A model-based cluster analysis of social experiences in clinicallyanxious youth: links to emotional functioning

Cynthia Suvega*, Marni L. Jacobb, Monica Whiteheada, Anna Jonesa andJulie Newman Kingeryc

aDepartment of Psychology, University of Georgia, Athens, GA 30602, USA; bDepartment ofPediatrics, University of South Florida, St. Petersburg, FL, USA; cDepartment of Psychology,

Hobart and William Smith Colleges, Geneva, NY, USA

(Received 13 August 2013; accepted 30 January 2014)

Social difficulties are commonly associated with anxiety disorders in youth, yet arenot well specified in the literature. The aim of this study was to identify patterns ofsocial experiences in clinically anxious children and examine the associations withindices of emotional functioning. A model-based cluster analysis was conducted onparent-, teacher-, and child-reports of social experiences with 64 children, ages 7–12years (M = 8.86 years, SD = 1.59 years; 60.3% boys; 85.7% Caucasian) with aprimary diagnosis of separation anxiety disorder, social phobia, and/or generalizedanxiety disorder. Follow-up analyses examined cluster differences on indices ofemotional functioning. Findings yielded three clusters of social experiences that wereunrelated to diagnosis: (1) Unaware Children (elevated scores on parent- and teacher-reports of social difficulties but relatively low scores on child-reports, n = 12),(2) Average Functioning (relatively average scores across all informants, n = 44), and(3) Victimized and Lonely (elevated child-reports of overt and relational victimizationand loneliness and relatively low scores on parent- and teacher-reports of socialdifficulties, n = 8). Youth in the Unaware Children cluster were rated as moreemotionally dysregulated by teachers and had a greater number of diagnoses thanyouth in the Average Functioning group. In contrast, the Victimized and Lonely groupself-reported greater frequency of negative affect and reluctance to share emotionalexperiences than the Average Functioning cluster. Overall, this study demonstratesthat social maladjustment in clinically anxious children can manifest in a variety ofways and assessment should include multiple informants and methods.

Keywords: anxiety; children; social adjustment; emotion regulation

Research involving nonclinical samples of youth has identified links between anxietysymptoms and various social difficulties, including lower peer acceptance, fewer closefriends, lower-quality friendships, increased peer victimization, and poor social skills(Crick & Grotpeter, 1996; Erath, Flanagan, & Beirman, 2007; La Greca & Harrison,2005). However, there is a stark lack of research examining the social experiences ofclinically anxious youth and a corresponding need for methodologically rigorous studieson this topic (Kingery, Erdley, Marshall, Whitaker, & Reuter, 2010). Given thedevelopmental significance of peer experiences for youths’ adjustment (e.g., depression,self-esteem, and academic achievement; Parker, Rubin, Erath, Wojslawowicz, & Buskirk,

*Corresponding author. Email: csuveg@uga.edu

Anxiety, Stress, & Coping, 2014Vol. 27, No. 5, 494–508, http://dx.doi.org/10.1080/10615806.2014.890712

© 2014 Taylor & Francis

2006), research with clinically anxious samples is crucial to better understand the socialexperiences of these youth, which has the potential to refine current models of childanxiety and inform treatment strategies.

Social experiences in youth with anxiety disorders

The primary goal of the current study is to consider multiple reports of social functioningthat may provide divergent, yet meaningful, information and to identify different patterns,or clusters, of social experiences among clinically anxious youth. This study focuses onsocial experiences that may be especially salient for these youth: peer victimization,loneliness, and receipt of prosocial behavior. Peer victimization includes the recurrence ofadverse actions directed at a child by others in his/her age group through either relational(e.g., purposeful damage of one’s reputation) or physical aggression (Crick & Grotpeter,1996). Studies examining victimization with clinically anxious samples have focusedalmost exclusively on obsessive-compulsive disorder (OCD). For example, Storch et al.(2006) found that, in comparison to youth with a chronic medical condition and healthycontrols, youth with OCD experienced more victimization, which predicted higher levelsof loneliness and depression. Using path analyses, Crawford and Manassis (2011)identified two pathways to victimization in a sample of youth diagnosed with a variety ofanxiety diagnoses (e.g., generalized anxiety disorder – GAD and OCD) and a comparisongroup of children recruited through a school. In this study, anxiety and friendship qualitywere both independently associated with peer victimization, and friendship quality waspredicted by social skills. Though the model generally fit both the anxiety disorder andthe comparison group, the fit indices were stronger for the anxiety disorder sample.Further, though social skills deficits had a direct link to victimization for the comparisonsample, this link was not found for the anxiety disorder sample. The authors posited thatanxious youth may not have many close friendships given their inhibited nature, whichmay then place the child at greater risk of being bullied, whereas the comparison groupmay evidence more apparent social skills deficits. Either way, the results reflectequifinality, where youth may come to experience victimization via different pathwaysand suggest the importance of considering multiple perspectives and aspects offunctioning when assessing social experiences in anxious youth.

