Running head: SOCIAL PHOBIA: A REVIEW 1

Running head: SOCIAL PHOBIA: A REVIEW 1 Social Phobia: A Review of Childhood Risk Factors Amy Williams University of Calgary

SOCIAL PHOBIA: A REVIEW 2 Social Phobia: A Review of Childhood Risk Factors Anxiety disorders are currently among the most commonly diagnosed disorders in children and adolescents (Cartwright-Hatton, McNicol, & Doubleday, 2006). Of the 12 anxiety disorders included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000), social phobia is one that deserves particular attention. According to Peleg-Popko and Dar (2001), developmental studies of children s fears and worries have consistently identified social concerns as an important area of anxiety (p. 469). The DSM-IV defines social phobia as a disorder characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior (American Psychiatric Association, p. 429). Social situations can include social gatherings, school, and the workplace, whereas performance situations can include public speaking, eating in public places, or using public restrooms. In both social and performance situations, people with social phobia experience fear or excessive worries with regard to experiencing embarrassment or rejection by peers, colleagues, or even strangers (Mash & Barkley, 2003). This fear translates into uncomfortable physiological symptoms such as blushing, sweating, palpitations, and gastrointestinal discomfort; people with social phobia sometimes fear these symptoms as much as they fear the social or performance situation itself (Mash & Barkley, 2003). Although the exact etiology of social phobia is unknown, many theories regarding the onset of this disorder exist. According to Merikangas, Lieb, Wittchen, and Avenevoli (2003), most theories of anxiety assume an underlying genetic predisposition (p. 34). Other theories hold that environmental factors play an important role in the development of social phobia. For example, conditioning theory and stress theories emphasize the effects traumatic events have on

SOCIAL PHOBIA: A REVIEW 3 the development of specific phobias (Magee, 1999). Chartier, Walker, and Stein (2001) posit that because early adolescence is the average age of onset of this disorder, it is especially appropriate to study childhood risk factors (p. 308). This paper examines research findings in the area of childhood risk factors associated with social phobia, and highlights the implications these risk factors hold for understanding the development of this disorder. Parental Psychopathology One childhood risk factor consistently associated with social phobia is a positive family history of this disorder (Merikangas et al., 2003). Several studies have investigated the role of parental psychopathology and children s subsequent development of social phobia. Merikangas et al. (2003) analyzed data obtained from the Yale Family Study, a high-risk study in which probands with social phobia and their adult relatives and children were interviewed and assessed. Child psychiatrists reviewed diagnostic interviews, questionnaires, family history reports, and both school and medical records before making diagnoses in probands children. Results of the present study indicated a moderate association between social anxiety disorder in parents and child and adolescent offspring (p. 33). According to Merikangas et al. (2003), these results provide compelling evidence for the familial aggregation of social anxiety disorder (p. 33). The Early Developmental Stages of Psychopathology (EDSP) (Lieb et al., 2000) is another study that examined the link between social phobia and parental psychopathology. A prospective-longitudinal survey, the EDSP included a community sample of 3021 people between the ages of 14 to 24 in Munich, Germany whose parents most often mothers were interviewed in regard to family psychopathology and their children s early development. Results of the EDSP study indicated that children of parents diagnosed with social phobia had greater

SOCIAL PHOBIA: A REVIEW 4 rates of this disorder themselves than did children of parents without social phobia (Lieb et al., 2000). The present study also suggested that comorbidity plays an important role in the development of social phobia: rates of social phobia were also elevated in adolescents whose parents met criteria for other anxiety, depressive, or alcohol use disorders (p. 862). Thus social phobia was not the only parent psychopathological disorder identified as a precipitating factor in the development of social phobia. Bandelow et al. (2004) shed light on another study regarding social phobia and family history of mental disorders. In this study, both respondents with social anxiety and control subjects completed a retrospective interview in which they answered questions pertaining to parental psychopathology (for example, alcohol addiction, anxiety disorders, and other mental illnesses). Results of the interviews showed that respondents with social anxiety disorder reported more frequent instances of parental psychopathology, including social anxiety disorder and other anxiety disorders (Bandelow et al., 2004). In addition, higher rates of suicidality and alcohol abuse were reported by these respondents, the latter being reported more frequently in relation to fathers (Bandelow et al., 2004). Implications The findings of the aforementioned studies are significant because they suggest that parental psychopathology is a precipitating factor in the development of social phobia. Researchers have turned to environmental influences to explain this link. In particular, parent behavior has gained attention for its potential association with the onset of social phobia. According to Lieb et al. (2000),

