Research Review: The relationship between social anxiety and social cognition in children and adolescents: a systematic review and meta-analysis

Global Prevalence of Social Anxiety Disorder in Children, Adolescents and Youth: A Systematic Review and Meta-analysis

Social anxiety disorder is a prevalent mental health condition that significantly impairs social interactions, academic performance, and professional functioning in children, adolescents, and youth. This study aimed to investigate the global prevalence of social anxiety disorder across these developmental stages. Six electronic databases (PubMed, Scopus, Web of Science, Embase, ScienceDirect and Google Scholar) were systematically searched for studies related to the prevalence of social anxiety disorder in children, adolescents and youth. Random-effects models were employed for data analysis and Comprehensive Meta-Analysis Version 2.0. Heterogeneity was assessed using the I2 index. A total of 38 studies were included in the final analysis. The global prevalence of social anxiety disorder was estimated to be 4.7% in children, 8.3% in adolescents, and 17% in youth. These findings suggest a progressive increase in the prevalence of SAD across these developmental stages. Considering the prevalence of social anxiety disorder in this study, policymakers can use the findings of this study to inform and develop effective prevention strategies for individuals and communities most susceptible to this disorder.

Social anxiety is more likely to influence reputation management decisions than autistic traits

People manage their social reputation by selectively sharing achievements, thereby shaping the way others think about them. Autistic traits and social anxiety may have opposing impacts on reputation management. This study aimed to identify the influence of autistic traits and social anxiety on reputation management behavior, independently and in co-occurrence with one another. Seventy-seven adults with varying levels of autistic and social anxiety traits completed a novel self-disclosure task that required them to complete a computerized game and decide whether to disclose their scores to another participant. This design provided a safe social environment for sharing performance outcomes and allowed us to manipulate performance outcomes for participants and set a perceived 'norm' of high self-disclosure. Results showed that participants were more likely to disclose their high than low scores to the other player. Social anxiety reliably predicted the likelihood of disclosing their scores while high autistic traits predicted the likelihood of disclosure only in combination with high social anxiety. Additionally, establishing the norm of high disclosure facilitated self-disclosure in all the participants. This study shows that social anxiety may influence reputation management via selective self-disclosure more when co-occurring with high autistic traits. People with varying levels of autistic traits may not behave differently to maintain a social reputation.

The relevance of social anxiety for understanding social functioning and facial emotion recognition in individuals at clinical high-risk for psychosis

AIM

Individuals at clinical high risk (CHR) for psychosis often experience poor social functioning and impaired facial emotion recognition (FER); however, the impact of frequently comorbid symptoms upon these processes is underexplored. In particular, social anxiety is characteristic of this population and also related to poor social functioning and FER biases, such as misinterpreting neutral faces as negative or threatening; however, little is known about how social anxiety relates to these processes in CHR individuals. The present study examined the overlap of social anxiety, social functioning, and FER accuracy and bias.

METHOD

Participants (CHR N = 62, healthy controls N = 52) completed the self-report Social Interaction Anxiety Scale (SIAS), Penn Emotion Recognition-40 (ER-40) behavioural task, and interviewer-rated Global Functioning Scale-Social (GFS-S). The ER-40 was used to assess both FER accuracy (e.g., overall number of correct responses) and bias (e.g., mislabelling neutral faces as angry).

RESULTS

Consistent with previous research, relative to controls, CHR participants had more social anxiety (d = -1.07), poorer social functioning (d = -1.62), and performed more poorly on the FER task (e.g., d = -.37). Within CHR participants, social anxiety was related to an anger detection bias (r = .28), above and beyond positive symptom severity, which in turn was related to FER accuracy (r = .26) and social functioning (r = -.28).

CONCLUSION

These findings suggest that ongoing work examining social processes within CHR individuals needs to account for social anxiety and that social anxiety may be a useful preventive intervention target.