Loneliness is another aspect of social experience that can contribute to theexacerbation of anxiety symptoms and also feelings of depression (Barchia & Bussey,2010). For example, Beidel et al. (2007) found that adolescents with social phobiareported higher levels of loneliness and social isolation than adolescents in a nonclinicalcontrol group. A study by Strauss, Lease, Kazdin, Dulcan, and Last (1989) also revealedthat clinically anxious children had higher levels of self-reported loneliness, lower levelsof perceived social competence, and higher parent and teacher ratings of shyness andsocial withdrawal than nonreferred youth. Relatedly, Beidel, Turner, and Morris (1999)found that the majority of youth diagnosed with social anxiety disorder had no or fewfriends. Regarding peer status, Strauss, Lahey, Frick, Frame, and Hynd (1988) reportedthat youth with anxiety disorders received significantly fewer “like-most” peer nomina-tions than nonclinical control children and were more likely than both controls andchildren diagnosed with conduct disorder to be placed in the neglected peer statuscategory (i.e., lowest number of both “like-most” and “like-least” nominations from theirpeers). Similarly, in a lab-based study, Verduin and Kendall (2008) found that children

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with anxiety disorders were rated lower on likability compared to their nonanxious peers(based upon perceived likability judgments of a videotaped speech sample made by anunknown peer). Although not all of these studies measured loneliness directly, a robustbody of literature supports associations between poor peer relationships (e.g., few or nofriends, poor-quality friendships, low peer status) and higher levels of loneliness anddepression (e.g., Nangle, Erdley, Newman, Mason, & Carpenter, 2003), indicating thatanxious youth with peer difficulties are at increased risk for experiencing loneliness.However, a recent study by Scharfstein, Alfano, Beidel, and Wong (2011) highlights thatpeer difficulties may not be universal, as youth with GAD had fewer total friends but didnot differ from controls in the presence of a best friend. With respect to friendship quality,significant associations between social anxiety symptoms and lower-quality friendshipshave been established among nonclinical samples of children and adolescents (e.g., Festa& Ginsburg, 2011; La Greca & Harrison, 2005). However, we are not aware of anystudies that have examined qualitative aspects of the friendship among clinically anxiousyouth (see Kingery et al., 2010 for a review).

Although loneliness is often viewed as a psychological or an emotional adjustmentvariable in the peer relations literature, loneliness can also be conceptualized as children’sperceptions of the difficulties that they are having in their relationships with peers(Hymel, Tarulli, Thomson, & Terrell-Deutsch, 1999). For this reason, we chose to includeloneliness as part of our relatively broad assessment of children’s social experiences inthe present study. Given possible variations in the social experiences of clinically anxiousyouth, the fact that loneliness can serve as a mediator of treatment outcome for childanxiety (Alfano et al., 2009), and the scant research examining loneliness with clinicallyanxious samples, it is important to further examine this aspect of anxious children’s socialexperience.

The receipt of prosocial behavior, which is often defined by positive peer experiences(Crick & Grotpeter, 1996), may be protective for anxious youth. Prosocial behaviorfrequently leads to increases in positive affect, life satisfaction, and emotional well-being(Martin & Huebner, 2007), whereas a lack of prosocial behavior may lead to socialwithdrawal and increased social anxiety (Erath et al., 2007). In one study, sociallyanxious youth were less likely to receive positive responses from peers than a nonclinicalcontrol group (Spence, Donovan, & Brechman-Toussant, 1999). At least some portion ofclinically anxious youth may experience lower rates of prosocial behavior because theylack the social competence to successfully initiate and maintain peer interactions(Settipani & Kendall, 2012). A greater understanding of the receipt of prosocial behavioramong these youth could inform treatment strategies.

