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Factors associated with social interaction anxiety among Chinese adolescents.

Introduction

It has long been recognised that social anxiety is a common disorder among children and adolescents. (1) In large-scale cross-sectional and longitudinal studies mainly conducted in North America, European countries, and New Zealand, the prevalence of such social anxiety disorder has been estimated to range from 0.5 to 11.1%. (2-8) The detrimental effects of social anxiety disorder on the development of young persons have also been documented in these countries. Such effects include impaired psychosocial functioning, disruptions in social development and interaction skills, poor academic performance, depression, and substance use. (9-13) Among the few studies reported from North and South-East Asian countries, one was an epidemiological investigation from Taiwan. (14) This latter study examined mental disorders among young persons in junior high schools and reported a social anxiety disorder prevalence of between 1.8 and 3.4% in different age-groups.

In terms of risk factors associated with anxiety disorders among adolescents, a volume of work has been undertaken and reviewed. According to Beesdo et al, (15) these risk factors can be categorised into several broad groups, namely: (1) demographic variables such as gender, socioeconomic status, and education level; (2) familial and parental variables, such as parenting style; (3) personal variables, such as personality; and (4) life events, such as childhood abuse or trauma. These broad categories were also reflected in the study by van Oort et al, (16) which reported risk indicators of anxiety grouped into 3 main types: child, family, and peer factors. In terms of child factors, it has been consistently demonstrated that females are at higher risk of developing anxiety than males. (17) Studies have also shown that low self-esteem is a significant risk factor for anxiety. (18,19) Regarding familial and parental factors, parental rejection and overly protective parents are factors significantly related to anxiety disorder in children, (20,21) while parental stress, anxiety, and depression also increased the risk. (22,23) Peer factors were mainly concerned with the relationship between the individual and his / her peers, particularly in terms of bullying and victimisation, and were similar to the stressful life events highlighted by Beesdo et al. (15) Studies have also found that victimisation is a significant risk factor of anxiety in young people. (24)

van Oort et al (16) noted that the majority of studies on the risk factors of anxiety among adolescents reported in the literature were conducted in high-risk populations, the main focus being on anxiety as a whole. Relatively few were conducted on specific types of anxiety such as social anxiety. Far fewer studies have been found particularly on social interaction anxiety, which is defined as the distress caused when meeting and talking with other people, as well as fears of an inability to interact socially and being ignored. (25) For adolescents, during the time of growth and development, the effect of this type of anxiety becomes more prominent and may also be detrimental to other important areas in their lives, such as achievement at school and attention from the opposite sex. (26) In addition to the lack of studies on specific types of anxiety, those conducted among young persons from non-western cultures are very limited, and none dealt with the risk factors of social interaction anxiety among Chinese adolescents. This exploratory study therefore aimed to bridge this knowledge gap and examine potential risk factors for social anxiety, particularly social interaction anxiety, among adolescents in the Chinese population.

Methods

Sample and Procedure

This cross-sectional health survey was conducted in Guangzhou city, the provincial capital of Guangdong Province in Southeast China. Guangdong is China's most populous province, and that Guangzhou city is the largest and most populated in the province, with an estimated population of nearly 13 million according to the latest population census in 2010. (27) Approval to conduct this study was granted by the Human Research Ethics Committee of the Sun Yat-Sen University, Guangzhou, China.

The sample frame of the study was the total population of adolescents aged 13 to 18 years who attended high school, and covered grades 1 to 6 of the entire high school period. There were 128 senior high schools in the Guangzhou city with an average of 4 classes in each year and about 45 students per class. Hence, there were more than 100,000 young adolescents in the sample frame. The sampling entailed a 2-stage process. First, using individual schools as the primary sampling unit, 4 schools were randomly selected with a probability, which was proportional to the size of the target population in each school. Second, using the class as the secondary sampling unit, 1 class for each grade was randomly selected from each selected school. Students were thus considered clustered in classes.

The health survey was conducted on campus at different schools within the same week. Selected students from different schools were invited to participate in the survey via school principals and their teachers, and were encouraged to fill in a self-reported questionnaire designed specifically for this study. Consent was implied by a voluntarily response to the questionnaire.

