these cutoffs were interviewed with the Anxiety Disorders Interview Scale for Children (ADIS-C) (Silverman and Nelles, 1988). Mothers of the children were interviewed with the ADIS-C parent version. Eighteen children who met diagnostic criteria for SP and 11 children who met diagnostic criteria for OAD were the focus of this investigation. These children did not meet criteria for any other DSM-III-R disorder. There was one child who met diagnostic criteria for both OAD and SP, but this child was excluded from the study. Interrater reliability for the diagnostic categories based on the kappa statistic was K = 0.87 for SP and K = 0.83 for OAD. Differences were resolved by consensus agreement. Eighteen normal controls (who scored in the nontest anxious range on the TASC and who did not meet criteria for any DSM-III-R disorder) were matched to either a social phobic or overanxious child on sex, age, race, and grade. Demographic characteristics are presented in Table 1. ASSESSMENT
Self-Report
All children completed the State Trait Anxiety Inventory for Children (STAIC) (Spielberger, 1973), the Perceived Competence Scale for Children (PCSC) (Harter, 1982), and the Dimensions of Temperament Scale-Revised (DOTS-R) (Windle and Lerner, 1985, unpublished manuscript). The STAIC assesses state and trait anxiety. The PCSC assesses perception of self-competence across four domains: cognitive, social, physical, and general self-worth. The DOTSR assesses various dimensions of the child's temperament including general activity, sleep activity, approach-withdrawal, flexibility-rigidity, mood, sleep rhythmicity, eating rhythmicity, daily habits rhythmicity, task orientation, distractibility, and persistence. Daily Monitoring
Children were provided with a structured daily diary (Beidel et aI., 1990, submitted manuscript) and instructed to make an entry in the diary each time an anxiety producing event occurred. The diary used a structured format, and children were required to record the date, time and place, a description of the event, and their response to the event. Events relevant to children with concerns about their competence or social performance were listed in the diary and included taking tests, reading aloud before a group, writing J.Am.Acad. Child Adolesc.Psychiatry, 30:4, July 1991
SOCIAL PHOBIA AND OVERANXIOUS DISORDER TABLE
Age Sex Male Female Race White
African-American
1. Demographic Characteristics
Social Phobia
Overanxious Disorder
Normal Controls
10.6
10.0
10,8
7 II
3 8
II 7
11
o
7 II
11 7
on the board, giving a report, getting back a test, performing in front of others (sports, dance, or music recitals), and an "other" category. Potential responses to the events were also listed and included positive coping behaviors, such as extra practice or reassuring oneself; negative behaviors, such as crying, avoidance, and somatic complaints; or neutral behavior (i.e., did as directed). Raters blind to diagnostic category classified the child's response as positive, negative, or neutral. Interrater reliability was completed on 25% of the responses, with a resultant kappa coefficient of K = 0.95. In addition, the children rated the severity of their anxiety using a five-point Likert scale. Diaries were scored for the total number of events occurring in 2-week period, the specific type of event, child's behavioral response to the event (positive, negative, or neutral), and average distress rating when the events occurred. Previous research on the feasibility and validity of this structured diary format indicates acceptable compliance and good validity for this form of behavioral assessment (Beidel et aI., 1990, submitted manuscript). Behavioral Task
Each child participated in a psychophysiological assessment designed to elucidate physiological and cognitive responses during two behavioral tasks: taking an age-appropriate vocabulary test and reading aloud before a small audience of three young adult research assistants. Each task was 10 minutes in duration. The vocabulary section from the Metropolitan Achievement Test was used for the behavioral assessment. The story to be read aloud was Jack and the Beanstalk. Physiological assessment of pulse rate was recorded at the following intervals: baseline-the 2nd, 4th, 6th, 8th, and 10th minutes; test-taking-the 2nd, 4th, 6th, 8th, and 10th minutes; and reading aloud-the 2nd, 4th, 6th, 8th, and 10th minutes. After each task, children reported any cognitions that occurred to them during the task. The cognitions were categorized by raters blind to diagnostic group as positive, negative, or neutral. The kappa coefficient for interrater reliability was K = 0.92. Only negative thoughts were included in the data analysis. In addition, the children recorded their subjective distress using a Self-Assessment Manikin (SAM) (Lang and Cuthbert, 1984), a five-point rating scale using pictures to illustrate increasing severity of anxious distress. Results Scores on the self-report instruments (STAlC, PCSC, J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991