Given the multifaceted nature of social functioning, it is clear that an integratedassessment based on parent-, child-, and teacher-reports is essential to provide the mostcomprehensive understanding of the social experiences of anxious youth (Dibartolo &Grills, 2006). Yet, discrepancies among informants are the norm, particularly whenassessing internalizing disorders (Hawley & Weisz, 2003; Kolko & Kazdin, 1993). Thisstudy aims to move the literature forward by utilizing a model-based cluster analysis toidentify groups of anxious youth based on social experience profiles. Cluster analysisprovides the opportunity to consider multiple reports that may provide divergent, yetmeaningful, information. The study also provides a unique contribution to the literatureby considering both risk (e.g., loneliness) and protective (e.g., receipt of prosocialbehavior) social factors.

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Links between emotional and social functioning

A second goal of the study was to examine relations among the identified socialexperience clusters and indices of emotional functioning, given that these domains ofdevelopment are closely linked in a bidirectional fashion (Eisenberg, Fabes, Guthrie, &Reiser, 2000; Hubbard & Coie, 1994). Further, because youth with anxiety disordersexperience deficits in both social and emotional domains (Southam-Gerow & Kendall,2002; Suveg & Zeman, 2004), it is important to examine these variables in tandem.Research shows that intense, moody, or emotionally negative children experience poorerrelationships with peers (Dougherty, 2006). On the other hand, youth who engage inchronic emotional inhibition may also be lonely and experience greater social difficultiesthan youth who express their emotions appropriately (Kochenderfer-Ladd & Skinner,2002). Youth who demonstrate a balance of positive and negative emotions are likely toexperience the best psychosocial adjustment.

The balanced display of positive and negative emotions is achieved through emotionregulation. Emotion regulation skills are the “intrinsic and extrinsic processes responsiblefor monitoring, evaluating, and modifying emotional reactions, especially their intensiveand temporal features, to accomplish one’s goals” (Thompson, 1994, pp. 27–28).Competent social functioning is associated with high levels of emotion regulation(Eisenberg et al., 2000; Kochenderfer-Ladd & Skinner, 2002). A child who is notregulating his/her emotions may be poorly perceived by peers due to the unfavorablejudgments that may be associated with inappropriate emotional displays (e.g., excessivecrying and extreme fearfulness). Research finds that youth with anxiety disordersexperience emotion regulation deficits (Carthy, Horesh, Apter, Edge, & Gross, 2010). Inone study, clinically anxious youth were more likely to regulate their emotions indysregulated (e.g., slamming doors when angry) ways than a nonclinical control group(Suveg & Zeman, 2004). It is likely that emotion regulation difficulties are related to thesocial challenges that some clinically anxious youth experience, though this questionawaits empirical investigation as no prior studies have considered these indices ofemotional functioning and the social experiences of anxious youth in tandem.

Youth with anxiety disorders experience social and emotional difficulties, but thespecific nature of social functioning difficulties, and the ways that emotional and socialfunctioning are related have been largely unexplored in the literature. Using a model-based cluster analysis, this study aims to identify groups of anxious youth based on socialexperience profiles to better understand types of social difficulties that these youthexperience, which could exacerbate anxiety symptoms or serve as a risk factor for futuremaladjustment. Consistent with previous research (Hawley & Weisz, 2003; Kolko &Kazdin, 1993), we expect reports among informants to differ; cluster analysis providesthe opportunity to consider multiple reports that may provide divergent, yet meaningful,information. Due to the exploratory nature of the cluster analysis, we did not makespecific predictions between the social experience profiles and indices of emotionalfunctioning. However, we anticipated that when parent-, teacher-, and child-reports ofsocial problems converged, youth would experience greater diagnostic severity andemotion-related deficits in functioning (i.e., emotion regulation difficulties and expressivereluctance). This hypothesis was based on prior research, showing that clinically anxiousyouth experience difficulties in both social and emotional domains and the theoretical andempirical literature that suggests that social and emotional functioning is closely linked(Hubbard & Coie, 1994; Settipani & Kendall, 2012; Verduin & Kendall, 2008).

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Coherence in reports of social problems may be evidence of greater social difficulties,which in turn, may generalize to greater diagnostic severity and difficulties in theemotional functioning domain. In contrast, convergent reports of low levels of socialproblems were expected to be associated with less severity of diagnosis and moreadaptive emotional functioning.