SOCIAL PHOBIA: A REVIEW 5 The examination of the interactions between parenting behavior and parental psychopathology with regard to respondents social phobia status revealed that the association between parental rejection and adolescents social phobia is significantly greater when parents are affected by psychopathology, irrespective of the specific parental disorders. (p. 863) A parent with a disorder either social phobia itself or another disorder such as depression - may demonstrate a lack of emotional warmth or rejection toward their child as a result of his or her psychopathology; this in turn may lead to the child experiencing anxiety. Parent-Child Interaction and Rearing Styles Adverse parental behavior and rearing styles have been connected to both childhood and adult disorders (Bandelow et al., 2003). In fact, Merikangas et al. (2003) hold that parental behavior is the most widely studied environmental vulnerability factor for the development of either depression or anxiety (p. 34). Over the past two decades, several studies have been conducted in which the association between parental behaviors and social phobia has been investigated; however, much debate surrounds the issue of both parent-child interaction and rearing styles as risk factors in the development of this disorder (Elizabeth et al., 2006). Arrindell, Methorst, Van Der Ende, and Moritz (1989) investigated the perception of socially phobic in-patients regarding parental rearing styles. Rejection and emotional warmth were common maternal and paternal characteristics reported by patients, and these characteristics were rated more highly and frequently by patients than by subjects in the control group. In addition, social phobic patients reported both maternal and paternal rearing styles as more inconsistent in comparison to reports of the control group. While paternal overprotection was not identified as a significant factor, maternal overprotection was.

SOCIAL PHOBIA: A REVIEW 6 Lieb et al. (2000) published results with respect to the EDSP study in which diagnostic interviews were conducted and adolescents answered questions regarding their parents rearing styles. According to their findings, higher parental overprotection and higher parental rejection were significantly associated with increased rates of social phobia in offspring (p. 862). Merikangas et al. (2003) divided the category of parental overprotection into maternal and paternal for this study, indicating a stronger association of social phobia with maternal overprotection and rejection. In terms of rating parental emotional warmth, very little difference was reported between respondents with social phobia and respondents in the control group (Lieb et al., 2000). Peleg-Popko and Dar (2001) conducted a study in which Israeli mothers completed a questionnaire regarding their children. This questionnaire contained items related to both negative evaluation (for example, a child s perception of other children talking behind his or her back) and social avoidance (for example, shyness and worries related to meeting new children). According to the results of this study, [a child s] general social avoidance and inhibition score was positively related to family cohesion as was fear of negative evaluation (Peleg-Popko & Dar, 2001, p. 477). Finally, Bandelow et al. (2003) had subjects with social anxiety complete retrospective interviews regarding parental behavior. They found that paternal behavior involving dominance and short-temperedness was reported frequently among respondents. In addition, subjects with social anxiety perceived punishment as being more common and severe than the control subjects did, and they reported lack of emotion and restriction of autonomy (overprotection) demonstrated by both parents more frequently than did control subjects (Bandelow et al., 2003). Implications

SOCIAL PHOBIA: A REVIEW 7 According to these studies, a relationship between parent-child interaction and the development of social phobia exists; however, difficulty determining the direction of causality regarding this relationship also exists. According to Peleg-Popko and Dar (2001), Parent s behavior may clearly influence the development of social anxiety in children, but social anxiety in children may also bias the interpretation of and response to parental behavior (p. 483). Furthermore, that studies investigating parental rearing styles involve patient questionnaires and interviews - and patients responses are therefore subjective may have an impact on obtained results (Bandelow et al., 2003). Arrindell et al. (1989) argue that an indirect test may raise the possibility of one s memories producing a distorted view of one s parent s rearing behavior rather than reflecting actual rearing practices (p. 533). Consideration of healthy parenting styles, however, is helpful in understanding the onset or prevention - of social phobia: It is possible that flexible parents, who enable their child to encounter all sorts of experiences independently, strengthen his or her self-efficacy and ability to cope with a variety of situations (Peleg-Popko & Dar, 2001, p. 482). It can be argued then that parenting styles that encourage risk-taking and promote a child s self-esteem more often result in healthy child development. Further investigation is required to identify the complex causal network (Peleg-Popko & Dar, 2001, p. 483) connecting parent-child interaction and rearing styles and the development of social phobia. Marital Conflict Marital conflict is yet another risk factor often associated with childhood disorders; however, controversy exists regarding the connection this factor has with the development of social phobia. Peleg-Popko and Dar (2001) conducted a study in which mothers of five to six year olds in northern Israel anonymously completed questionnaires pertaining to marital quality, family