DOTS-R) as well as pulse rates and distress ratings during the behavioral tasks were analyzed with one way analyses of variance. Significant overall F values were further analyzed with Tukey's procedure. The frequency of children from each group who reported the occurrence of negative cognitions during the behavioral tasks were examined with chi-square tests. Out of the total sample of 47 children, 29 (11 children with SP, II normal controls, and 7 overanxious children) were assessed during the school year (the rest of the sample was assessed during summer recess). Because most of the daily diary items pertained to school-related activities, only those children assessed during the school year completed the daily diary. Because of the reduced sample, t-tests were used to compare mean number of events during the 2-week period and average distress ratings elicited by these events. Differences in the daily diary coping responses were analyzed with a chi square, and the overall significant effect was further analyzed with Fisher's exact tests. Self-Report Instruments
There was a significant difference among the three groups on the TASC score (F = 9.6; df = 2,44; P < 0.0005). As expected, the normal controls scored significantly lower than the SP and OAD children (p < 0.05), who did not differ from each other. Similarly, there was a significant difference among the groups on the STAlC trait score (F = 8.3; df = 2, 44; P < 0.001), where both the SP and OAD children scored significantly higher than the normal controls (p < 0.05) but not different from each other. In contrast, the SP children scored significantly lower on the cognitive competence subscale of the PCSC than both the OAD children and the normal controls (F = 3.17; df = 2, 44; P < 0.05). In addition, there was a trend for the groups to be significantly different on the flexibility-rigidity dimension of the DOTS-R (F = 2.9; df = 2,44, p < 0.07), where the SP children had the highest scores, the OAD children scored midway, and the normal controls had the lowest scores. There were no significant differences on any other subscales of the STAIC, PCSC, or DOTS-R. Scores for the three groups on all of the self-report measures are presented in Table 2. Behavioral Assessment
The groups were significantly different on baseline pulse rates (F = 4.79; df = 2, 44;p < 0.01). The OAD children's pulse rates were significantly higher than those of the SP children (p < 0.05). The pulse rates of the normal controls were not significantly different from either of the other two groups, but still 8 beats per minute (BPM) lower than the OAD group. In addition, there were trends for the groups to have significantly different pulse rate changes during the vocabulary test (F = 2.51; df = 2, 44; p < 0.09) and the read-aloud task (F = 2.35; df = 2, 44; p < 0.10). During the vocabulary test, the OAD group's pulse rate decreased an average of 6 BPM, whereas the SP and normal controls had increases of 4 BPM and 1 BPM, respectively. During the read-aloud task, the OAD children had an increase of only 1 BPM, the SP group had an increase of 6 BPM, and 547
BEIDEL
TABLE 2. Means and Standard Deviations for Social Phobia. Overanxious. and Normal Control Children on Self-Report Instruments
Measure TASC STAIC State Trait PCSC Cognitive Social Physical General self-esteem DOTS-R General activity Sleep activity Approach withdrawal Flexibility rigidity Mood Sleep rhythmicity Eating rhythmicity Daily habits rhythmicity Task orientation Distractibility Persistence
Social Phobia (N = 18)
Overanxious Disorder (N = 11)
X
SD
X
SD
X
SD
15.8a
7.4
18.8"
5.3
8.5"
6.0
9.62
0.0005
30.2 37.3 a
7.8 6.8
32.2 41.4"
9.9 6.0
26.5 28.3"
4.5 10.8
1.85 8.29
0.001
2.3" 2.8 2.7 2.5
0.9 1.0 1.0 0.8
3.1" 2.8 2.6 2.9
0.7 0.8 1.1 0.5
2.9" 2.8 2.8 2.9
0.9 1.0 0.9 1.0
3.17 0.49 0.71 0.92
17.2 10.3 17.3 13.7 21.7 14.9 12.6 11.2 20.5 12.1 8.4
4.9 3.9 3.4 2.5 4.3 3.2 3.2 2.8 5.4 3.3
19.1 12.1 18.6 14.5 22.8 14.9 15.3 11.5 21.6 13.4 8.3
5.1 3.8 4.4 4.6 3.9 2.2 2.8 2.1 5.0 3.8 2.0
17.2 11.9 19.1 15.9 21.1 13.4 12.7 10.6 20.3 12.5 7.8
5.2 3.9 3.6 2.6 5.4 5.1 4.5 3.3 5.2 3.2 2.5
0.46 0.96 0.91 2.24 0.35 0.71 1.49 0.33 0.18 0.35 0.36
1.7
Note: Means not sharing superscripts are significantly different from each other (p
Normal Controls (N = 18)
F Cdf
= 2,44)
p
0.05
0.D7
< 0.05).
the normal controls, 4 BPM. The pulse rate changes are depicted in Figure 1. With respect to subjective anxiety, there were significant differences during the vocabulary test (F = 3.5; df = 2, 44; p < 0.05). The SP children had significantly higher distress ratings than the normal controls (p < .05), whereas the OAD children were not significantly different from the others. There were no differences among the three groups on ratings of subjective anxiety during the read-aloud task. Only the SP and OAD children reported the occurrence of negative thoughts during the vocabulary test (X 2 = 5.35, df = 2, P < 0.06). During the read-aloud task, only the SP children and the normal control children reported any negative cognitions during the task. Again, the overall frequencies (as depicted in Table 3) were quite low, and, although indicative of a trend, the resultant chi square was nonsignificant (X 2 = 5.02, df = 2, P < 0.08). Scores for the three groups on all variables included in the behavioral assessment are presented in Table 3.