Method

Participants

The sample consisted of 64 children, ages 7–12 years (M = 8.86 years, SD = 1.59 years)with a primary diagnosis of separation anxiety disorder, social phobia, and/or GAD basedon the Anxiety Disorder Interview Schedule for DSM-IV: Child Version (Silverman &Albano, 1996). Both child and parent report was considered to reach a consensusdiagnosis. Nearly 93% of the sample had a comorbid anxiety diagnosis and 34.4% had acomorbid externalizing disorder diagnosis (i.e., oppositional defiant disorder and/orattention deficit hyperactivity disorder – ADHD). Exclusionary criteria included currentsuicidal ideation, active psychotic symptoms, the use of psychotropic medications otherthan those for the treatment of ADHD, and current enrollment in psychotherapy. Thirty-eight (60.3%) of the children were boys, and the majority of children in the sample(85.7%) were Caucasian (n = 54). Other participants identified themselves as African-American (6.3%), Asian (1.6%), Latino/Hispanic (1.6%), and “other” (4.8%). Themajority of parents were married (74.6%). Income ranged from $10,000 to $29,999(9.6%), between $30,000 and $49,999 (15.8%), between $50,000 and $69,999 (17.4%),and from $70,000 to over $80,000 (57.2%).

Measures

Demographics

Parents completed a demographics form that assessed sociodemographic factors.

Child psychopathology

The Anxiety Disorders Interview Schedule for DSM-IV: Child Version (ADIS-IV-C/P;Silverman & Albano, 1996) is a psychometrically sound semistructured diagnosticinterview that is administered to parents and to children to diagnose anxiety and otherdisorders (Silverman, Saavedra, & Pina, 2001). Interviews were administered by graduatestudents in clinical psychology. Diagnoses were assigned if either the parent or the childindicated interfering symptoms and the diagnostician assigned a clinician severity rating(CSR) of four or greater. For the current study, reliability was conducted onapproximately 10% of randomly selected interviews (k = .76; “very good”; Cohen, 1960).

Social experiences

Children completed the 15-item Social Experience Questionnaire – Self Report (SEQ-SR;Crick & Grotpeter, 1996), which assesses a child’s perception of peer behaviors towardhimself/herself along three domains: overt victimization (α = .85; “How often do you gethit by another kid?”), relational victimization (α = .85; “How often does another kid say

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they won’t like you unless you do what they want you to do?”), and prosocial behaviortoward the child (α = .69; “How often do other kids let you know that they care aboutyou?”). Children also completed the 16-item Asher Loneliness Scale (ALS; Asher,Hymel, & Renshaw, 1984) to assess their feelings of loneliness and isolation (α = .92; “Ihave nobody to talk to”).

Parents completed the Child Behavior Checklist (CBCL; Achenbach & Rescorla,2001), a 113-item assessment of child emotional and behavioral problems. This studyused the social problems (α = .73) subscale that measures feelings of rejection, difficultieswith friendships, and appropriateness of social behaviors (11 items; e.g., “doesn’t getalong with other kids”). The CBCL is one of the most widely used instruments forassessing child behaviors, and its social problems subscale is commonly used as ameasure of social functioning (Settipani & Kendall, 2012).

Teachers completed the Teacher’s Report Form (TRF; Achenbach & Rescorla, 2001),a parallel version of the CBCL. The social problems (α = .72) subscale was used for thisstudy, which consists of the same items as those that comprise the social problemssubscale of the CBCL.

Emotional experiences

Children completed the Positive and Negative Affect Scale for Children (PANAS-C;Laurent et al., 1999), a self-report measure of how often they felt 30 emotions over thepast two weeks. The PANAS-C has two subscales: positive affect (α = .80) and negativeaffect (α = .80).

Children also completed the Emotion Expression Scale for Children (EESC; Penza-Clyve & Zeman, 2002), which consists of 16-items. For purposes of this study, theexpressive reluctance subscale (α =.68) that measures a child’s unwillingness to show orto express emotions (e.g., “I keep feelings to myself”) was used.

Parents and teachers completed the Emotion Regulation Checklist (ERC; Shields& Cicchetti, 1997), a 24-item measure that yields two subscales, emotion regulation(8 items) and lability/negativity (15 items). The first subscale measures adaptive methodsof managing emotional experiences (e.g., “can modulate excitement in emotionallyarousing situations”) and the latter measures mood lability and dysregulated negativeaffect (e.g., “exhibits wide mood swings”). Alpha coefficients were acceptable for bothparents and teachers on the emotion regulation (.70 and .75, respectively) and lability/negativity (.83 and .87, respectively) subscales.