Encouraging a Peer in Need: The Impacts of Social Anxiety and Peer Familiarity

Extant research has produced conflicting findings regarding the link between social fearfulness and prosocial behavior, with some studies reporting negative relations and others reporting null effects. Furthermore, these studies have focused predominantly on toddlerhood, and few have examined prosociality between peers. The present study investigated whether the link between social anxiety and a prosocial behavior (i.e., providing encouragement) varied depending on interpersonal and situational factors (i.e., one's familiarity with a peer, the level of support sought by a peer, respectively). We tested this question using a multimethod approach, which included an ecologically valid stress inducing task and dyadic design with a sample of 9- to 10-year-olds (N = 447). Results revealed that social anxiety was related negatively to providing encouragement among familiar and unfamiliar dyads. In familiar dyads, however, this main effect was qualified by an interaction with the level of support sought by one's peer. Compared to those low in social anxiety, children high in social anxiety provided relatively less encouragement in response to higher levels of support seeking from their peers. The findings are considered in relation to theorizing regarding the effect of overarousal on children's prosocial behavior.

Longitudinal follow-up of subsequent psychiatric comorbidities among children and adolescents with autism spectrum disorder

BACKGROUND

The mental health of children and adolescents with autism spectrum disorder (ASD) is a concern of recent years. However, a large-scale longitudinal study investigating the risk and the time course of subsequent psychiatric comorbidities is still lacking.

METHODS

Using the Taiwan National Health Insurance Research Database, 13,382 children and adolescents with ASD, and 53,528 age- and sex-matched non-ASD controls were enrolled between 2001 and 2009, and followed to the end of 2011. The adjusted hazard ratio (HR) with a corresponding 95 % confidence interval for psychiatric comorbidities among children and adolescents with ASD vs matched controls was estimated. The subjects who developed schizophrenia, bipolar disorder, depressive disorder, anxiety disorder, and obsessive-compulsive disorder (OCD) were identified during the follow-up.

RESULTS

Children and adolescents with ASD compared with controls were more likely to be diagnosed with schizophrenia (19.21; 13.74, 26.88), bipolar disorder (17.59; 12.66, 24.44), depressive disorder (5.56; 4.72, 6.56), anxiety disorder (5.01; 4.49, 5.59), and OCD (16.12; 11.66, 22.30) later in life. The time course of subsequent psychiatric comorbidity showed that anxiety disorder occurred first, usually in late childhood, with psychotic and affective disorders proceeding in adolescence. Those with ASD and anxiety disorder had an additionally increased likelihood of developing subsequent psychiatric comorbidity compared with those with ASD only.

LIMITATION

In claims data analysis, clinical parameters or possible confounders may not be fully captured.

CONCLUSION

Patients with ASD are predisposed to the development of anxiety disorder in late childhood, as well as schizophrenia, bipolar disorder, depressive disorder, and OCD in adolescence.

In the moment social experiences and perceptions of children with social anxiety disorder: A qualitative study

OBJECTIVES

Childhood social anxiety disorder (SAD) is a common and disabling condition. General forms of cognitive behavioural treatments have demonstrated poorer efficacy for childhood SAD when compared to other childhood anxiety disorders and further understanding of the psychological factors that contribute to the maintenance of childhood SAD is warranted. Examining the social experiences of children with SAD may help to identify relevant psychological factors and increase our understanding of what keeps childhood SAD going.

METHODS

The current study used reflexive thematic analysis to analyse the transcripts of interviews with 12 children aged 8-12 years with SAD who had been interviewed about their 'in the moment' social experiences during a social stress induction task. The interview topic guide included factors hypothesized to maintain SAD in adult cognitive models of the disorder.

RESULTS

The interviews revealed both variety and commonalities in the experiences and interpretations of social events in children with SAD, captured in three related main themes: (i) Discomfort being the centre of attention, (ii) (Lack of) awareness of cognitions and (iii) Managing social fears. Findings indicated likely developmental influences on which maintenance mechanisms apply at which point in time.

CONCLUSIONS

There is variation in the psychological mechanisms that children with SAD endorse and developmental factors are likely to influence when specific mechanisms are relevant. We now need further studies that take a developmentally informed approach to understand the nature of the association between the factors identified in this study and social anxiety in childhood to inform the development of more effective interventions for childhood SAD.

The Therapy Process Observational Coding System: Group cohesion scale in youth anxiety treatment: Psychometric properties

BACKGROUND

There are no well-established measures of group cohesion, defined as the collaborative bond between group members, in group cognitive behavioral therapy (GCBT) with youth. We therefore examined the Therapy Process Observational Coding System for Child Psychotherapy-Group Cohesion Scale (TPOCS-GC), which has previously only been used with adult samples, in a youth sample.