groups. Furthermore, only the SP children reported anxiety when reading aloud, giving an oral report, or writing on the board. With respect to the children's responses to these events (i.e., coping behaviors), there was a significant overall difference in how the children reacted (X 2 = 19.9, df = 4, p < 0.0005). Follow-up analyses with Fisher's exact tests indicated that the SP children were Significantly more likely to have negative reactions than the other groups (i.e., 46% of the SP responses were negative compared with 21 % of the normals and 26% for the OAD group, p < 0.01 and p < 0.05, respectively). In contrast, the predominant response of the OAD children was neutral (i.e., they just did as they were instructed; 55% in the OAD group), which was a significantly higher percentage than either the SP or normal control groups (23%, p < 0.001 and 33%, p < 0.01, respectively). Data from the daily diary ratings are depicted in Table 4.
Daily Diary Ratings
In order to determine if social phobia and overanxious disorder could be discriminated, the variables on which the two diagnostic groups appeared most different from the normal control group were entered into a discriminant function analysis: the STAIC trait score, the PCSC cognitive competence score, baseline pulse rate, and SAM ratings during the vocabulary test. Three of the variables (PCSC cognitive competence score, baseline pulse, and STAIC trait anxiety score) resulted in a highly significant discriminant function equation, X2 (df = 3) = 16.82, P < 0.001. The follow-up jack-knifed classification analysis indicated that
The SP children recorded significantly more anxiety-producing events over the 2-week period than the normal controls (t = 2.69, P < 0.01). There were no differences between the OAD children and the normal controls or between the SP and OAD groups on this variable. In addition, the SP group reported more distress at the occurrence of those events than the normal controls (t = 2.13, p < 0.05). Again there was no difference in distress ratings between the OAD and normal controls or between the SP and OAD 548
Discriminant Function Analysis
l.Am.Acad. Child Ado/esc. Psychiatry, 30:4, luly 1991
SOCIAL PHOBIA AND OVERANXIOUS DISORDER
82% of the SP children were correctly classified as were 91 % of the GAD children. The overall classification accuracy was 86%, with only three children (one GAD and two SP) incorrectly classified. Discussion The purpose of this study was to examine the psychopathology of children with diagnoses of SP or GAD in order to characterize these conditions and to determine areas of similarities and differences. Turning first to SP, the results indicate that these children exhibit features consistent with those found in adult SPs. For example, the children endorsed significantly lower perceptions of their cognitive competence, higher trait anxiety and higher anxiety during the vocabulary test. Furthermore, the pulse rate pattern of the SP children was typical of that expected for other SP groups (e.g., Beidel et aI., 1985). Specifically, the SP group had resting pulse rates that were no different from normal controls and significantly lower than the GAD children. When actually engaged in an anxiety-provoking activity, the SP children had increased pulse rates (although not significantly higher than the normal controls), and this increase remained elevated throughout the task's duration. The pattern of pulse rate response is what would be expected from those with a phobic disorder.
A diagnosis of SP results in significant distress and impairment in daily functioning as evident from the children's diaries, which detailed the occurrence of more anxiety producing events and more distress when events did occur. Moreover, they were the only children to report anxiety when engaged in activities, such as reading aloud, giving reports, and writing on the board. These latter three events require performing in front of others and also are characteristic of the concerns of socially phobic adults. Furthermore, when faced with these situations, behaviors, such as crying, somatic symptoms, and behavioral avoidance, were the predominant responses of this group, illustrating the negative impact of these events and confirming that this disorder results in serious impairment in daily functioning. Interestingly, a preliminary report from the DSM-IV subcommittee on SP has questioned the appropriateness of the term social phobia to describe social anxiety in children because they may not have the opportunity to avoid interactions (Spitzer and Schneier, 1990, unpublished manuscript). However, the results of this study dispute that contention and indicate that children do engage in a variety of avoidance strategies. In contrast to the SP children, children with GAD had significantly higher trait anxiety. Nonetheless, this increased anxiety did not appear to impede their daily functioning.
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FIG. 1. Pulse rate changes in overanxious, social phobic, and normal control children.
l.Am.Acad. Child Adolesc.Psychiatry, 30:4,July 1991
549
BEIDEL TABLE
3. Means and Standard Deviations for Social Phobic. Overanxious. and Normal Control Children on Psychophysiological Assessment
Social Phobic (N = 18)
Measure
X
Baseline pulse rate
SD Vocabulary test Pulse rate change (from baseline) Distress rating
X X SD
79.7" 8.9
Overanxious Disorder (N = II) 90.9 b 12.5 -6.0 2.0"b 0.8
3.8 2.4" 1.0
Normal Controls (N = 18)
(df
=
F 2,44)
p
82.2"b 8.1
4.78
0.01
0.8
2.51 3.45
0.09 0.05
1.6b
0.9 2
X
Negative cognitions (number of children reporting occurrence of at least one negative thought) Read-aloud task
2 (11%)
3 (27%)
0 (0%)
(df = 2) 5.35
F (df
X X
Pulse rate change (from baseline) Distress rating
0.06
SD
6.4 2.9 0.9
4.0 2.2 1.2
0.8 2.7 1.4
=
2,44) 2.35 1.90
0.10
X2 Negative cognitions (number of children reporting occurrence of at least one negative thought).