Procedure

This study was part of a larger study examining treatment outcome for anxious youth.Participants were recruited primarily from flyers posted throughout a small city and itssurrounding areas in the southeastern part of the USA. The flyers were posted at schools,doctors’ offices, on bulletin boards, and other community places and advertised atreatment study for anxious youth. Following a phone screen to determine eligibility,participants provided consent (children provided assent) to complete an approximatelytwo-hour assessment. Parents and children were administered the ADIS-IV-C/P and thencompleted study measures with help as necessary. Parents gave questionnaires to one of

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the child’s teachers, which were then mailed back to the lab directly from the teacher.Children received a token of appreciation (e.g., small toy) for their participation.

Data analytic plan

A model-based cluster analysis was conducted using the social experience measuresrather than other profile-analysis approaches because the former is known to be lesssusceptible to biases, is able to compare a different number of solutions simultaneously,can be used with small samples sizes, and utilizes a goodness-of-fit index (Mun, von Eye,Bates, & Vaschillo, 2008a; Mun, Windle, & Schainker, 2008b). Currently, there is nostandard rule-of-thumb to determine a minimum sample size necessary to conduct acluster analysis (Dolnicar, 2002; Mooi & Sarstedt, 2011). Therefore, we referred to theextant literature that utilized this technique to determine a reasonably acceptable samplesize. One author suggested a minimum of 2k participants, where k is the number ofvariables used to identify the clusters (Formann, 1984). Following this rule, we needed aminimum sample size of 64 (our current N). Several studies, however, have successfullyused cluster-based analyses with smaller sample sizes. For example, Wolff (2009) foundsignificant results when using a sample size of 40 with nine different scales. The model-based cluster analysis uses the Bayesian Information Criteria (BIC) to find the best-fittingmodel, where the larger the absolute value, the better the fit (Milligan & Cooper, 1985).This method provides a probability index, the probability that each case belongs to itsidentified cluster. The higher the probability index (out of 1.00), the stronger thelikelihood that each individual will be classified correctly and the better fit for the data.

Chi-square tests for independence and analyses of variance (ANOVAs) wereconducted to examine cluster differences on demographic, diagnostic, and emotionalfunctioning variables. Cohen’s d was also computed (.20, .50, and above .80 interpretedas small, medium, and large effect size, respectively; Cohen, 1992).

Results

Model-based cluster analysis

The Mclust package in R software (Fraley & Raftery, 2006) was used to conduct thecluster analysis. Six multi-informant social experience measures were entered: SEQ-SRovert victimization, SEQ-SR relational victimization, SEQ-SR receipt of prosocialbehavior, ALS, CBCL social problems, and the TRF social problems. The best-fittingmodel was a three-cluster solution with a diagonal distribution, variable volume, equalshape, and coordinate axes orientation, indicating that the clusters have different within-cluster variability and that the relationships between the social measures differ betweenclusters. The best-fitting model had a BIC value of −2140.84. The second best-fittingmodel included a BIC value of −2143.85 and a difference of 3.01 from the first model.According to Raftery (1995), a difference between 2 units and 6 units is consideredpositive support for the better fitting model. Further evidence for the three-cluster solutionwas provided by the mean posterior probability for cluster membership; the probabilitythat each case belonged to its identified cluster was as follows: .97, .99, and greater than.99, respectively. Furthermore, the first model includes a larger BIC value, indicating thatit is a more appropriate fit for the data compared to the latter model. All other models

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included smaller BIC values (BIC < −2151.98). Collectively, the analyses providedstrong support for the three-cluster solution.

Differences from the sample mean were calculated for each measure within eachcluster to examine conceptual differences between them (see Table 1 and Figure 1).Labels for the clusters were created by examining these differences. Cluster 1 (UnawareChildren, n = 12; 58.3% boys) describes anxious youth who are exhibiting socialdifficulties based on both teacher and parent reports but who report no difficultiesthemselves (i.e., low on peer victimization and moderate on receipt of prosocial behaviorand loneliness). Of those classified as Unaware, 58.3% had a primary diagnosis of GAD,33.3% with primary social phobia, 8.3% with separation anxiety disorder, and 41.7% hada comorbid externalizing disorder. All children in this group also met criteria for acomorbid anxiety disorder. Cluster 2 (Average Functioning, n = 44; 58% boys) includesanxious children who are functioning similarly to their peers based on parent, teacher, andchild-reports of social experiences (i.e., scores on all measures hover around the mean).

Table 1. Means and standard deviations of social measures within each model-based cluster.

