Anxious solitude and clinical disorder in middle childhood: bridging developmental and clinical approaches to childhood social anxiety

Anxious-Withdrawal and Sleep Problems during Adolescence: The Moderating Role of Peer Difficulties

Anxious-withdrawal is a well-established individual risk factor for psychosocial difficulties during adolescence. It is unknown, however, whether it also places youth at increased risk for physical health problems, such as sleep difficulties. This study examines the concurrent and prospective associations between anxious-withdrawal and six types of sleep difficulties (i.e., sleeping too much, sleeping too little, talking/walking in sleep, being overtired, nightmares, and general trouble sleeping). We further evaluate whether these associations differ for adolescents who are high versus low in exclusion and victimization. The participants were 395 adolescents (Mage = 13.61 years; 35% ethnic minority) who completed peer nominations of anxious-withdrawal, exclusion, and victimization at Time 1 (T1). Their mothers completed reports of sleep difficulties at T1 and at Time 2 (T2). Path analyses revealed unique associations between anxious-withdrawal and several types of sleep difficulties (e.g., sleeping too much) at T1. Analyses also revealed a significant interaction effect between T1 anxious-withdrawal and exclusion/victimization such that anxious-withdrawal was prospectively associated with trouble sleeping only for those young adolescents who are highly excluded/victimized. Our findings are the first to link anxious-withdrawal to a physical health outcome in adolescence and point to the need for future research to not only examine anxious-withdrawal and physical health but also to include assessments of peer difficulties.

Two Models of the Development of Social Withdrawal and Social Anxiety in Childhood and Adolescence: Progress and Blind Spots

This commentary features a review of two recently reformulated models of the development of child and adolescent: (1) social withdrawal by Rubin and Chronis-Tuscano 2021, and (2) social anxiety by Spence and Rapee 2016. The articles that present these reformulated models now cover advances made during the prior 12 to 18 years of research, including increased knowledge of genetic vulnerability to anxiety and longitudinal patterns of development, and acknowledgement of multiple pathways towards and away from the development of social withdrawal or social anxiety (i.e., equifinality, multifinality). However, these reformulated models also contain several blind spots. The model of social withdrawal development would be improved by explicitly referring to peer treatment (not only attitudinal peer rejection), especially peer exclusion; and incorporating the potential development of clinically significant anxiety in childhood (not only adolescence) and delays in developmental milestones in adulthood. The model of social anxiety development would be improved by featuring social withdrawal as a proximal affective-behavioral profile (rather than a temperament) and drawing upon the literature on social withdrawal and its links to peer relations. Overall, there is a continuing lack of integration between developmental and clinical research and models of the development of social withdrawal and social anxiety.

Moderating Effects of Teacher-Child Relationship on the Association Between Unsociability and Play Behaviors

The present study aimed to examine the moderating role of the quality of the relationship between children and their teachers (i.e., closeness and conflict), in children's unsociability and play behaviors (i.e., reticent behavior, social play). Participants were 211 three- to six-year-old children (M = 64.08 months, SD = 10.92, 94 girls, 117 boys). Mothers reported their unsociability; teachers reported teacher-child relationships and children's play behaviors. Results showed that close teacher-child relationships moderated the association between unsociability and social play in children (buffering effect). Teacher-child conflict exacerbated the relations between unsociability and reticent behavior. Findings show that teacher-child closeness is effective in revealing social play behaviors of unsociable children. Teachers can improve their relationship with unsociable children to provide nurturing social play behavior.

Relations Among Anxious Solitude, Peer Exclusion, and Maternal Overcontrol from 3rd Through 7th Grade: Peer Effects on Youth, Youth Evocative Effects on Mothering, and the Indirect Effect of Peers on Mothering via Youth