6 (33%)
Note: Means not sharing superscripts are significantly different from each other (p
TABLE
0.08
< 0.05).
4. Means and Standard Deviations for Daily Diary Data
(N = 11)
Overanxious Disorder (N = 7)
Normal Controls (N = 11)
6.1" 3.6 3.2" 0.8
4.3"b 3.2 2.9"b 1.0
2.4b 3.2 2.3 b 0.9
Social Phobia Variable Mean number of events during a 2-week period
X SD
Distress rating
3 (17%)
0 (0%)
(df = 2) 5.02
X SD
t
(df
=
17)
p
2.69
Abstract. Epidemiological data indicate that, based on current diagnostic criteria, anxiety disorders are the most common childhood disorders. Furthermore, the comorbidity rate among the various diagnostic categories is quite high, and relatively little attention has been given to delineating the specific and distinct parameters of these disorders. The current study examined the characteristics of overanxious disorder and social phobia by comparing children who have these disorders to matched normal controls. The results indicated that children with social phobia could be differentiated from the other groups, based on self-report inventories, daily diary data, and a psychophysiological assessment. However, there were few variables that distinguished overanxious children. The results provide strong support for the diagnostic validity of social phobia in children but lesser support for overanxious disorder as currently defined. l. Am. Acad. Child Adolesc. Psychiatry. 1991,30,4:545-552. Key Words: overanxious disorder, childhood social phobia, psychophysiological assessment. There has been increased interest in childhood anxiety disorders in the past 10 years. Although diagnostic categories such as separation anxiety disorder and overanxious disorder were described in the DSM-lII, until recently there were few data on even the basic epidemiology of these conditions. Recently, however, a longitudinal study conducted in New Zealand (Anderson et aI., 1987; McGee et al., 1990) indicated that anxiety disorders were very common in cross-sectional samples of children II or 15 years of age. At age II, the population prevalence rate was 3.5% for separation anxiety disorder (SAD), 2.9% for overanxious disorder (OAD), and 0.9% for social phobia (SP) (Anderson et aI., 1987). When the children were reassessed 4 years later (at age 15), anxiety disorders were the most prevalent disorder, affecting approximately 12.6% of the population (McGee et aI., 1990). However, nearly half of the adolescents diagnosed with an anxiety disorder were given the diagnosis of OAD. The overall prevalence rates for the general population were OAD (5.9%), SAD (2%), simple phobia (3.6%; most common was the fear of public speaking, although it was unclear why this was included as a simple phobia rather than a social phobia), and SP (worry about making mistakes-I.I %). Similar epidemiological investigations conducted in the United States (Kashani et aI., 1987; Kashani and Orvaschel, 1988) corroborate the New Zealand findings. Among adolescents aged 14 to 16, anxiety disorders and conduct disorder were most common (each with an 8.7% prevalence rate). Among the children with anxiety disorders, 85% of the diagnoses were OAD. Phobias accounted for the other 15%. Finally, two cross-sectional epidemiological studies (Kashani et aI., 1989; Kashani and Orvaschel, 1990) more Accepted February 27. 1991. Dr. Beidel is with the Department ofPsychiatry. University ofPittsburgh School of Medicine. Western Psychiatric Institute and Clinic. This project was supported by NIMH Grant MH43252. The author would like to thank Karen Trager. M.A .• Amy Lederer. and lonathan Rubin for their assistance in data collection and analysis. Reprint requests to Dr. Beidel. WPIC 3811 O'Hara Street. Pittsburgh. PA 15213. 0890-8567/91/3OO4-0545$03.OO/0© 1991 by the American Academy of Child and Adolescent Psychiatry. l.Am.Acad. Child Adolesc. Psychiatry. 30:4,luly 1991
closely examined children aged 8, 12, or 17. In these samples, based on the child's report of symptoms, 21 % had an anxiety disorder, making it more prevalent than any other disorder. Among the anxiety disorders, SAD and OAD were equally prevalent (12.9% and 12.4%, respectively). Simple phobia accounted for 3.3%, and 1.1% had SP. These data indicated that, based on current diagnostic criteria, anxiety disorders are the most common childhood disorder. Within samples of children referred to an anxiety disorders clinic (Last et aI., 1987a), prevalence data indicated that nearly 33% suffered from a primary diagnosis of SAD, 15% had primary OAD, 15% had primary school phobia (which was social in origin), and 15% had primary major depression. Data from a second, somewhat larger sample (Last et al., 1987b) also highlighted the prevalence of SAD and OAD in clinic samples, where 76% of the clinic referrals had one or both of these conditions. Comparing prevalence rates for epidemiological and clinic-referred samples indicated that although OAD appeared more prevalent in the general population, OAD and SAD were equally prevalent among children referred to a clinic. These data suggest that despite OAD's higher prevalence in the general population, SAD may result in more serious impairment, thus generating a higher proportion of clinic referrals. In addition to their substantial prevalence rates, there appears to be a high comorbidity rate among the anxiety disorders. Last et al. (I987b) reported that 41 % of children