Validation of the Social Phobia and Anxiety Inventory for Children (SPAI-C) in a sample of Brazilian children.

The purpose of the present study was to examine the factor structure and psychometric properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C), an instrument developed in the United States and applied to a sample of Brazilian schoolchildren. The process included the translation of the original material from English into Portuguese by two bilingual psychiatrists and a back translation by a bilingual physician. Both the front and back translations were revised by a bilingual child psychiatrist. The study was performed using a cross-sectional design and the Portuguese version of the SPAI-C was applied to a sample of 1954 children enrolled in 3rd to 8th grade attending 2 private and 11 public schools. Eighty-one subjects were excluded due to an incomplete questionnaire and 2 children refused to participate. The final sample consisted of 1871 children, 938 girls (50.1%) and 933 boys (49.8%), ranging in age from 9 to 14 years. The majority of the students were Caucasian (89.0%) and the remainder were African-Brazilian (11.0%). The Pearson product-moment correlation showed that the two-week test-retest reliability coefficient was r = 0.780 and Cronbach's alpha was 0.946. The factor structure was almost similar to that reported in previous studies. The results regarding the internal consistency, the test-retest reliability and the factor structure were similar to the findings obtained in studies performed on English speaking children. The present study showed that the Portuguese language version of SPAI-C is a reliable and valid measure of social anxiety for Brazilian children.

Validation of the Social Phobia and Anxiety Inventory for Children (SPAI-C) in a sample of Brazilian children

The purpose of the present study was to examine the factor structure and psychometric properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C), an instrument developed in the United States and applied to a sample of Brazilian schoolchildren. The process included the translation of the original material from English into Portuguese by two bilingual psychiatrists and a back translation by a bilingual physician. Both the front and back translations were revised by a bilingual child psychiatrist. The study was performed using a cross-sectional design and the Portuguese version of the SPAI-C was applied to a sample of 1954 children enrolled in 3rd to 8th grade attending 2 private and 11 public schools. Eighty-one subjects were excluded due to an incomplete questionnaire and 2 children refused to participate. The final sample consisted of 1871 children, 938 girls (50.1 percent) and 933 boys (49.8 percent), ranging in age from 9 to 14 years. The majority of the students were Caucasian (89.0 percent) and the remainder were African-Brazilian (11.0 percent). The Pearson product-moment correlation showed that the two-week test-retest reliability coefficient was r = 0.780 and Cronbach's alpha was 0.946. The factor structure was almost similar to that reported in previous studies. The results regarding the internal consistency, the test-retest reliability and the factor structure were similar to the findings obtained in studies performed on English speaking children. The present study showed that the Portuguese language version of SPAI-C is a reliable and valid measure of social anxiety for Brazilian children.

The treatment of childhood social anxiety disorder.

The concept of shyness in young children is not new; however, only recently has it been recognized that childhood SAD is a prevalent and severe disorder, with both immediate and long-term implications for academic, social, and emotional functioning. With the recognition that this disorder can result in severe lifetime impairment, both pharmacologic and psychosocial interventions for youth with social phobia are now beginning to be developed, and their efficacy, to be determined. The study of efficacious pharmacologic treatments with childhood anxiety disorders is limited at this time. There has been even less research regarding pharmacotherapy samples of children with childhood social phobia or social anxiety only. Only seven clinical trials have been conducted, and among those, only three were placebo-controlled, double-blind studies. In all of the open-labeled trials, anxious children showed improvement on both SSRIs and benzodiazepines; however, two of the three double-blind studies were unable to replicate these treatment benefits compared with placebo. The inability to find treatment effects may be a manifestation of the small sample sizes used and the comorbidity of the samples used to date. Further examination of the SSRIs and benzodiazepines with placebo-controlled studies is needed to provide more conclusive support for the efficacy of pharmacologic treatment. Similar to pharmacologic studies, research has begun to accumulate that sheds light on effective psychosocial interventions for childhood social phobia. Future research investigating the relative contribution of specific treatment components will allow for greater efficiency in the delivery of these services. Currently, which components are necessary or sufficient is unknown, although, based on meta-analyses conducted with adult outcome studies, exposure in some form seems to be the key ingredient. In addition, little attention has been given to developmental considerations regarding understanding the utility of specific psychosocial treatment components. For example, Spence et al reported that younger socially phobic children (aged 7-9 years) experienced difficulty in understanding the concept of "cognitive challenging," thus necessitating a reduction of this treatment component for this group. In addition, because differences in treatment effects across age groups was not reported, is it unclear whether the addition of a cognitive challenging component is even warranted. Similarly, Beidel et al reported significant improvement rates without the inclusion of a specific cognitive restructuring component. Thus, future research is needed to clarify the exact utility of including this intervention in treatment. Investigations have begun to accumulate that focus solely on the treatment of childhood social phobia, as opposed to general anxiety symptoms. As a result, preliminary evidence supports the use of pharmacologic and psychosocial treatments. Nonetheless, further research is needed to provide a better understanding of the efficacy of different interventions and, in the case of psychosocial treatments, different treatment components for socially phobic children across different developmental periods. Moreover, controlled treatment outcome studies that include specific measures of social anxiety and functioning, in addition to DSM diagnostic criteria, should provide a better (i.e., more thorough) evaluation of specific treatment effects for socially phobic children and adolescents.