This study evaluated a transactional model of youth anxious solitude and peer and maternal relations from 3rd through 7th grade. Participants were 230 American youth (57% girls) selected for longitudinal study from a screening sample recruited from public schools (N = 688). Peers reported on anxious solitude and peer exclusion and youth reported on their mother's overcontrol annually. In an autoregressive cross-lagged panel analytic model peer exclusion predicted incremental increases in anxious solitude during elementary school and after the middle school transition. Additionally, anxious solitude evoked incremental increases in maternal overcontrol during elementary school. Finally, anxious solitude in 4th grade mediated the positive indirect relation between peer exclusion in 3rd grade and maternal overcontrol in 5th grade. These results suggests that peer relations can indirectly effect mothering via increased youth anxious solitude over time. Taken together, evidence supports a Transactional Model of anxious solitude development. Additionally, consistent with previous evidence, elevated youth anxious solitude at the end of elementary school in 5th grade predicted decreased peer exclusion after the middle school transition in 6th grade when youth experience a fresh start with peer relations. Nonetheless, youth (especially girls) demonstrated greater year-to-year stability in anxious solitude across the first two years of middle school than in the last three years of elementary school.

Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder

In current classification systems, selective mutism (SM) is included in the broad anxiety disorders category. Indeed, there is abundant evidence showing that anxiety, and social anxiety in particular, is a prominent feature of SM. In this article, we point out that autism spectrum problems in addition to anxiety problems are sometimes also implicated in SM. To build our case, we summarize evidence showing that SM, social anxiety disorder (SAD), and autism spectrum disorder (ASD) are allied clinical conditions and share communalities in the realm of social difficulties. Following this, we address the role of a prototypical class of ASD symptoms, restricted and repetitive behaviors and interests (RRBIs), which are hypothesized to play a special role in the preservation and exacerbation of social difficulties. We then substantiate our point that SM is sometimes more than an anxiety disorder by addressing its special link with ASD in more detail. Finally, we close by noting that the possible involvement of ASD in SM has a number of consequences for clinical practice with regard to its classification, assessment, and treatment of children with SM and highlight a number of directions for future research.

Anxious Solitude, Reciprocated Friendships with Peers, and Maternal Overcontrol from Third through Seventh Grade: A Transactional Model

Guided by a Transactional Model of anxious solitude development, we tested friend and maternal influences on continuity and change in youth anxious solitude from 3rd through 7th grade, as well as the influence of youth anxious solitude on decreased friendship participation and increased maternal overcontrol over time. Participants were 230 American youth (57% girls) selected for longitudinal study from a public-school screening sample (n = 688). Peers reported on anxious solitude, both peers and youth reported on reciprocated friendship, and youth reported on their mother’s overcontrol annually. Stability and incremental change in youth, friend, and maternal factors were tested in an autoregressive cross-lagged panel analytic model. Having few mutual friendships predicted incremental increase in youth anxious solitude in mid-elementary school, then youth anxious solitude predicted the loss of friendships after the middle school transition. Additionally, youth anxious solitude in third grade evoked increased maternal overcontrol in fourth grade, but the reverse direction of effect was not supported. Youth’s participation in few friendships also evoked mothers’ overcontrol, which exacerbated their child’s loss of friendships in elementary school. Taken together, having few mutual friends contributed to youth anxious solitude and maternal overcontrol, and subsequently these factors further exacerbated youth’s loss of friendships.

The social withdrawal and social anxiety feedback loop and the role of peer victimization and acceptance in the pathways

Social withdrawal and social anxiety are believed to have a bidirectional influence on one another, but it is unknown if their relationship is bidirectional, especially within person, and if peer experiences influence this relationship. We investigated temporal sequencing and the strength of effects between social withdrawal and social anxiety, and the roles of peer victimization and acceptance in the pathways. Participants were 2,772 adolescents from the population-based and clinically referred cohorts of the Tracking Adolescents' Individual Lives Survey. Self- and parent-reported withdrawal, and self-reported social anxiety, peer victimization, and perceived peer acceptance were assessed at 11, 13, and 16 years. Random-intercept cross-lagged panel models were used to investigate within-person associations between these variables. There was no feedback loop between withdrawal and social anxiety. Social withdrawal did not predict social anxiety at any age. Social anxiety at 11 years predicted increased self-reported withdrawal at 13 years. Negative peer experiences predicted increased self- and parent-reported withdrawal at 13 years and increased parent-reported withdrawal at 16 years. In turn, self-reported withdrawal at 13 years predicted negative peer experiences at 16 years. In conclusion, adolescents became more withdrawn when they became more socially anxious or experienced greater peer problems, and increasing withdrawal predicted greater victimization and lower acceptance.