SOCIAL PHOBIA: A REVIEW 8 cohesion, and family adaptability. Although the present study detected a link between marital conflict and parent-child interaction, no such link was made between marital conflict and social phobia. According to Peleg-Popko and Dar (2001), marital and parent-child relationships are so tightly interwoven that one cannot draw valid inferences about the effects of marital disagreements without at the same time considering the nature of parent-child relations (p. 467). These researchers explain the effect marital conflict can have on parent-child interaction: frequent conflict may be emotionally draining to parents and thus diminish their ability to recognize and respond to their children s emotional needs. Children may perceive parental inattention or withdrawal as rejection, which in turn, may have a host of effects on their emotional and behavioral adjustment. They may also experience feelings of rejection if marital conflict leads to greater tension or conflict between parents and children. (p. 467) Thus the present study holds that marital conflict has a negative effect on parental behavior, which in turn can impact the development of social phobia. Other studies, however, have detected a direct relationship between parental marital conflict and social phobia. Magee (1999) analyzed data pertaining to American respondents childhood and negative life experiences and found that martial conflict particularly verbal aggression plays an important role in the development of social phobia. Chartier et al. (2001) reported data from a study in which Canadian respondents answered questions pertaining to a variety of risk factors associated with social phobia. In comparison to the control group, respondents with social phobia more frequently reported parental marital conflict during their upbringings. Those respondents with generalized social phobia reported higher rates of marital discord than respondents with specific social phobia (public speaking) did. Bandelow et al.

SOCIAL PHOBIA: A REVIEW 9 (2004) also discovered in their study involving subjects with social anxiety and perceived parenting styles that Patients reported more frequently that their parents had had marital discord (p. 400). In this study, separation and divorce were included within the category of marital problems. Implications Findings regarding the link between marital conflict and the development of social phobia are inconsistent. Children s perceptions of the conflict they experience are important factors to take into consideration when interpreting the results of psychological studies concerning this disorder; so too are children s relationships with their parents. According to Peleg-Popko and Dar (2001), children with stable parental relationships may be less distressed by the conflict because they believe that family cohesion is strong and that their parents will protect them from harm (p. 467). These researchers further hold that conflict between parents places stress on the relationship between the parents and child, which can lead to hostility (Peleg- Popko & Dar, 2001). A connection may therefore exist between marital quality and parent-child interaction. Due to inconsistent findings regarding the link between parental marital conflict and the development of social phobia, however, marital conflict as a childhood risk factor is an area that requires further research. Early Life Trauma Early life experiences particularly childhood trauma - have also been investigated for their link to the onset of various phobias. According to Magee (1999), if stress precipitates phobia onset, then all types of aversive experiences should significantly increase risk for onset (p. 343).

SOCIAL PHOBIA: A REVIEW 10 In a qualitative research investigation, Chartier, Hazen, and Stein (1998) interviewed respondents who met DSM-IV criteria for social phobia regarding perceptions of their disorder. When questioned about factors that they believed may have triggered the onset of their social phobia, several respondents reported instances of physical and sexual abuse. Death of a parent and suicide of a sibling were also reported as potential triggers. Finally, a negative school environment in which respondents feared criticism or disapproval was reported, and so was poverty. Chartier et al. conclude their research analysis by stating that childhood events can set the groundwork for social phobia by worsening low self-esteem (p. 120). Magee (1999) reported data obtained from a retrospective interview in which respondents with either agoraphobia, social phobia, or another specific phobia answered questions regarding 10 negative life events. These life events included experiencing natural disasters, war, physical and verbal violence, and rape and molestation. In this study, sexual abuse was shown to have a significant association with the development of social phobia in women, particularly when the perpetrator was a family member (Magee, 1999). Magee theorizes that the control and power associated with sexual abuse can lead to the onset of this disorder (Magee, 1999). Chartier et al. (2001) compared data collected from respondents with social phobia to data collect from control subjects without the disorder in an attempt to discover the relationship between certain childhood risk factors and the onset of social phobia. Among risk factors reported most frequently among respondents with social phobia were running away from home, physical abuse, and sexual abuse, the latter being more pronounced in reports by females. High frequency in reporting sexual abuse held true for both subjects with severe social phobia and social phobia involving only public speaking.

SOCIAL PHOBIA: A REVIEW 11 Finally, Bandelow et al. (2004) analyzed date from a study in which patients with social phobia and control subjects were asked questions regarding early traumatic life events during a telephone interview. Traumatic life events included but were not limited to separation from or death of a parent, family violence, illness, and sexual abuse. Significant differences existed between patient and control subjects responses in the following categories (with the former reporting higher frequencies): maternal hospitalization, frequent paternal absences, absence of both parents (being raised by another family member), maternal unemployment, and parental and sibling violence. Sexual abuse was reported by both patients and control subjects but was reported to have begun later in life and to have lasted longer by the former group of respondents (Bandelow et al., 2004). Implications These studies suggest that certain traumatic events precipitate the onset of social phobia. Sexual abuse, in particular, was reported by subjects with social phobia the most frequently (Chartier et al., 1998; Magee, 1999; Chartier et al., 2001; Bandelow et al., 2004), implicating the occurrence of this event as an important risk factor associated with this disorder. Researchers caution, however, that the validity of studies involving retrospective questionnaires pertaining to early traumatic events is not always strong (Bandelow et al., 2004) as results obtained from these studies are based on perceived factors (Chartier et al., 1998). Bandelow et al. (2004) shed light on another issue: Although social [phobia] is very common, a sample of pure social anxiety disorder patients has not yet been compared with a healthy control group with regard to developmental trauma. This is surprising, as many theories on the etiology of social anxiety or shyness have been based on the influence of environmental factors. (p. 403)