METHODS

Observers coded 32 sessions from 16 groups with 83 youth aged 8 to 15 years (90.7% European White). Youth had anxiety disorders and received manualized GCBT in community clinics. We examined psychometric properties of the TPOCS-GC and its' construct validity in terms of relations with pretreatment variables, alliance and fidelity during treatment, and post-treatment variables. Group cohesion was measured twice during treatment (early and late).

RESULTS

The TPOCS-GC was internally consistent (α = 0.72) and was reliably coded (M ICC = 0.61). Higher clinical severity at pretreatment predicted lower early group cohesion. Higher youth age, higher clinical severity at pretreatment, and higher youth-rated early alliance predicted lower late group cohesion. Higher therapist-rated early alliance predicted higher early group cohesion. Higher therapist-rated late alliance predicted higher late group cohesion. Higher late group cohesion predicted lower clinical severity and higher client treatment satisfaction at post-treatment. Early group cohesion did not predict any post-treatment variables.

CONCLUSIONS

A four-item version of the TPOCS-GC can be reliably used in youth GCBT. The TPOCS-GC is distinct from, but associated with, multiple clinical variables.

Facing Uncertainty: Interpretation of Ambiguous Emotional Faces in Childhood Social Anxiety Disorder

OBJECTIVE

The current study examined whether children with a social anxiety disorder (SAD) demonstrate divergent facial emotion processing and a disorder-specific negative interpretation bias in the processing of facial emotional expressions. This study aimed to overcome previous study limitations by including both a nonsocially anxious control group and a healthy control group to examine whether childhood SAD is characterized by a general emotion labeling deficit, and/or by a negative interpretation bias, indicated by systematic misclassifications, or a lower threshold for recognizing threatening emotions.

METHOD

Participants were 132 children aged 7-12 years (M_age = 9.15; 45.5% female). Children with SAD (n = 42) were compared to children with other, nonsocial, anxiety disorders (n = 40) and healthy control children (n = 50) on a novel facial emotion recognition task. Children judged ambiguous happy/neutral, angry/neutral and fear/neutral faces that were morphed at different intensities (10%, 30%, 50%, 70%).

RESULTS

Children with SAD did not differ from other groups in their accuracy of identifying emotions. They did not show systematic misclassifications or a heightened sensitivity to negative, threatening faces either. Rather, children with nonsocial anxiety disorders showed a generally heightened sensitivity to emotional faces.

CONCLUSIONS

The current study does not provide evidence for a general deficit in labeling of emotional faces in childhood SAD. Childhood SAD was not characterized by an interpretation bias in processing emotional faces. Children with nonsocial anxiety disorders may benefit from assistance in accurately interpreting the degree of emotionality in interpersonal situations.

Trajectories of socially anxious behavior from age 5 to 13: Temperamental and sociocognitive pathways

The authors examined temperamental and sociocognitive predictors of socially anxious behavior from preschool to early adolescence. Children (N = 227; 59% male; 69% White) completed a speech task at ages 5, 7, 10, and 13 and socially anxious behaviors were coded. Behavioral inhibition (BI) was assessed at ages 2/3 and Theory of Mind (ToM) was assessed at age 4. Data collection occurred between 2003 and 2016. Three trajectories of socially anxious behavior were identified: high stable, average increasing, and low stable. Higher BI was related to the high stable trajectory, whereas lower ToM was related to the increasing trajectory of socially anxious behavior. There are heterogenous pathways of socially anxious behavior, which may be uniquely influenced by early temperamental and sociocognitive factors.