Multiple Trajectories in Anxious Solitary Youths: the Middle School Transition as a Turning Point in Development

This study aimed to identify divergent patterns of individual continuity and change in anxious solitude (AS) in the last half of elementary school (3rd - 5th grade) and the first two years of middle school (6th - 7th grade), and test predictors and outcomes of these pathways. Participants were 688 youths (girls n = 354, 51.5%; M age at outset = 8.66 years, SD = 0.50). Latent class growth analyses identified two AS trajectory classes in elementary school (moderate-decreasing, high-increasing) and three in middle school (low-stable, low-increasing, high-decreasing). The elementary school moderate-decreasing class was two-and-a-half times more likely than others to end in the middle school low-stable class. In contrast, the elementary school high-increasing class was twice as likely as others to end in the middle school low-increasing class, and four times as likely to end in the middle school high-decreasing class. Peer exclusion predicted membership in increasing AS trajectory classes in both elementary and middle school, whereas the middle school high-decreasing AS trajectory class demonstrated decreasing peer exclusion during middle school. Likewise, inability to defend oneself predicted membership in increasing AS trajectory classes in both elementary and middle school, whereas membership in the middle school high-decreasing AS trajectory class was predicted by inability to defend oneself in elementary but not middle school. High-decreasing AS youths' improved ability to defend themselves in middle school appeared to be related to a cascade of improvements in related domains. In contrast, membership in increasing AS classes in elementary and middle school predicted symptoms of social anxiety and depression.

Individual differences in anxiety trajectories from Grades 2 to 8: Impact of the middle school transition

This study examined the impact of the middle school transition on general anxiety trajectories from middle childhood to middle adolescence, as well as how youths’ individual vulnerability and exposure to contextual stressors were associated with anxiety trajectories. Participants were 631 youth (47% boys, M age = 7.96 years at Time 1), followed for 7 successive years from second to eighth grade. Teachers reported on youths’ individual vulnerability to anxiety (anxious solitude) in second grade; youth reported on their anxiety in second to eighth grade and aspects of their social contexts particularly relevant to the school transition (school hassles, peer victimization, parent–child relationship quality, and friendship quality) in sixth to eighth grade. The results revealed two subgroups that showed either strongly increasing (5%) or decreasing (14%) levels of anxiety across the transition and two subgroups with fairly stable levels of either high (11%) or low (70%) anxiety over time. Youth in the latter two subgroups could be distinguished based on their individual vulnerability to anxiety, whereas youth with increasing anxiety reported more contextual stressors and less contextual support than youth with decreasing anxiety. In sum, findings suggest that the middle school transition has the potential to alter developmental trajectories of anxiety for some youth, for better or for worse.

Anxious Solitude and Self-Compassion and Self-Criticism Trajectories in Early Adolescence: Attachment Security as a Moderator

Youths' attachment representations with their parents were tested as moderators of the relation between peer-reported anxious solitude and self-compassion and self-criticism trajectories from fifth to seventh grades. Participants were 213 youth, 57% girls, M = 10.65 years of age. Growth curves revealed that attachment representations with both parents moderated the relation between AS and self-processes such that AS youth with (a) dual secure attachments demonstrated the most adaptive self-processes, (b) one secure attachment demonstrated intermediately adaptive self-processes, and (c) dual insecure attachments demonstrated the least adaptive self-processes over time. AS youth with dual insecure attachments are of most concern because they demonstrated elevated and increasing self-criticism over time, given evidence for relations between self-criticism and internalizing psychopathology.

The role of stress reactivity in the long-term persistence of adolescent social anxiety symptoms

Social Anxiety Disorder (SAD) symptoms demonstrate a marked persistence over time, but little is known empirically about short-term processes that may account for this long-term persistence. In this study, we examined how self-reported and physiological stress reactivity were associated with persistence of SAD symptoms from early to late adolescence. A community sample of 327 adolescents (56% boys, M_age=13.01 at T₁) reported their SAD symptoms for 6 successive years and participated in a public speaking task, during which self-reported (i.e., perceived nervousness and heart rate) and physiological (i.e., cortisol and heart rate) measures of stress were taken. Overall, our results point to a developmental process in which adolescents with a developmental history of higher SAD symptoms show both heightened perceived stress reactivity and heart rate reactivity, which, in turn, predict higher SAD symptoms into late adolescence.