with primary SAD, 56% of children with primary OAD, and 63% of children with a school (social) phobia had one or more concurrent anxiety disorders. This high degree of cooccurrence may simply reflect the severity of a clinic population. Nonetheless, nearly 46% of the OAD children in the McGee et al. (1990) study cited above also had a concurrent disorder (usually another anxiety or depressive disorder). Thus, these findings seem to parallel those of the adult literature where there is a high probability of having a second anxiety disorder if there is a primary Axis I anxiety disorder. Similarly, there is considerable overlap with depression. Few studies have investigated the distinctive features of the various childhood disorders, as currently defined in the DSM-lII-R. Last and her colleagues (1987a) reported dif-
545
BEIDEL
ferences between SAD and OAD patients, based on demographic characteristics (sex and age of onset). In a second study (Last et al., 1989), scores on the Fear Survey Schedule for Children-Revised (FSSC-R) were compared for SAD, OAD, and SP children. Notwithstanding the different responses of the groups on several specific items describing their "most severe" fears, there was no significant differentiation on the FSSC-R total score or various factor scores. Although the lack of group differences on the total score was not surprising, the fact that the groups were not different on factor scores theoretically related to the children's "main fears" indicates that there may be significant overlap among the various conditions. Surprisingly, there have been few comparisons between these diagnostic groups and normal controls on relevant measures of psychopathology. Without the use of a control group, the differentiation of SAD and OAD based on demographic or self-report data, for example, documents that the two conditions are different from each other but not necessarily that both are disorders. For example, it is unclear if children with overanxious disorder have restrictions in their daily activities or suffer significant distress when compared with normal controls. Currently, functional impairment is not necessary for the diagnosis, although such a revision is under consideration by the DSM-IV subcommittee (Shaffer et aI., 1989). Furthermore, a recent study by Bell-Dolan et al. (1990) reported that overconcern about competence and excessive need for reassurance (two of the criteria for OAD) are present in about 33% of children who did not meet diagnostic criteria for any psychiatric disorder. The substantial prevalence of these symptoms in normal children questions the distinctiveness of OAD as a discrete syndrome, or at the least suggests that DSM-III-R criteria are far too liberal.
Fears of poor performance and negative evaluation by others are common among children with OAD as well as SP (Beidel and Turner, 1988). Understanding of the nature of SP in children mirrors our knowledge of OAD. That is, although all of the prevalence studies report that there are children who meet diagnostic criteria for SP, there are few data detailing how this disorder is expressed in children, and if, in fact these diagnostic criteria characterize a different group of children than OAD. In summary, although childhood anxiety states were formally introduced a decade ago, basic questions regarding the psychopathology and the validity of these disorders remain unanswered. Furthermore, with respect to OAD, convergent data from several studies raise questions abut the validity of this diagnostic condition as currently defined. First, it appears to have an inordinately high prevalence in epidemiological investigations. Second, several of its key diagnostic features are common among children without psychiatric disorders. Finally, there are no current data that document that these children are functionally impaired as a consequence of meeting criteria for the disorder. The purpose of this study was twofold. First, it was designed to compare the characteristics of children with OAD or SP with matched normal controls in order to characterize the nature of these conditions and the degree to which the children suffer impairment. The second objective
546
was to directly compare matched samples of social phobic and overanxious children to determine areas of similarities and differences. Method SUBJECTS
The 47 children who participated in this project were part of a larger investigation aimed at examining the relationship of test anxiety to DSM-III-R anxiety disorders. Children were initially screened for test anxiety using the Test Anxiety Scale for Children (TASC) (Sarason et aI., 1958). Previous research had validated scores of 16 or above for girls and 12 or above for boys as indicative of significant test anxiety (Beidel and Turner, 1988). Children scoring above these cutoffs were interviewed with the Anxiety Disorders Interview Scale for Children (ADIS-C) (Silverman and Nelles, 1988). Mothers of the children were interviewed with the ADIS-C parent version. Eighteen children who met diagnostic criteria for SP and 11 children who met diagnostic criteria for OAD were the focus of this investigation. These children did not meet criteria for any other DSM-III-R disorder. There was one child who met diagnostic criteria for both OAD and SP, but this child was excluded from the study. Interrater reliability for the diagnostic categories based on the kappa statistic was K = 0.87 for SP and K = 0.83 for OAD. Differences were resolved by consensus agreement. Eighteen normal controls (who scored in the nontest anxious range on the TASC and who did not meet criteria for any DSM-III-R disorder) were matched to either a social phobic or overanxious child on sex, age, race, and grade. Demographic characteristics are presented in Table 1. ASSESSMENT