Measure Cluster 1 Cluster 2 Cluster 3

P-social problems 7.25 (5.46) 3.52 (2.26) 6.00 (2.33)T-social problems 3.75 (2.22) 0.68 (1.09) 1.63 (2.07)Overt victimization 8.25 (2.67) 6.64 (1.67) 19.00 (3.46)Relational victimization 8.33 (3.42) 7.73 (3.07) 17.63 (5.63)Receipt of prosocial behavior 20.08 (3.09) 18.55 (3.68) 19.38 (5.45)Loneliness 35.58 (15.50) 29.09 (9.18) 50.25 (16.24)

Note: P-social problems = social problems subscale of the CBCL; T-social problems = social problems subscaleof the TRF; overt victimization = overt victimization subscale of the SEQ-SR; relational victimization =relational victimization subscale of the SEQ-SR; receipt of prosocial behavior = receipt of prosocial behaviorsubscale of the SEQ-SR; loneliness = total score of the ALS.

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Unaware childrenAverage functioningVictimize and lonely

Figure 1. Patterns of social measures by differences from the sample grand mean.Note. P-social problems = social problems subscale of the CBCL; T-social problems = socialproblems subscale of the TRF; overt victimization = overt victimization subscale of the SEQ-SR;relational victimization = relational victimization subscale of the SEQ-SR; receipt of prosocialbehavior = receipt of prosocial behavior subscale of the SEQ-SR; loneliness = total score of the ALS.

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Fifty-four percent of youth in this group had a primary diagnosis of GAD, 20.5% hadprimary social phobia, and 25% had primary separation anxiety disorder. The majoritymet criteria for a comorbid anxiety disorder (91%), and 27.3% met criteria for a comorbidexternalizing disorder. The final cluster, Cluster 3 (Victimized and Lonely, n = 8; 75%boys) describes children who report high peer victimization and loneliness, and parentsand teachers who report low levels of social problems in comparison. In this group, 50%had a primary diagnosis of GAD, 37.5% for primary social phobia, and 12.5% forprimary separation anxiety disorder. All children in this group met criteria for a comorbidanxiety disorder and 62.5% of children met criteria for a comorbid externalizing disorder.

There were no significant cluster differences on demographic variables, primarydiagnosis, or the presence of an externalizing or depressive disorder: child sex: χ2(2) =.83, p = .66; child age: F (2) = 1.92, p = .16; child race: χ2(8) = 8.36, p = .40; parenteducation: χ2(8) = 13.48, p = .10; household income group: χ2(6) = 5.96, p = .43; parentmarital status: χ2(8) = 3.56, p = .90; primary diagnosis: χ2(4) = 2.82, p = .59; presence ofexternalizing disorder: χ2(2) = 4.07, p = .13; presence of depressive disorder: χ2(2) =5.82, p = .06.

Profile differences

ANOVAs were conducted to examine differences between the clusters on two measures ofanxiety severity: total diagnostic count and the clinician severity rating of the primarydiagnosis. Clusters differed on total diagnostic count, F (2, 61) = 3.68, p = .03; UnawareChildren had more total diagnoses than the Average-Functioning group, (p = .03, d = .81).Clusters did not differ on severity rating for the primary diagnosis, F (2, 61) = 1.85, p = .17.

A multivariate analysis of variance (MANOVA) examined differences in self-reportedexperience of negative and positive emotions (see Table 2) and was significant, F (4, 122) =3.77, p < .01; Tukey’s post-hoc test revealed that children in the Victimized and Lonely

Table 2. Means and standard deviations of emotional experience measures within each cluster.

Measure Cluster 1 Cluster 2 Cluster 3

Primary CSR 5.67 (0.89) 5.43 (1.00) 6.13 (0.83)Diagnostic count 5.75 (1.82)a 4.00 (2.24)b 5.00 (1.20)Child-report

Positive affect 51.25 (12.94) 53.09 (9.42) 51.50 (9.32)Negative affect 35.58 (11.14)a 33.43 (10.44)a 50.50 (12.65)b

Expressive reluctance 23.25 (4.83) 20.88 (5.66)a 26.38 (5.90)b

Parent-reportEmotion regulation 23.58 (3.42) 24.77 (2.84) 26.13 (3.00)Lability/negativity 34.08 (6.27)a 29.61 (5.72)b 32.00 (6.23)

Teacher-reportEmotion regulation 22.83 (4.67) 24.00 (3.63) 25.00 (3.74)Lability/negativity 29.25 (8.10)a 22.18 (4.57)b 23.88 (7.68)

Note: CSR = Clinician Severity Rating on the Anxiety Disorders Interview Schedule for DSM-IV: ChildVersion; Positive Affect = PANAS Positive Affect subscale; Negative Affect = PANAS Negative Affectsubscale; Expressive Reluctance = EESC Expressive Reluctance subscale; Emotion Regulation = ERC EmotionRegulation subscale; Lability/Negativity = ERC Lability/Negativity subscale. Means in the same row withdifferent superscripts differ significantly at p < .05. No superscript indicates that the mean was not different fromeither of the other means.