Behavior therapy for vestibular rehabilitation.

Patients with panic disorder and patients with vestibular disorders often share symptomatology, such as dizziness, spatial disorientation, and anxiety in particular environments. Because of the similar clinical presentations, it is not always apparent whether these symptoms are due primarily to a vestibular disorder or to panic disorder. Depending on where and how these patients enter the medical system, their symptoms may be remedied by treatment from behavioral therapists or physical therapists trained in vestibular rehabilitation. Although vestibular rehabilitation developed independently of behavioral treatment for anxiety disorders, there are remarkable similarities in treatment conceptualization and implementation. For example, both use exposure procedures designed to produce habituation of dizziness and disorientation, as well as enhancing functional compensation. Furthermore, there appears to be a subset of individuals with panic disorder who also have vestibular pathology and thus, may benefit from both interventions. In this paper, similarities and differences in the clinical presentation, treatment goals, and specific interventions for patients with panic disorder or vestibular pathology is examined, and future implications are discussed.

Recognition of facial affect by children and adolescents diagnosed with social phobia.

This study compared the ability of children with social phobia and children with no psychiatric disorder to accurately judge facial affect. Fifteen children and adolescents with social phobia and 14 control children were asked to identify emotions depicted in slides from the Pictures of Facial Affect. In addition, they rated their level of anxiety on a pictorial Likert scale prior to and upon completion of the facial recognition task. The results indicated that children with social phobia had significantly poorer facial affect recognition skills than normal controls and reported greater anxiety upon completion of the recognition task. Multivariate analysis revealed significant differences between groups in the number of errors based on the type of facial affect. Posthoc analysis indicated that deficits were most pronounced for facial representations of happiness, sadness, and disgust. The results are discussed in relation to an integrated model of social skills training that includes facial affect recognition training as a integral component in treatment programs for children and adolescents with social phobia. Directions for future research with larger samples of more ethnically diverse children and adolescents are presented.

Behavioral treatment of childhood social phobia.

Sixty-seven children (ages 8 and 12) with social phobia were randomized to either a behavioral treatment program designed to enhance social skills and decrease social anxiety (Social Effectiveness Therapy for Children, SET-C) or an active, but nonspecific intervention (Testbusters). Children treated with SET-C were significantly more improved across multiple dimensions, including enhanced social skill, reduced social fear and anxiety, decreased associated psychopathology, and increased social interaction. Furthermore, 67% of the SET-C group participants did not meet diagnostic criteria for social phobia at posttreatment compared with 5% of those in the Testbusters group. Treatment gains were maintained at 6-month follow-up. The results are discussed in terms of treatment of preadolescent children with social phobia and the durability of treatment effects.

Teaching study skills and test-taking strategies to elementary school students. The Testbusters Program.

A pilot program to reduce test anxiety and related social-evaluative concerns is presented. Testbusters is a program designed specifically for elementary and middle school children in grades 4 through 7 that teaches effective study habits, study skills, and test-taking strategies and includes a behavioral contract to ensure consistent study behavior. The assessment strategy includes self-report instruments, a behavioral assessment, and children's grade point averages. After a 6-month waiting period, eight children with moderate to severe test anxiety participated in the 11-week program. The results indicated that Testbusters decreased general levels of test anxiety and self-ratings of distress when taking a test. Overall grade point average improved significantly and grades in the majority of the subjects showed positive improvement. There was no change in overall self-esteem or judgments of cognitive competence. The results are discussed in terms of the use of a skills strategy to decrease anxiety and improve academic achievement.

Discriminant validity of self-reported anxiety and depression in children: generalizability to clinic-referred and ethnically diverse populations.

In the present study, we investigated the relation of childhood anxiety and depression with 240 children (56% clinical referrals, 44% nonclinical referrals) ages 8 to 14 years. Participants were administered the State-Trait Anxiety Inventory for Children (STAIC) and the Children s Depression Inventory (CDI), two commonly used self-report measures of childhood anxiety and depression. The principal focus of this study was to examine the discriminant validity of these measures at the level of individual items through factor analysis. Although high correlations were found between overall scores on the CDI and STAIC, factor analysis yielded distinct factors of anxiety and depression. Thus, with the inclusion of clinic-referred and ethnically diverse groups, the present study provided support for the generalizability of findings of similar research with non-clinic-referred, primarily-Caucasian samples.