Materials

A survey questionnaire, which consisted of different validated and standardised assessment scales, was designed to gather information. Social interaction anxiety was assessed using the Social Interaction Anxiety Scale (SIAS). (25) The SIAS was designed to measure fears or phobias of general social interactions. The scale was developed in accordance with the descriptions of circumscribed social phobia in the DSM-III-R. (28) The SIAS consists of 19 items designed to assess distress and fears elicited during social interactions with other persons, such as those of the opposite sex and strangers. The scale was constructed as a 5-point Likert scale (0-4) asking respondents to indicate the degree to which statements were characteristic or true for them. Validation studies indicated that the SIAS consisted of a single factor, with a high level of internal consistency (Cronbach's alpha = 0.94) and a test-retest reliability of 0.92 over a 4-week re-test period. (25)

Other information collected in the survey questionnaire included some important risk factors of anxiety disorder among adolescents previously identified in the literature. In terms of demographics, variables such as age, gender, single child status, family structure, parental education levels, and family incomes were included. Child factors including self-perception on school performance, relationship with teachers and peers, and satisfaction with self-image were also assessed. These factors were measured using a self-rating method to indicate the level of achievement or satisfaction of the respondent. Perception on the parenting style of the mother was also evaluated by asking respondents to nominate a specific style of parenting that best described their mothers from a pre-determined list. Parent-child relationships, specifically the relationship between respondents and their mothers, were assessed using the mother attachment subscale of the Inventory of Parent and Peer Attachment (IPPA). (29) The inventory has been commonly used in research relating to parenting and parent-child attachment. (30,31) The IPPA was constructed based on the theoretical framework of attachment theory and designed to evaluate adolescents' cognition of relationships with parents and close friends. It was also designed to assess the positive and negative affect of these relationships with parents and close friends. Information on other potential risk factors was also collected including self-esteem and some personality measures such as anger and hostility. Self-esteem was assessed using the Rosenberg Self-Esteem Scale, which is commonly used for assessing self-esteem among adolescents. (32) Anger and hostility were measured using the anger and hostility subscales of the Aggression Questionnaire. (33)

Data Analyses

Data were analysed using the Stata V10.0b statistical software program. (34) Since the study entailed a cluster sampling design, data were set up with the survey design function utilising the svy commands for handling the cluster sampling effect. Bivariate analyses were conducted to examine the unadjusted relationships between all variables of interest and social interaction anxiety. The majority of potential risk factors were categorical or ordinal by nature, thus comparisons across groups were conducted. Equality of means among groups was examined using F tests with adjustments for the cluster sampling design. The linear regression modelling was then applied to investigate associations between selected potential risk factors and social interaction anxiety, with adjustment for the cluster sampling. For the inclusion of any variable in the initial regression model, the criteria of a bivariate association with p < 0.20 were used. Multiple linear regression models were constructed with a backward elimination process aiming to derive a parsimonious model which contained significant variables only. A significance level of 5% was used for hypothesis testing. The interaction terms of significant variables retained in the model were then tested for statistical significance. A significance level of 0.1% was used for hypothesis testing of all interaction terms.