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group reported experiencing more negative affect compared to the Average Functioning(p < .001, d = 1.58) and the Unaware Children groups (p = .01, d = 1.27). There wereno group differences on positive affect. A one-way ANOVA demonstrated groupdifferences on child-reported expressive reluctance, F (2, 61) = 3.70, p = .03. Tukey’stest revealed that the Victimized and Lonely group was more reluctant to expressemotions compared to children in the Average Functioning group, p = .03, d = 0.97.

The overall MANOVA examining group differences on parent and teacher report ofemotion regulation was significant, F (8, 118) = 2.58, p = .01 (see Table 2). Tukey’s post-hoc test found that teachers of the Unaware Children’s group reported more lability andnegativity compared to teachers of children in the Average Functioning group (i.e., ERCLability/Negativity subscale), p = .001, d = 1.29. Parent-reported lability and negativityapproached significance. Similar to teachers, parents of the Unaware Children’s groupreported more lability and negativity compared to parents of the Average Functioninggroup, p = .06. No differences were found for parent report, F (2, 48) = 1.87, p = .17, orteacher report, F (2, 48) = 0.30, p = .75 of child emotion regulation.

Discussion

This study identified three distinct patterns of social experiences in clinically anxiousyouth; findings that could not be attributed to differences among the clusters ondemographic or diagnostic variables. On the one hand, our results are promising giventhat nearly 69% of youth with anxiety disorders were functioning in the average range;though clinically anxious youth experience significant impairment in some domains offunctioning related to their anxiety disorder diagnosis, the impairment does notnecessarily extend to social experiences. On the other hand, however, 31% of youthwere experiencing significant social maladjustment – a meaningful percentage of youththat strongly suggests a need for a continued research focus on this relativelyunderstudied area.

The first identified cluster was a group of clinically anxious youth who appeared to befunctioning relatively well socially across informants. Commensurate findings were notedon indices of emotional adjustment, and this group had fewer diagnoses in comparison tothe Unaware Children group. The results are consistent with our hypothesis that youthwith convergent low scores on the social functioning measures would experience fewerdifficulties on the emotional adjustment measures. Having relatively adaptive levels offunctioning may buffer clinically anxious youth from a chronic course of maladjustment,given that social experiences can provide developmental benefits (e.g., validation andcompanionship) that enhance self-esteem, decrease feelings of depression, and protectyouth from the negative effects of peer victimization (Parker et al., 2006). Positive socialexperiences may also give youth opportunities to overcome their fears and serve as anaffirmative outlet in the midst of anxiety.

The second cluster, Unaware Children, was characterized by relatively high parent-and teacher-reports of social problems but average scores on child self-reports. Youth inthis group were also rated higher on teacher and parent reports of lability/negativity.Youth who are labile and emotionally dysregulated are likely to be more noticeable toparents and to teachers than those who are withdrawn and reluctant to express emotions.A lack of child insight is problematic because it may contribute to the maintenance ofdifficulties. These youth may be less likely to monitor their behaviors in social

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interactions or modify problematic patterns of social functioning. Though we labeled thiscluster, Unaware Children, we acknowledge that this group of youth may be aware oftheir problems but minimize them. Regardless of whether youth in this cluster wereactually unaware of or minimized their social problems, the result is likely similar – thecontinuance of behaviors that contribute to their ongoing difficulties.