Improving the Prediction of Risk for Anxiety Development in Temperamentally Fearful Children

Pediatric anxiety disorders are among the most common disorders in children and adolescence resulting in both short-term and long-term negative consequences across a variety of domains including social and academic. Early fearful temperament has emerged as a strong predictor of anxiety development in childhood; however, not all fearful children become anxious. The current article summarizes theory and evidence for heterogeneity in the identification of temperamentally fearful children and trajectories of risk for anxiety. The findings presented in this article reveal that identification of subgroups of fearful temperament improves prediction of who is at risk for developing anxiety problems.

Early Childhood Reticent and Solitary-Passive Behaviors and Adjustment Outcomes in Chinese Children

Little is known about the developmental outcomes of children's social withdrawal in non-Western societies. The present study examined how two main forms of social withdrawal, social reticence and solitary-passive behavior, in early childhood were associated with adjustment in late childhood in Chinese children (75 boys and 92 girls). Data on reticent and solitary-passive behaviors were collected at 4 years of age from laboratory observations. Follow-up data on school, behavioral, and psychological adjustment were collected at 11 years of age from multiple sources. It was found that whereas reticent behavior mainly predicted later psychological problems such as loneliness and depression, solitary-passive behavior predicted later school incompetence and externalizing problems. The results suggest that reticence and solitary-passive behavior may represent distinct forms of withdrawal that play different roles in maladaptive development in Chinese context.

Nature and psychological management of anxiety disorders in youth

Anxiety disorders affect around 5% of the paediatric population at any given time and are associated with high social and personal impact. These disorders typically begin early in life, and children with anxiety disorders are at increased risk for a variety of later difficulties across the life-span. Although causes of anxiety in childhood are not fully understood, there is a strong heritable component. Additional risk factors include temperament, parent psychopathology, parent handling and peer interactions. Psychological treatments have demonstrated good efficacy with around 60% of anxious youth being in diagnostic remission immediately following treatment and a further 10% remitting over the following months. Because young people with anxiety disorders are among the least likely to seek appropriate help, paediatricians are in a unique position to identify anxious young people, educate families and recommend appropriate intervention.

Kindergarteners' self-reported social inhibition and observed social reticence: moderation by adult-reported social inhibition and social anxiety disorder symptoms

Prevention of later anxiety problems would best be accomplished by identifying at-risk children early in development. For example, children who develop Social Anxiety Disorder (SAD) may show social withdrawal in the form of social inhibition (i.e., shyness with unfamiliar adults and peers) at school entry. Although the use of children's perceptions of their own social inhibition would provide insight into early risk, the utility of young children's self-reports remains unclear. The current study examined whether children deemed more extreme on social inhibition or social anxiety by adult report provided self-report of social inhibition that related to observed social reticence in the laboratory. Participants included 85 kindergarten children (36 female, 49 male), their parents, and their teachers. Moderation analyses revealed that children's self-reported social inhibition related significantly to observed social reticence under the conditions of high parent-reported social inhibition, high teacher-reported social inhibition, and high SAD symptoms. These results suggest that the most inhibited children are aware of their behavior and can report it in a meaningfully way as young as kindergarten age.

Comorbidity of anxiety and depression in children and adolescents: 20 years after