Psychopathology of childhood social phobia.

OBJECTIVE: To describe the clinical syndrome of social phobia in preadolescent children. METHOD: Fifty children with DSM-IV social phobia were assessed with semistructured diagnostic interviews, self-report instruments, parental and teacher ratings, a behavioral assessment, and daily diary recordings. In addition, the behaviors of these children were compared with those of a sample of normal peers. RESULTS: Children with social phobia had a high level of general emotional over-responsiveness, social fear and inhibition, dysphoria, loneliness, and general fearfulness. Sixty percent suffered from a second, concurrent disorder. Socially distressing events occurred quite frequently and were accompanied by maladaptive coping behaviors. In addition, children with social phobia had significantly poorer social skills. There were few differences based on gender or race. CONCLUSIONS: Children with social phobia suffer pervasive and serious functional impairment. In addition, the clinical presentation suggests specific avenues for psychosocial interventions.

Social anxiety disorder: etiology and early clinical presentation.

Behavioral and biological theories addressing the etiology of social anxiety disorder are discussed. Although not often diagnosed until adolescence or adulthood, social anxiety disorder can have its onset during childhood. Early recognition and treatment of this condition may prevent both immediate and long-term detrimental outcomes and, possibly, the onset of comorbid conditions. However, special considerations are required for the diagnosis and treatment of childhood social anxiety disorder. Therapists face special challenges when treating youth with social anxiety disorder, including patient and parent considerations. Although not documented specifically for children with social anxiety disorders, data from families with anxious children suggest that familial factors may play a role in treatment outcome.

Psychotherapy in the overall management strategy for social anxiety disorder.

Cognitive-behavioral therapies (CBTs) are effective treatments for social anxiety disorder/social phobia. Although a variety of procedures are included under the term cognitive-behavioral treatment, it is, however, clear that the key factor influencing treatment outcome for social anxiety disorder is exposure to feared situations. Two formalized CBT programs are cognitive-behavioral group therapy (CBGT) and social effectiveness training (SET). They both involve exposure, but differ in that CBGT focuses on correction of cognitive errors, whereas SET uses social skills training in addition to exposure to feared social situations. CBGT is more efficacious than a psychological placebo and has shown efficacy comparable to that of phenelzine in a double-blind, placebo-controlled study. The onset of effect of phenelzine was more rapid, whereas the effect of CBGT was more sustained. The major component of SET, imaginal and/or in vivo exposure, has been demonstrated to be more effective than pill placebo or the beta-blocker atenolol. Many questions remain regarding CBT strategies and their place in the overall management of patients with social anxiety disorder. Depending upon the particular patient profile, various combinations of drug and/or CBT may prove to be the optimal treatment strategy.

Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety.

OBJECTIVE: The goal of this consensus statement is to provide primary care clinicians with a better understanding of management issues in social anxiety disorder (social phobia) and guide clinical practice with recommendations for appropriate pharmacotherapy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Other faculty invited by the chair were Julio Bobes, Deborah C. Beidel, Yukata Ono, and Herman G. M. Westenberg. EVIDENCE: The consensus statement is based on the 7 review papers published in this supplement and on the scientific literature relevant to the issues reviewed in these papers. CONSENSUS PROCESS: The group met over a 2-day period. On day 1, the group discussed each review paper, and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSIONS: The consensus statement underlines the importance of recognizing social anxiety disorder and provides recommendations on how it may be distinguished from other anxiety disorders. It proposes definitions for response and remission and considers appropriate management strategies. Selective serotonin reuptake inhibitors are recommended as first-line therapy, and effective treatment should be continued for at least 12 months. Long-term treatment is indicated if symptoms are unresolved, the patient has a comorbid condition or a history of relapse, or there was an early onset of the disorder.

Self-reported symptoms of social anxiety in a sample of combat veterans with posttraumatic stress disorder.

The relationship between posttraumatic stress disorder (PTSD) and self-reported levels of social anxiety among combat veterans was assessed using the Social Phobia and Anxiety inventory (SPAI). Participants were 45 veterans with combat-related PTSD assessed using a multimeasure assessment package. The veterans reported a high level of social anxiety and agoraphobia-like symptoms. Agoraphobia scores were predicted by PTSD severity and elevated by Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales of acute distress and psychopathology. Social phobia scores were predicted by severity of depression. The relationship between social anxiety, depression, and PTSD is discussed. Implications for the assessment and treatment of PTSD are also discussed.

At risk for anxiety: I. Psychopathology in the offspring of anxious parents.