The final cluster, Victimized and Lonely, comprised youth with the highest levels ofloneliness and relational and overt victimization. Previous research found youth withanxiety disorders to have few or no friends and to be neglected or disliked by peers(Beidel et al., 1999; Strauss et al., 1989; Verduin & Kendall, 2008), but very few studieshave examined their subjective reports of loneliness. Consistent with one previous studyreporting increased loneliness among adolescents with social phobia (Beidel et al., 2007),our findings provide further support for the notion that at least some anxious youthexperience loneliness, perhaps due to not receiving positive peer interactions. Our resultsare also consistent with prior work identifying links between loneliness and victimization(Kochenderfer & Ladd, 1996). The experiences of loneliness and peer victimization havebeen associated with a variety of other indices of maladjustment, including depression,low academic achievement, early school drop-out, and mental health problems to overalllife satisfaction and symptoms of psychopathology in adulthood (Bagwell, Newcomb, &Bukowski, 1998), providing risk for the developmental trajectory of anxious youth. Thepotential for increased risk is perhaps particularly salient for this group, given that parent-and teacher-reports were relatively average. The findings suggest that parents andteachers may be unaware of the social maladjustment experienced by some anxiousyouth. It could be that these youth are withdrawn and inhibited and therefore, unlikely toshare their social difficulties with adults. Support for this explanation is provided by thefinding that youth in this cluster self-reported a greater reluctance to share their feelingswith others. In part, the reluctance may be due to discomfort expressing feelings (e.g., “Ido not like to talk about how I feel”) and/or a sense that their expression would not bewell received (e.g., “Other people don’t like it when you show how you really feel”).Regardless, chronic inhibition of emotional experience may lead to an increase inemotional arousal that could further intensify the experience (Suveg & Zeman, 2004).Indeed, youth who reported experiencing loneliness and peer victimization also reportedgreater negative affect in comparison to the Average group. These findings point to theimportance of directly assessing loneliness and victimization when working with anxiousyouth in clinical settings. Further, the findings suggest the need to alert significant adultsto the social difficulties that the youth may be experiencing in an effort to provideappropriate supports.

Because no group emerged with convergence on parent-, teacher-, and child-reportsof social problems, we could not test our hypothesis that such a group would experiencethe most emotional adjustment problems. The lack of convergence might be due to thediversity of symptoms that clinically anxious youth experience, with some youthevidencing severe impairment across domains of functioning and others not. For instance,a child with separation anxiety might experience difficulty going to school but exhibitdevelopmentally appropriate social skills. On the other hand, a child with generalizedworries may show high academic achievement and social functioning, but may haveimpairment in the home setting due to an excessive need for reassurance. Anotherpossibility is that though we attempted to assess a diverse range of social experiences,there are still many others that could have been assessed. For instance, convergence may

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be found when assessing difficulties with close friendships or observations of peerinteractions. Finally, this group may not have emerged because youth were truly unawareof their social problems. It could be that the Unaware Children cluster really reflected agroup that experienced among the greatest social difficulties, given that this group wasrated poorly on parent- and teacher-reports of emotional functioning (suggesting broadimpairment) and had the greatest number of diagnoses.

Collectively, our results suggest that the ways in which clinically anxious youthexperience social maladjustment is varied. Assessment should not only measure anxietysymptoms but also address various components of children’s social experiences. Potentialclinical implications of our findings include incorporating an emotion regulationcomponent into treatment for some anxious youth and considering interventions toimprove youths’ social experiences as an adjunctive component to standard cognitivebehavioral treatment programs for child anxiety. For example, clinicians may need to helpyouth develop strategies for managing peer victimization, teach social skills to increasefriendships with same-aged peers and reduce loneliness, and work closely with parentsand teachers to create increased opportunities for the receipt of prosocial behavior. Inaddition, anxious youth who are showing social maladjustment should be monitored forthe development of comorbid, non-anxiety disorders over time. For instance, anxiousyouth who are unaware of their social difficulties might be monitored for the emergenceof externalizing disorders, whereas anxious youth experiencing victimization andloneliness might be monitored for depressive symptoms.

The results of the study yielded a meaningful set of findings with important clinicalimplications, yet several limitations are noted. The sample size was small andhomogenous in terms of socioeconomic status and ethnicity. The social experiencesassessment used multiple informants but lacked a behavioral observation component. Thedata are cross-sectional and preclude statements regarding the order of effects. Futureresearch using larger samples of diverse youth and behavioral observation paradigms willhelp to explicate the ways that social experiences and emotional functioning interact overtime in clinical samples of youth. The assessment of social experiences could beexpanded to include variables such as the size and the quality of friendship networks,observed and perceived social skills, peer acceptance, friendship status, and social-cognitive processes. A larger sample followed longitudinally will allow for the testing ofmediators and moderators that are important for understanding the developmentaltrajectory of clinically anxious youth. For example, a larger sample size would allowfor a more rigorous examination of the ways that child sex and developmental level maymoderate the relationship between anxiety and social functioning. Despite theselimitations, the findings highlight the varied nature of social experiences in anxiousyouth and the ways that social and emotional functioning are related in a clinical sample.

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