Self- but Not Other-Dimensions of Mentalizing Moderate the Impairment Associated With Social Anxiety in Adolescents From the General Population

Mentalizing, or social cognition, refers to the brain's higher order capacity that allows humans to be aware of one's own and others' mental states (e.g., emotions, feelings, intentions). While cognition in social anxiety has been broadly analyzed, there is a paucity of research regarding the role of social cognition. Moreover, mentalizing or social cognition research is traditionally focused on the understanding of others' mental states, rather than self-mentalizing. Finally, most studies analyze the role of social cognition in the development or maintenance of social anxiety, yet no study to date has analyzed whether social cognition moderates functional impairment associated with it. This study analyzes whether self- and other-mentalizing moderate the relationship between social anxiety and impairment in social and self-functioning. A sample of 262 adolescents from the non-clinical population was assessed on measures of social anxiety, self- and other- mentalization, indicators of social functioning (social competence and sociometric status), and indicators of self-functioning (depression and self-esteem). Multiple linear regressions were conducted to test possible moderation effects of self-mentalizing and other-mentalizing on the relationships between social anxiety and social and self-functioning. Results revealed that other-mentalizing does not moderate social- nor self-functioning, while self-mentalizing moderates the impairment of all of them. While impairment in social functioning is buffered by one dimension of self-mentalizing (emotional clarity; b = 0.003, p = 0.043 and b = 0.016, p = 0.008 for social competence and sociometric status, respectively), impairment in self-functioning is strengthened by the other dimension (attention to emotions; b = -0.007, p = 0.008 and b = 0.009, p = 0.047 for self-esteem and depression, respectively). Probing the moderation at the 16th, 50th, and 84th percentiles revealed that the negative imbalance between dimensions (i.e., high attention and low clarity) tended to exacerbate impairment most on all indicators, while the positive imbalance (i.e., low attention and high clarity) was usually the most buffering condition. This supports that "low-flying" or implicit mentalizing provides more resilience than explicit mentalizing (i.e., high attention and high clarity). Findings suggest that the work on emotional self-awareness should be stressed in the intervention of the social anxiety spectrum conditions in order to improve prevention, functioning, and ultimately, treatments, of people impaired by symptoms of social anxiety.

Theory of mind in neurodevelopmental disorders: Beyond autistic spectrum disorder

INTRODUCTION

Theory of mind (ToM) is the human ability to perceive, interpret, and attribute the mental states of other people, and the alteration of this cognitive function is a core symptom of autistic spectrum disorder (ASD). In such other neurodevelopmental disorders as childhood-onset obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) that can present with cognitive dysfunctions, ToM has been less extensively studied, especially in the young population. The aim of the study was to compare advanced ToM between groups of young people diagnosed with OCD, TS, or ASD and a control group.

METHODS

Clinical interviews were conducted with male patients aged between 11 and 17 years with a main diagnosis of OCD (n=19), TS (n=14), or ASD (n=18), and a control group (n=20). We administered instruments for estimating intelligence quotient and severity of psychiatric symptoms, and tasks to evaluate ToM (the "Stories from everyday life" task and the "Reading the mind in the eyes" test).

RESULTS

Young people with TS and with ASD present similar difficulties in solving advanced ToM tasks, whereas patients with childhood-onset OCD present similar results to controls.

CONCLUSIONS

ToM is altered in other neurodevelopmental disorders beyond ASD, such as TS.

Theory of Mind as a Mechanism That Accounts for the Continuity or Discontinuity of Behavioral Inhibition: A Developmentally Informed Model of Risk for Social Anxiety

Research has established that children with high levels of early behavioral inhibition (BI) - a subdued, timid, fearful response to novel or mildly challenging stimuli or events - are at an elevated risk for social anxiety in later childhood and adolescence. Yet, substantial heterogeneity has been documented in those developmental trajectories; consequently, understanding factors that moderate children's paths from early BI to social anxiety is an important goal. We proposed that the association between children's BI at toddler age and social anxiety at early school age is (a) mediated by their BI at preschool age, and (b) moderated by the level of social understanding, or Theory of Mind (ToM). In 102 typically developing community children, we observed BI in the laboratory at age 2 and 4.5 in "Risk Room" paradigms and assessed ToM at age 4.5 and 5.5 using false belief tasks. Mothers and fathers rated children's social anxiety symptoms at age 6.5. We supported the proposed moderated mediation model, with the path from BI at age 2 to BI at age 4.5 to social anxiety at age 6.5 unfolding only for children whose ToM abilities were relatively low, but not for those whose ToM abilities were relatively high. Results also supported a curvilinear relation between ToM and social anxiety, which highlights the risk of elevated social anxiety for children with extremely low ToM abilities. Taken together, proficiency in mindreading may help inhibited children navigate social environments and thus reduce risks for social anxiety.