SOCIAL PHOBIA: A REVIEW 12 As with other risk factors, then, early childhood trauma and its association with social phobia is an area of research that requires further investigation Conclusion The aforementioned studies suggest that parental psychopathology, parent-child interaction and rearing styles, marital conflict, and early traumatic experiences influence the onset of social phobia. Data obtained from these studies, however, are inconclusive. Potential recall bias (Chartier et al., 1998) associated with some of these studies may affect the quality of information respondents provide. In addition, the interrelatedness of risk factors such as parental psychopathology and parent behavior makes identifying the exact etiology of social phobia difficult. Furthermore, Elizabeth et al. (2006) pose that a host of factors converge to occasion the onset and maintenance of [social phobia] in children and youth with genetic influences, behavioral inhibition, and parent-child interactions being crucial but by no means the only influences (Elizabeth et al., 2006, p. 159). Identifying a causal relationship in the onset of social phobia is therefore a complex process (Chartier et al., 1998). Nevertheless, understanding social phobia and its associated risk factors is essential for professionals who work with children, including school psychologists, guidance counselors, and teachers. Children with this disorder often go undetected because of their inhibited natures. Peleg-Popko and Dar (2001) caution that although children whose problems take the form of fears and social anxiety may be well-behaved and present few management problems, they are just as much at risk as children who are disruptive (p. 484). In particular, fear of social situations can lead to withdrawal and prevent children from developing relationships with peers, which in turn can affect their social development (Peleg-Popko, 2001).

SOCIAL PHOBIA: A REVIEW 13 Treatment of this disorder must therefore begin at an early age. Increasing awareness of social phobia among parents, teachers, and school counselors is an important step in early intervention (Chartier et al., 2001). In addition, professionals providing treatment must adopt a holistic perspective (Peleg-Popko, 2001, p. 484), one that takes into consideration all aspects of a child s development.

SOCIAL PHOBIA: A REVIEW 14 References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, (4 th ed., text revision). Washington, DC: American Psychiatric Association, Arrindell, W. A., Methorst, M. T., Van Der Ende, J., Pol, E., & Moritz, B. M. (1989). Perceived parental rearing styles of agoraphobic and socially phobic in-patients. British Journal of Psychiatry, 155, 526-535. Bandelow, B., Torrente, A. C., Wedekind, D., Broocks, A., Hajak, G., & Ruther, E. (2004). Early traumatic life events, parental rearing styles, family history of mental disorders, and birth risk factors in patients with social anxiety disorder. European Archives of Psychiatry and Clinical Neuroscience, 254, 397-405. Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. Clinical Psychology Review, 26, 817-833. Chartier, M. J., Hazen, A. L., & Stein, M. B. (1998). Lifetime patterns of social phobia: A retrospective study of the course of social phobia in a nonclinical population. Depression and Anxiety, 7, 113-121. Chartier, M. J., Walker, J. R., & Stein, M. B. (2001). Social phobia and potential childhood risk factors in a community sample. Psychological Medicine, 31, 307-315. Elizabeth, J., King, N., Ollendick, T. H., Gullone, E., Tonge, B., Watson, S., & MacDermott, S. (2006, June). Social anxiety disorder in children and youth: A research update on aetiological factors. Counselling Psychology Quarterly, 19(2), 151-163. Lieb, R., Wittchen, H., Hofler, M., Fuetsch, M., Stein, M. B., & Merikangas, K. R. (2000, September). Parental psychopathology, parenting styles, and the risk of social phobia in

SOCIAL PHOBIA: A REVIEW 15 offspring: A prospective-longitudinal community study. Archives of General Psychiatry, 57, 859-866. Magee, W. J. (1999). Effects of negative life experiences on phobia onset. Social Psychiatry and Psychiatric Epidemiology, 34, 343-351. Mash, E. J., & Barkley, R. A. (2003). Child psychopathology (2nd ed.). New York, NY: The Guilford Press. Merikangas, K., Lieb, R., Wittchen, H., & Avenevoli, S. (2003). Family and high-risk studies of social anxiety disorder. Acta Psychiatrica Scandinavica, 108, 28-37. Peleg-Popko, O., & Dar, R. (2001, December). Marital quality, family patterns, and children s fears and social anxiety. Contemporary Family Therapy, 23(4), 465-485.