Brady and Kendall (1992) concluded that although anxiety and depression in youths are meaningfully linked, there are important distinctions, and additional research is needed. Since then, studies of anxiety-depression comorbidity in youths have increased exponentially. Following a discussion of comorbidity, we review existing conceptual models and propose a multiple pathways model to anxiety-depression comorbidity. Pathway 1 describes youths with a diathesis for anxiety, with subsequent comorbid depression resulting from anxiety-related impairment. Pathway 2 refers to youths with a shared diathesis for anxiety and depression, who may experience both disorders simultaneously. Pathway 3 describes youths with a diathesis for depression, with subsequent comorbid anxiety resulting from depression-related impairment. Additionally, shared and stratified risk factors contribute to the development of the comorbid disorder, either by interacting with disorder-related impairment or by predicting the simultaneous development of the disorders. Our review addresses descriptive and developmental factors, gender differences, suicidality, assessments, and treatment-outcome research as they relate to comorbid anxiety and depression and to our proposed pathways. Research since 1992 indicates that comorbidity varies depending on the specific anxiety disorder, with Pathway 1 describing youths with either social phobia or separation anxiety disorder and subsequent depression, Pathway 2 applying to youths with coprimary generalized anxiety disorder and depression, and Pathway 3 including depressed youths with subsequent social phobia. The need to test the proposed multiple pathways model and to examine (a) developmental change and (b) specific anxiety disorders is highlighted.

Depression in Low-Income Elementary School Children in South Korea

This study examined depression in low-income elementary school children and identified gender differences in factors that influence depression from an ecological perspective. Participants were 262 first- to sixth-grade children recruited from six Korean community centers. Personal factors were anxiety and self-concept. Environmental factors consisted of caregiver (perceived caregiving style), school (perceived school life and quality of peer relations), and neighborhood. The outcome variable was depression. The predictors of boys’ depression were anxiety, perceived school life, and neighborhood. Predictors of girls’ depression were anxiety, self-concept, caregiving style, and neighborhood. School nurses are encouraged to screen elementary school children for depressive symptoms and consider gender differences and environmental factors when intervening in depression. School-focused interventions may be more effective for boys; family-focused interventions may be more beneficial for girls.

Annual research review: conceptualising functional impairment in children and adolescents

Functional impairment is a key factor in the clinical importance of mental health problems in children. Yet, the nature of impairment and criteria for defining and assessing impairment in childhood disorders has been surprisingly overlooked in much of the literature. The current article examines the extant literature on the conceptualisation, nature and assessment of impairment in childhood disorders. Relations between diagnostic symptoms and functional impairment are discussed together with the influence of impairment on diagnostic decisions and prevalence rates. Several factors influencing impairment in childhood such as culture, development and gender are considered. This article concludes with a discussion of the utility of separating judgements of impairment from specific diagnoses, which is proposed for consideration in the forthcoming DSM-5.

Social skills as a mediator between anxiety symptoms and peer interactions among children and adolescents

The present study used a cross-sectional design to examine the relations among youth anxiety symptoms, positive and negative peer interactions, and social skills. Also examined was the mediating role of social skills in the relations between youth anxiety symptoms and positive and negative peer interactions. Youth sex and age were examined as moderators. The sample consisted of 397 children and adolescents (M = 10.11 years; 53.4% boys; 74.8% Hispanic Latino) referred to an anxiety disorders clinic. Anxiety symptoms, positive and negative peer interactions, and social skills were assessed using youth and parent ratings. Structural equation modeling results indicated that for youth ratings only, youth anxiety symptoms were negatively related to positive peer interactions controlling for primary social phobia and comorbid depressive disorders. For both youth and parent ratings, youth anxiety symptoms were positively related to negative peer interactions and negatively related to social skills. Also for both youth and parent ratings, social skills mediated the relations between youth anxiety symptoms and positive and negative peer interactions. For parent ratings only, the effects of youth anxiety symptoms and social skills on peer interactions were significantly moderated by youth age. Youth sex was not a significant moderator using youth and parent ratings. Findings suggest that difficulties with social skills and peer interactions are problematic features of youth referred for anxiety problems. Findings highlight the need to improve understanding of anxiety symptoms, social skills, and peer interactions in this population.