Results

A total of 1083 high school students were recruited from 4 high schools, with a class randomly selected from each grade. There was a response rate of 90% from a total of 1204 students invited. Comparisons between respondents and non-respondents suggested no significant differences in terms of age and gender. The characteristics of the sample, including demographics, personal and familial variables, parental attachment, and social interaction anxiety are summarised in Table 1. The majority of these students were < 16 years (n = 593, 73%), with an even distribution of males and females (49% vs. 51%). About 66% (n = 667) of these youngsters were living in a nuclear family household, and the majority were single children (n = 784, 77%). Most of their parents had attained education levels higher than junior high school (84% of fathers and 79% of mothers). Slightly more than one-third of these subjects were living in households with a monthly family income of RMB [greater than or equal to] 6000 (n = 344, 34%). In terms of their personal characteristics, 12% (n = 120) rated themselves as Band 1 students (in the top 20% of the class) and 30% as Band 2 (next 20% of the class). The majority of these young persons considered themselves to be in a good relationship with their teachers and peers (63% and 78%, respectively). Nearly half (n = 513) were satisfied with their self-image and 90 (7%) considered their image as unsatisfactory. As a whole group, these youngsters scored moderately high on self-esteem (mean = 29.5, standard error [SE] = 0.4), but relatively low on anger (16.4 [0.2]) and hostility (18.8 [0.3]) scores. Also, over half of the sample considered their parents as authoritative (n = 602, 61%); 15% felt they were permissive, about 4% considered them uninvolved, and about 20% stated that they were authoritarian and / or unpredictive. The mean (SE) score for attachment to the mother was 10.4 (0.1). The social interaction anxiety scores of these young persons were also moderately high with a mean (SE) score of 42.4 (0.3) and a median of 42 out of a maximum 76.

The bivariate relationships between social interaction anxiety, student demographics, personal and familial characteristics, and parental attachment were examined, with results summarised in Table 2. As shown, after adjusting for the cluster sampling effect, a number of variables were significantly associated with social interaction anxiety. They included gender of the respondent, family income, personal and familial characteristics, parenting style, and attachment to the mother. These variables were included in further analyses. Parental education levels were also selected, because the associations between these variables and social interaction anxiety attained significance (p [less than or equal to] 0.20).

The final results from the multivariate linear regression analyses are presented in Table 3. Three variables remained significant in the final model after adjusting for each other as well as the cluster sampling effect. Among these adolescents, lower family income was significantly associated with social interaction anxiety (t = 3.63, p = 0.001) with a [beta] of 0.59. Notably for every reduction of about RMB 2000 in monthly income per person within the household, there was a corresponding increase of about 0.6 in the social interaction anxiety score. There was also a significant negative relationship between self-esteem and social interaction anxiety (t = -5.25, p < 0.001).

With every increment of 1 unit in self-esteem, there was a corresponding decrease in social interaction anxiety score of 0.3 ([beta] = -0.33, SE = 0.06). On the other hand, hostility was significantly and positively associated with social interaction anxiety (t = 7.78, p < 0.001) with a [beta] of 0.51, indicating that for every increasing unit on the hostility score, the social interaction anxiety score also increased by about 0.5. An examination of the interaction terms of these variables indicated that none were significant, suggesting that they were independent potential risk factors of social interaction anxiety. In our sample, variables identified as risk factors of anxiety disorder in the literature, such as gender, were not associated with social interaction anxiety.

Discussion

This study aimed to examine potential risk factors associated with social interaction anxiety in a Chinese adolescent population. To our knowledge, this is one of the few reports on this topic in Chinese adolescents, and one that investigated potential risk factors for this specific form of anxiety. Our results suggested that 3 variables are significantly related to social interaction anxiety. One of these was variable related to demographics, while the others related to personal characteristics.

Due to the scarcity of studies in similar population groups, comparison of study results was difficult. Compared to studies among young people in other countries, our results were consistent with findings already reported. Thus, regarding financial status or family household income, it has been reported that low household incomes or unsatisfactory financial situations in the family were significantly associated with anxiety disorders in adolescents. (35,36) In a recent study conducted in the Netherlands by van Oort et al, (16) low parental income might have been a risk factor for social anxiety disorder throughout adolescence. However, the strength of the association between these 2 parameters was not as significant as other child and family factors (such as parental problems). (16) The significant negative association between self-esteem and social interaction anxiety noted in our study was also consistent with findings in the literature. (18,19) Previous work had identified low self-esteem as a potential risk factor for social anxiety disorder. In the study by van Oort et al, (16) self-esteem-related variables (scholastic competence, physical appearance, and global self-worth) were significantly related to social phobias. However, the degree of anxiety seemed to decline across the adolescent period. (16) In terms of the temperament or personality characteristics of individuals in this study, hostility but not anger was significantly related to social interaction anxiety. While other personality characteristics (such as behavioural inhibition) were recognised as risk factors for social anxiety disorder, adolescent hostility has not been reported in the literature as a potential risk factor for social phobia. (37,38) Thus, the findings of this study could be considered as unique.