OBJECTIVE AND METHOD: Children of parents with anxiety disorders, depressive disorders, mixed anxiety/depressive disorders, and no psychiatric disorder were assessed with semistructured interviews to determine rates of overall psychopathology and to determine specifically the presence of anxiety disorders. RESULTS: Children of the three "high-risk" groups were significantly more likely to have a diagnosable disorder (including anxiety disorders) than offspring of normal parents, but there were no differences among the children from the three parental diagnostic groups. However, when examined specifically for anxiety disorders, offspring of anxious parents were significantly more likely to have only anxiety disorders. Offspring of depressed or mixed anxious/depressed parents had a broader range of disorders and more comorbid disorders. Family socioeconomic status was related to the probability that a child would have a disorder. CONCLUSIONS: Anxiety disorders are common among offspring of anxious and depressed parents. However, when a parent has depression, children exhibit a broader range of psychopathology than when a parent has an anxiety disorder alone.

Clinical features affecting treatment outcome in social phobia.

Characteristics of social phobics were examined to determine their effect on treatment acceptance, drop-out rate and amount of improvement at post-treatment. The rate of treatment non-acceptance was low and those who entered treatment differed from those who did not only on ratings of social phobia severity. The drop-out rate also was relatively low, and there were no differences between those who dropped out and those who completed treatment. When patients were divided on the specific versus generalized subtype dichotomy, a number of interesting findings emerged. Response to treatment was similar, but the specific subtype was significantly more improved at post-treatment than the generalized subtype. When compared on composite indexes of overall improvement and endstate functioning, there was no difference between the number of specific and generalized social phobics achieving significant or moderate improvement. However, a greater number of the specific subtype were judged to have high or moderate endstate status than the generalized subtype. A similar outcome was found when social phobics with comorbid disorders were compared with those who were non-comorbid. The results are discussed in terms of factors affecting outcome in social phobia treatment.

Trauma management therapy: a preliminary evaluation of a multicomponent behavioral treatment for chronic combat-related PTSD.

The development and initial evaluation of a new, comprehensive and multicomponent behavioral treatment (Trauma Management Therapy, or TMT) for chronic combat-related Post-Traumatic Stress Disorder (PTSD) is described. The program utilizes elements of intensive exposure therapy, programmed practice, and structured social and emotional skills training to target the multiple aspects of chronic combat-related PTSD. The treatment was found to be effective in alleviating a broad spectrum of difficulties in combat veterans with chronic PTSD, most of whom had co-occurring Axis I and/or Axis II disorders. The results are discussed with respect to the implementation of the new treatment and the general need for a comprehensive approach to treating combat-related PTSD. Implications for the potential cost-effectiveness of the treatment program also are discussed.

Stability of anxious symptomatology in children.

The stability of anxiety states and symptoms was assessed in a sample of 150 anxious and nonanxious children. A number of assessment methods including a semistructured interview, self-report instruments, psychophysiological measures, and parental reports were used initially and at intervals up to 6 months later. The majority of children with a diagnosed anxiety disorder at the initial assessment still manifested significant symptomatology at the 6 month follow-up. However, stability of specific anxiety symptoms when assessed by self- and parental reports was mixed. With respect to psychophysiological assessment, stability of responses was evident at 2 weeks but not after 6 months. Results are discussed in terms of the stability of diagnoses and symptomatology, and the need for thematically relevant self-reports and behavioral assessment tasks. Recommendations are made for the development of a reliable, multimethod strategy to assess the multiple domains of childhood anxiety.

Emotional impact of children's exposure to community violence: a preliminary study.

OBJECTIVE: To use multiple methods and measures to investigate preliminarily the emotional impact of children's exposure to community violence. METHOD: Thirty-seven schoolchildren between the ages of 7 and 12 years were categorized into groups with "high" or "low" frequency of exposure. RESULTS: Differing levels of exposure to community violence did not appear to have an impact on DSM-III-R diagnoses. Exposure to high levels of community violence was not related to internalizing behavior and disorders, but rather was associated with externalizing behavior. CONCLUSIONS: There appears to be an adverse relationship between high levels of exposure to community violence and emotional and conduct problems. Vicarious learning serves as an explanatory construct for these findings.

Social phobia: an analysis of possible developmental factors.

Sixty-eight individuals with specific or generalized social phobia and 25 normal controls were assessed for presence of a family history of anxiety, childhood shyness, traumatic conditioning experiences, neuroticism, and extraversion. Subtype differences emerged, including significantly greater neuroticism and a more frequent history of shyness in the generalized subtype. Those with the generalized subtype also had significantly lower extraversion scores, and those with the specific subtype had a significantly higher frequency of traumatic conditioning episodes. Together, traumatic conditioning and childhood shyness predicted the presence of social phobia, although other unidentified factors also appeared to be relevant. The results are discussed in terms of potentially different modes of onset for the subtypes of social phobia and the role of neuroticism and introversion in the development of the disorder.