Self-Report
All children completed the State Trait Anxiety Inventory for Children (STAIC) (Spielberger, 1973), the Perceived Competence Scale for Children (PCSC) (Harter, 1982), and the Dimensions of Temperament Scale-Revised (DOTS-R) (Windle and Lerner, 1985, unpublished manuscript). The STAIC assesses state and trait anxiety. The PCSC assesses perception of self-competence across four domains: cognitive, social, physical, and general self-worth. The DOTSR assesses various dimensions of the child's temperament including general activity, sleep activity, approach-withdrawal, flexibility-rigidity, mood, sleep rhythmicity, eating rhythmicity, daily habits rhythmicity, task orientation, distractibility, and persistence. Daily Monitoring
Children were provided with a structured daily diary (Beidel et aI., 1990, submitted manuscript) and instructed to make an entry in the diary each time an anxiety producing event occurred. The diary used a structured format, and children were required to record the date, time and place, a description of the event, and their response to the event. Events relevant to children with concerns about their competence or social performance were listed in the diary and included taking tests, reading aloud before a group, writing J.Am.Acad. Child Adolesc.Psychiatry, 30:4, July 1991
SOCIAL PHOBIA AND OVERANXIOUS DISORDER TABLE
Age Sex Male Female Race White
African-American
1. Demographic Characteristics
Social Phobia
Overanxious Disorder
Normal Controls
10.6
10.0
10,8
7 II
3 8
II 7
11
o
7 II
11 7
on the board, giving a report, getting back a test, performing in front of others (sports, dance, or music recitals), and an "other" category. Potential responses to the events were also listed and included positive coping behaviors, such as extra practice or reassuring oneself; negative behaviors, such as crying, avoidance, and somatic complaints; or neutral behavior (i.e., did as directed). Raters blind to diagnostic category classified the child's response as positive, negative, or neutral. Interrater reliability was completed on 25% of the responses, with a resultant kappa coefficient of K = 0.95. In addition, the children rated the severity of their anxiety using a five-point Likert scale. Diaries were scored for the total number of events occurring in 2-week period, the specific type of event, child's behavioral response to the event (positive, negative, or neutral), and average distress rating when the events occurred. Previous research on the feasibility and validity of this structured diary format indicates acceptable compliance and good validity for this form of behavioral assessment (Beidel et aI., 1990, submitted manuscript). Behavioral Task
Each child participated in a psychophysiological assessment designed to elucidate physiological and cognitive responses during two behavioral tasks: taking an age-appropriate vocabulary test and reading aloud before a small audience of three young adult research assistants. Each task was 10 minutes in duration. The vocabulary section from the Metropolitan Achievement Test was used for the behavioral assessment. The story to be read aloud was Jack and the Beanstalk. Physiological assessment of pulse rate was recorded at the following intervals: baseline-the 2nd, 4th, 6th, 8th, and 10th minutes; test-taking-the 2nd, 4th, 6th, 8th, and 10th minutes; and reading aloud-the 2nd, 4th, 6th, 8th, and 10th minutes. After each task, children reported any cognitions that occurred to them during the task. The cognitions were categorized by raters blind to diagnostic group as positive, negative, or neutral. The kappa coefficient for interrater reliability was K = 0.92. Only negative thoughts were included in the data analysis. In addition, the children recorded their subjective distress using a Self-Assessment Manikin (SAM) (Lang and Cuthbert, 1984), a five-point rating scale using pictures to illustrate increasing severity of anxious distress. Results Scores on the self-report instruments (STAlC, PCSC, J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991
DOTS-R) as well as pulse rates and distress ratings during the behavioral tasks were analyzed with one way analyses of variance. Significant overall F values were further analyzed with Tukey's procedure. The frequency of children from each group who reported the occurrence of negative cognitions during the behavioral tasks were examined with chi-square tests. Out of the total sample of 47 children, 29 (11 children with SP, II normal controls, and 7 overanxious children) were assessed during the school year (the rest of the sample was assessed during summer recess). Because most of the daily diary items pertained to school-related activities, only those children assessed during the school year completed the daily diary. Because of the reduced sample, t-tests were used to compare mean number of events during the 2-week period and average distress ratings elicited by these events. Differences in the daily diary coping responses were analyzed with a chi square, and the overall significant effect was further analyzed with Fisher's exact tests. Self-Report Instruments