Some variables identified as risk factors of anxiety disorder in the literature were not associated with social interaction anxiety in our study. It has been consistently demonstrated that female gender is a risk factor for the development of anxiety disorders. (15) In our sample however, after adjusting for potential risk factors, no significant differences between male and female adolescents were noted in terms of social interaction anxiety scores. Since parenting style has been suggested to have a bearing on anxiety disorders of adolescents, one potential explanation could be related to parenting, particularly the parenting style of mothers. In other words, in the past there might have been greater differences in the parenting styles for males and females than currently, which could have resulted in a greater difference in anxiety. In this study, the distribution of parenting for males and females was found to be rather even. While the distribution of parenting styles of mothers in relation to the gender of their children in previous studies was unknown, this hypothesis is worth further investigation. Moreover, adolescents with social anxiety often suffer other co-morbidities, such as depression, that may affect associations between these potential risk factors and social anxiety. Regrettably, these co-morbidities were not assessed in this study and obviously require further exploration.

This was a population-based study that included a random sample of adolescents using a 2-stage cluster sampling design, which entailed a rigorous sampling methodology and achieved a high response rate (90%) capable of generating a representative sample. Comparisons between respondents and non-respondents indicated no significant differences, which facilitated generalisability of results. Moreover, the sample size was sufficient to provide enough power for the study to draw meaningful conclusions. The use of standardised and validated instruments for the measurement of important variables, such as parental attachment, self-esteem, anger, hostility, and social interaction anxiety, minimised information bias. One potential limitation of this study was that maternal parenting style was assessed using a self-nomination method, not a standardised tool. A second limitation was that several possible risk factors were not evaluated. The latter included: personal and familial stressful life events, family history of anxiety disorders, depression, parental psychopathology, and substance abuse (as suggested in the literature). Had these potential factors been included in the analysis using a regression approach, a more predictive risk model could have been formulated. Finally, the cross-sectional nature of the study provided only associative results and was insufficient to draw any causal inferences. Further investigations should employ a better study design, such as a longitudinal cohort that could elucidate the possible causal relationship between such potential risk factors and social interaction anxiety.

Declaration

The authors declare no financial support for the conduct of the study.

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Dr Zi-Wen Peng, MBBS, School of Public Health, Sun Yat-Sen University, Guangzhou, PR China.

A/Prof. Lawrence T. Lam, MAppPsy, MPH, PhD, School of Medicine Sydney, The University of Notre Dame Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, The University of Sydney, Australia.

Prof. Jing Jin, MBBS, PhD, School of Public Health, Sun Yat-Sen University, Guangzhou, PR China.

Addresses for correspondence: A/Prof. Lawrence T. Lam, School of Medicine Sydney, The University of Notre Dame Australia, Darlinghurst Campus, 160 Oxford Street, Darlinghurst NSW 2010, Australia. Tel: (6-12) 8204 4477; Fax: (6-12) 9357 7680; Email: lawrence.lam@nd.edu.au

Prof. Jing Jin, School of Public Health, Sun Yat-Sen University, Guangzhou, PR China.

Email: jingjin@mail.sysu.edu.cn

Submitted: 13 July 2011; Accepted: 5 September 2011
Table 1. Descriptive information on the demographics, personal
and familial variables, parental attachment, and social
interaction anxiety of participants (n = 1083).