Integrating etiological models of social anxiety and depression in youth: evidence for a cumulative interpersonal risk model

Models of social anxiety and depression in youth have been developed separately, and they contain similar etiological influences. Given the high comorbidity of social anxiety and depression, we examine whether the posited etiological constructs are a correlate of, or a risk factor for, social anxiety and/or depression at the symptom level and the diagnostic level. We find core risk factors of temperament, genetics, and parent psychopathology (i.e., depression and anxiety) are neither necessary nor sufficient for the development of social anxiety and/or depression. Instead, aspects of children's relationships with parents and/or peers either mediates (i.e., explains) or moderates (i.e., interacts with) these core risks being related to social anxiety and/or depression. We then examine various parent- and peer-related constructs contained in the separate models of social anxiety and depression (i.e., parent-child attachment, parenting, social skill deficits, peer acceptance and rejection, peer victimization, friendships, and loneliness). Throughout our review, we report evidence for a Cumulative Interpersonal Risk model that incorporates both core risk factors and specific interpersonal risk factors. Most studies fail to consider comorbidity, thus little is known about the specificity of these various constructs to depression and/or social anxiety. However, we identify shared, differential, and cumulative risks, correlates, consequences, and protective factors. We then put forth demonstrated pathways for the development of depression, social anxiety, and their comorbidity. Implications for understanding comorbidity are highlighted throughout, as are theoretical and research directions for developing and refining models of social anxiety, depression, and their comorbidity. Prevention and treatment implications are also noted.

Socially isolated mice exhibit a blunted homeostatic sleep response to acute sleep deprivation compared to socially paired mice

Sleep is an important physiological process underlying maintenance of physical, mental and emotional health. Consequently, sleep deprivation (SD) is associated with adverse consequences and increases the risk for anxiety, immune, and cognitive disorders. SD is characterized by increased energy expenditure responses and sleep rebound upon recovery that are regulated by homeostatic processes, which in turn are influenced by stress. Since all previous studies on SD were conducted in a setting of social isolation, the impact of the social contextual setting is unknown. Therefore, we used a relatively stress-free SD paradigm in mice to assess the impact of social isolation on sleep, wakefulness and delta electroencephalogram (EEG) power during non-rapid eye movement (NREM) sleep. Paired or isolated C57BL/6J adult chronically-implanted male mice were exposed to SD for 6h and telemetric polygraphic recordings were conducted, including 18 h recovery. Recovery from SD in the paired group showed a significant decrease in wake and significant increase in NREM sleep and rapid eye movement (REM), and a similar, albeit less robust response occurred in the isolated mice. Delta power during NREM sleep was increased in both groups immediately following SD, but paired mice exhibited significantly higher delta power throughout the dark period. The increase in body temperature and gross motor activity observed during the SD procedure was decreased during the dark period. In both open field and elevated plus maze tests, socially isolated mice showed significantly higher anxiety than paired mice. The homeostatic processes altered by SD are differentially affected in paired and isolated mice, suggesting that the social context of isolation stress may adversely affect the quantity and quality of sleep in mice.

Anxious solitude/withdrawal and anxiety disorders: conceptualization, co-occurrence, and peer processes leading toward and away from disorder in childhood

This chapter contains (1) an analysis of commonalities and differences in anxious solitude and social anxiety disorder, and a review of empirical investigations examining (2) correspondence among childhood anxious solitude and anxiety and mood diagnoses and (3) the relation between peer difficulties and temporal stability of anxious solitude and depressive symptoms. Findings support a diathesis-stress model in which anxious solitude forecasts symptoms of psychopathology primarily in the context of interpersonal stress. Additionally, evidence for individual and environmental factors which moderate risk for peer difficulties among anxious solitary children is reviewed. Implications for intervention are discussed.

A meta-analysis of the cross-cultural psychometric properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C)

Several studies have found that the Social Phobia and Anxiety Inventory for Children (SPAI-C), an empirically derived self-report instrument to assess DSM-IV social phobia in childhood and adolescence, has good psychometric properties. While these findings were replicated across different cultures, the overall strength of the psychometric properties of the SPAI-C remains unknown. We assessed the validity of the SPAI-C by meta-analytic techniques across studies collected from PubMed, PsycInfo and Eric databases, conducted in different countries, among subjects of different age, and sex. A total of 21 articles were retained, predominantly from Europe and North America. We found that the psychometric properties based on Cronbach alpha, mean score differences between sexes, and construct validity, were robust for the SPAI-C scale. Girls scored significantly higher than boys, and geographical differences played a moderating effect on sex-related score differences. These results further support the SPAI-C as an instrument to identify Social Phobia in youth.