There was a significant difference among the three groups on the TASC score (F = 9.6; df = 2,44; P < 0.0005). As expected, the normal controls scored significantly lower than the SP and OAD children (p < 0.05), who did not differ from each other. Similarly, there was a significant difference among the groups on the STAlC trait score (F = 8.3; df = 2, 44; P < 0.001), where both the SP and OAD children scored significantly higher than the normal controls (p < 0.05) but not different from each other. In contrast, the SP children scored significantly lower on the cognitive competence subscale of the PCSC than both the OAD children and the normal controls (F = 3.17; df = 2, 44; P < 0.05). In addition, there was a trend for the groups to be significantly different on the flexibility-rigidity dimension of the DOTS-R (F = 2.9; df = 2,44, p < 0.07), where the SP children had the highest scores, the OAD children scored midway, and the normal controls had the lowest scores. There were no significant differences on any other subscales of the STAIC, PCSC, or DOTS-R. Scores for the three groups on all of the self-report measures are presented in Table 2. Behavioral Assessment
The groups were significantly different on baseline pulse rates (F = 4.79; df = 2, 44;p < 0.01). The OAD children's pulse rates were significantly higher than those of the SP children (p < 0.05). The pulse rates of the normal controls were not significantly different from either of the other two groups, but still 8 beats per minute (BPM) lower than the OAD group. In addition, there were trends for the groups to have significantly different pulse rate changes during the vocabulary test (F = 2.51; df = 2, 44; p < 0.09) and the read-aloud task (F = 2.35; df = 2, 44; p < 0.10). During the vocabulary test, the OAD group's pulse rate decreased an average of 6 BPM, whereas the SP and normal controls had increases of 4 BPM and 1 BPM, respectively. During the read-aloud task, the OAD children had an increase of only 1 BPM, the SP group had an increase of 6 BPM, and 547
BEIDEL
TABLE 2. Means and Standard Deviations for Social Phobia. Overanxious. and Normal Control Children on Self-Report Instruments
Measure TASC STAIC State Trait PCSC Cognitive Social Physical General self-esteem DOTS-R General activity Sleep activity Approach withdrawal Flexibility rigidity Mood Sleep rhythmicity Eating rhythmicity Daily habits rhythmicity Task orientation Distractibility Persistence
Social Phobia (N = 18)
Overanxious Disorder (N = 11)
X
SD
X
SD
X
SD
15.8a
7.4
18.8"
5.3
8.5"
6.0
9.62
0.0005
30.2 37.3 a
7.8 6.8
32.2 41.4"
9.9 6.0
26.5 28.3"
4.5 10.8
1.85 8.29
0.001
2.3" 2.8 2.7 2.5
0.9 1.0 1.0 0.8
3.1" 2.8 2.6 2.9
0.7 0.8 1.1 0.5
2.9" 2.8 2.8 2.9
0.9 1.0 0.9 1.0
3.17 0.49 0.71 0.92
17.2 10.3 17.3 13.7 21.7 14.9 12.6 11.2 20.5 12.1 8.4
4.9 3.9 3.4 2.5 4.3 3.2 3.2 2.8 5.4 3.3
19.1 12.1 18.6 14.5 22.8 14.9 15.3 11.5 21.6 13.4 8.3
5.1 3.8 4.4 4.6 3.9 2.2 2.8 2.1 5.0 3.8 2.0
17.2 11.9 19.1 15.9 21.1 13.4 12.7 10.6 20.3 12.5 7.8
5.2 3.9 3.6 2.6 5.4 5.1 4.5 3.3 5.2 3.2 2.5
0.46 0.96 0.91 2.24 0.35 0.71 1.49 0.33 0.18 0.35 0.36
1.7
Note: Means not sharing superscripts are significantly different from each other (p
Normal Controls (N = 18)
F Cdf
= 2,44)
p
0.05
0.D7
< 0.05).
the normal controls, 4 BPM. The pulse rate changes are depicted in Figure 1. With respect to subjective anxiety, there were significant differences during the vocabulary test (F = 3.5; df = 2, 44; p < 0.05). The SP children had significantly higher distress ratings than the normal controls (p < .05), whereas the OAD children were not significantly different from the others. There were no differences among the three groups on ratings of subjective anxiety during the read-aloud task. Only the SP and OAD children reported the occurrence of negative thoughts during the vocabulary test (X 2 = 5.35, df = 2, P < 0.06). During the read-aloud task, only the SP children and the normal control children reported any negative cognitions during the task. Again, the overall frequencies (as depicted in Table 3) were quite low, and, although indicative of a trend, the resultant chi square was nonsignificant (X 2 = 5.02, df = 2, P < 0.08). Scores for the three groups on all variables included in the behavioral assessment are presented in Table 3.
groups. Furthermore, only the SP children reported anxiety when reading aloud, giving an oral report, or writing on the board. With respect to the children's responses to these events (i.e., coping behaviors), there was a significant overall difference in how the children reacted (X 2 = 19.9, df = 4, p < 0.0005). Follow-up analyses with Fisher's exact tests indicated that the SP children were Significantly more likely to have negative reactions than the other groups (i.e., 46% of the SP responses were negative compared with 21 % of the normals and 26% for the OAD group, p < 0.01 and p < 0.05, respectively). In contrast, the predominant response of the OAD children was neutral (i.e., they just did as they were instructed; 55% in the OAD group), which was a significantly higher percentage than either the SP or normal control groups (23%, p < 0.001 and 33%, p < 0.01, respectively). Data from the daily diary ratings are depicted in Table 4.