Variable                                            Value *

Demographic variables

  Age-group (years)
    < 14                                           260 (33%)
    14-15                                          333 (40%)
    [greater than or equal to] 16                  457 (27%)
  Sex
    Male                                           515 (49%)
    Female                                         568 (51%)
  Family structure
    Extended family                                248 (25%)
    Nuclear family                                 667 (66%)
    Others                                          92 (9%)
  Single child
    Yes                                            784 (77%)
    No                                             260 (24%)
  Father's education level
    University or above                            488 (47%)
    Senior high school and technical college       403 (37%)
    Junior high school or below                    155 (16%)
  Mother's education level
    University or above                            420 (40%)
    Senior high school and technical college       408 (39%)
    Junior high school or below                    219 (21%)
  Average monthly family income (RMB)
    [greater than or equal to] 8000                212 (21%)
    6000-7999                                      132 (13%)
    4000-5999                                      141 (14%)
    2000-3999                                      255 (24%)
    900-1999                                       132 (14%)
    < 900                                          148 (14%)

Personal and environmental variables

  Perception on school performance
    Band 1                                         120 (12%)
    Band 2                                         315 (30%)
    Band 3                                         351 (31%)
    Band 4                                         209 (20%)
    Band 5                                          80 (7%)
  Perception on relationship with teachers
    Good                                           659 (63%)
    Usual                                          390 (34%)
    Bad                                             32 (3%)
  Perception on relationship with classmates
    Good                                           831 (78%)
    Usual                                          211 (20%)
    Bad                                             25 (3%)
  Satisfaction with self-image
    Very satisfied                                 130 (12%)
    Somewhat satisfied                             383 (37%)
    Neither satisfied nor dissatisfied             476 (44%
    Dissatisfied                                    40 (3%)
    Very dissatisfied                               50 (4%)
  Self-esteem (mean/standard error/median)        29.5/0.4/29
  Anger score (mean/standard error/median)        16.4/0.2/16
  Hostility (mean/standard error/median)          18.8/0.3/18
  Perception on mother's parenting style
    Authoritative                                  602 (61%)
    Permissive                                     164 (15%)
    Uninvolved                                      38 (4%)
    Others                                         212 (21%)

Parental attachment to mother                     10.4/0.1/10
  (mean/standard error/median)

Social interaction anxiety                        42.4/0.3/42
  (mean/standard error/median)

* Estimated after adjusting for cluster sampling effect, percentages
might not add up to 100% due to different sample weights.

Table 2. Unadjusted associations between parental attachment,
other potential risk factors and social interaction anxiety.

Variable                                   Results *       p Value

Demographic variables

  Age-group                             F(2, 22) = 1.68     0.21
  Sex                                   F(1, 23) = 4.67     0.04
  Family structure                      F(2, 22) = 0.04     0.96
  Single child                          F(1, 23) = 1.08     0.31
  Father's education level              F(2, 22) = 2.12     0.14
  Mother's education level              F(2, 22) = 3.12     0.06
  Average family income (RMB)           F(1, 23) = 22.35   < 0.001

Personal and environmental variables

  Perception on school performance      F(1, 23) = 3.17     0.01
  Perception on relationship with       F(2, 22) = 9.66     0.001
    teacher
  Perception on relationship with       F(2, 22) = 9.95     0.001
    classmate
  Satisfaction with self-image          F(1, 23) = 24.97   < 0.001
  Self-esteem                           F(1, 23) = 74.07   < 0.001
  Anger score                           F(1, 23) = 21.04   < 0.001
  Hostility                             F(1, 23) = 99.02   < 0.001
  Perception on mother's parenting      F(3, 21) = 4.64     0.01
    style

Parental attachment (to mother)         F(1, 23) = 10.72    0.003

* After adjusting for cluster sampling effect.

Table 3. Results from the final linear regression model with
adjustment for cluster sampling effect.

Variables remained in   [beta] (linearised   t Value   p Value
the model *              standard error)

Lower family income        0.59 (0.16)        3.63      0.001
Higher self-esteem         -0.33 (0.06)       -5.25    < 0.001
Higher hostility           0.51 (0.07)        7.78     < 0.001

Model statistics: F(3, 21) = 93.8; p < 0.001; design degrees
of freedom = 23; [R.sup.2] = 0.20.
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Title Annotation:Original Article
Author:Peng, Z.W.; Lam, L.T.; Jin, J.
Publication:East Asian Archives of Psychiatry
Geographic Code:9CHIN
Date:Dec 1, 2011
Words:4642
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