Daily Diary Ratings
In order to determine if social phobia and overanxious disorder could be discriminated, the variables on which the two diagnostic groups appeared most different from the normal control group were entered into a discriminant function analysis: the STAIC trait score, the PCSC cognitive competence score, baseline pulse rate, and SAM ratings during the vocabulary test. Three of the variables (PCSC cognitive competence score, baseline pulse, and STAIC trait anxiety score) resulted in a highly significant discriminant function equation, X2 (df = 3) = 16.82, P < 0.001. The follow-up jack-knifed classification analysis indicated that
The SP children recorded significantly more anxiety-producing events over the 2-week period than the normal controls (t = 2.69, P < 0.01). There were no differences between the OAD children and the normal controls or between the SP and OAD groups on this variable. In addition, the SP group reported more distress at the occurrence of those events than the normal controls (t = 2.13, p < 0.05). Again there was no difference in distress ratings between the OAD and normal controls or between the SP and OAD 548
Discriminant Function Analysis
l.Am.Acad. Child Ado/esc. Psychiatry, 30:4, luly 1991
SOCIAL PHOBIA AND OVERANXIOUS DISORDER
82% of the SP children were correctly classified as were 91 % of the GAD children. The overall classification accuracy was 86%, with only three children (one GAD and two SP) incorrectly classified. Discussion The purpose of this study was to examine the psychopathology of children with diagnoses of SP or GAD in order to characterize these conditions and to determine areas of similarities and differences. Turning first to SP, the results indicate that these children exhibit features consistent with those found in adult SPs. For example, the children endorsed significantly lower perceptions of their cognitive competence, higher trait anxiety and higher anxiety during the vocabulary test. Furthermore, the pulse rate pattern of the SP children was typical of that expected for other SP groups (e.g., Beidel et aI., 1985). Specifically, the SP group had resting pulse rates that were no different from normal controls and significantly lower than the GAD children. When actually engaged in an anxiety-provoking activity, the SP children had increased pulse rates (although not significantly higher than the normal controls), and this increase remained elevated throughout the task's duration. The pattern of pulse rate response is what would be expected from those with a phobic disorder.
A diagnosis of SP results in significant distress and impairment in daily functioning as evident from the children's diaries, which detailed the occurrence of more anxiety producing events and more distress when events did occur. Moreover, they were the only children to report anxiety when engaged in activities, such as reading aloud, giving reports, and writing on the board. These latter three events require performing in front of others and also are characteristic of the concerns of socially phobic adults. Furthermore, when faced with these situations, behaviors, such as crying, somatic symptoms, and behavioral avoidance, were the predominant responses of this group, illustrating the negative impact of these events and confirming that this disorder results in serious impairment in daily functioning. Interestingly, a preliminary report from the DSM-IV subcommittee on SP has questioned the appropriateness of the term social phobia to describe social anxiety in children because they may not have the opportunity to avoid interactions (Spitzer and Schneier, 1990, unpublished manuscript). However, the results of this study dispute that contention and indicate that children do engage in a variety of avoidance strategies. In contrast to the SP children, children with GAD had significantly higher trait anxiety. Nonetheless, this increased anxiety did not appear to impede their daily functioning.
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FIG. 1. Pulse rate changes in overanxious, social phobic, and normal control children.
l.Am.Acad. Child Adolesc.Psychiatry, 30:4,July 1991
549
BEIDEL TABLE
3. Means and Standard Deviations for Social Phobic. Overanxious. and Normal Control Children on Psychophysiological Assessment
Social Phobic (N = 18)
Measure
X
Baseline pulse rate
SD Vocabulary test Pulse rate change (from baseline) Distress rating
X X SD
79.7" 8.9
Overanxious Disorder (N = II) 90.9 b 12.5 -6.0 2.0"b 0.8
3.8 2.4" 1.0
Normal Controls (N = 18)
(df
=
F 2,44)
p
82.2"b 8.1
4.78
0.01
0.8
2.51 3.45
0.09 0.05
1.6b
0.9 2
X
Negative cognitions (number of children reporting occurrence of at least one negative thought) Read-aloud task
2 (11%)
3 (27%)
0 (0%)
(df = 2) 5.35
F (df
X X
Pulse rate change (from baseline) Distress rating
0.06
SD
6.4 2.9 0.9
4.0 2.2 1.2
0.8 2.7 1.4
=
2,44) 2.35 1.90
0.10
X2 Negative cognitions (number of children reporting occurrence of at least one negative thought).
6 (33%)
Note: Means not sharing superscripts are significantly different from each other (p
TABLE
0.08
< 0.05).
4. Means and Standard Deviations for Daily Diary Data
(N = 11)
Overanxious Disorder (N = 7)
Normal Controls (N = 11)
6.1" 3.6 3.2" 0.8
4.3"b 3.2 2.9"b 1.0
2.4b 3.2 2.3 b 0.9
Social Phobia Variable Mean number of events during a 2-week period
X SD
Distress rating
3 (17%)
0 (0%)
(df = 2) 5.02
X SD
t
(df
=
17)
p
2.69
