obese and anxiety

Social Anxiety in Obese Youth in Treatment Setting

Julia E. Thompson B. Allyson Phillips

Andy McCracken Kenneth Thomas

Wendy L. Ward

Published online: 11 August 2012

Springer Science+Business Media, LLC 2012

Abstract The aim of this study was to determine the prevalence of social anxietyin obese children treated in a weight management clinic. We hypothesized that

social anxiety would positively correlate with obesity, and that extremely obese

patients would have significantly higher rates of social anxiety when compared to

obese patients. Information was collected at a multidisciplinary treatment clinic

for obese youth during the first clinic visit. The social anxiety scale was adminis-

tered (including parent-report and self-report scales for both elementary and ado-

lescent versions) and demographic data was obtained. Social anxiety was found to

be significantly positively correlated with BMI percentile. In addition, extremely

obese patients had significantly higher social anxiety scores than obese youth at

least for elementary-age youth. Trends in gender differences and racial differences

in this obese pediatric clinical sample were consistent with results found in com-

munity samples. Social anxiety and obesity were found to be positively correlated in

this pediatric clinic-based population. For elementary-age patients, extremely

obese patients were at greater risk than obese patients for social anxiety and its

various symptomsfear of negative evaluation, social avoidance/distress in new

situations, and social avoidance/distress in general. Results for adolescents were less

clear. Clinical implications of these results were discussed. Limitations of this

study, and directions for future research were also discussed.

J. E. Thompson

Department of Psychology, Louisiana State University, Baton Rouge, LA, USA

B. Allyson Phillips A. McCracken W. L. Ward (&)UAMS Department of Pediatrics, College of Medicine, and Arkansas Childrens Hospital,

University of Arkansas for Medical Sciences, 1 Childrens Way, Slot 512-21, Little Rock,

AR 72202-3591, USA

e-mail: [email protected]

K. Thomas

Department of Psychiatry, University of Arkansas for Medical Sciences, College of Medicine,

Little Rock, AR, USA

123

Child Adolesc Soc Work J (2013) 30:3747

DOI 10.1007/s10560-012-0274-0

Keywords Pediatric obesity Social anxiety

Introduction

It is estimated that, within the United States, 15.3 % of school-age children are

considered obese along with 15.5 % of the adolescent population (Ogden et al.

2006; Pohl et al. 2006; Strauss and Pollack 2003). Along with the medical

comorbidities such as diabetes, high blood pressure, high cholesterol, heart disease,

fatty liver disease, and other life-threatening illnesses, overweight children and

adolescents are also suspected of being at an increased risk for internalizing

difficulties (internal emotional distress and/or mood states) such as depression (Pesa

et al. 2000; Williams et al. 2005) hopelessness (Falkner et al. 2001), suicide

attempts (Falkner et al. 2001), and low self-esteem (French et al. 1995; Williams

et al. 2005). Moreover, these youth may have a lower quality of life (Schwimmer

et al. 2003).

Overweight children and youth also suffer significant social difficulties. For

instance, overweight adolescents are more likely to be socially isolated and have

more peripheral roles in social networks than normal-weight adolescents (Falkner

et al. 2001; Strauss and Pollack 2003). Anecdotal evidence suggests significant peer

teasing, rejection, and isolation for many overweight youth (Hayden-Wade et al.

2005). These types of negative social responses might suggest an increased risk for

social anxiety and avoidance of social situations. In fact, one would anticipate social

anxiety to be prevalent in overweight youth, though to our knowledge, social

anxiety symptoms have not been examined directly.

Social anxiety is defined as the level of discomfort one feels in social situations

and in the context of perceived social evaluation. According to La Greca (1999),

social anxiety for youth has three main components: fear of negative evaluation

(FNE), social avoidance and distress in general (SAD-General), and social

avoidance and distress in new situations (SAD-New). FNE in children encompasses

fears of being teased, worrying that others are talking negatively about you, thinking

that others are talking behind your back, etc. Social avoidance and distress,

however, describes emotional distress related to interacting with others (either in

familiar or unfamiliar environments). Some children find meeting new people and

having to interact in new situations difficult, while others find it difficult to interact

in both new and familiar situations. Each subcomponent represents a distinct part of

social anxiety.

This study proposes to investigate the relationship between pediatric obesity and

social anxiety. In so doing, it will be important to investigate differences in social

anxiety among subgroups of obese youth. Much of the research on severely obese

youth is conducted with clinic samples where sample sizes also tend to be small,

which may mask the considerable psychological variability that exists among obese

individuals (Faith et al. 2004). In non-overweight, non-clinical samples girls are

found to have higher rates of social anxiety than boys (La Greca and Lopez 1998;

Inderbitzen-Nolan and Walters 2000; Crick and Ladd 1993; La Greca and Stone

1993). Similarly, in non-obese samples, Caucasian youth have higher rates of social

38 J. E. Thompson et al.

123

anxiety than African American youth (Himle et al. 2009). Further, younger children

have higher social anxiety scores than older children (Epkins 2002) and junior high

youth have higher social anxiety scores than high school youth (Inderbitzen-Nolan

and Walters 2000). It remains to be seen whether these differences hold true in the

pediatric obese population.

The present study intends to investigate social anxiety in youth who attend a

pediatric multidisciplinary treatment clinic for obesity. Hypotheses are as follows:

(1) We hypothesize that social anxiety may be exacerbated by the level of obesity

such that there is a positive correlation between social anxiety and BMI (the

latter as a continuous variable).

(2) We further hypothesize that extremely obese youth (those with [99thpercentile BMI) would have higher levels of social anxiety than obese youth

(9599th percentile BMI) in this clinic population.

(3) We plan to investigate the role of moderating variables We expect to find

differences in the means levels of social anxiety for boys versus girls, for

elementary-age versus adolescents, and for different racial groups.

(4) For all of these hypotheses, if significant differences in mean comparisons are

found for overall social anxiety then subdomains of social anxiety will be

investigated in the same fashion. We would expect that patterns would be

similar across all three of the subdomains of social anxiety though these

analyses are exploratory.

It is important to note that all analyses will be completed for both parent-report

and youth-report of social anxiety separately.

Methods

Sample

All children 6 years, 0 months through 17-years, 11-months old, treated in a

multidisciplinary treatment clinic for obese youth were eligible for inclusion in the

study. Exclusion criteria include: (1) caregiver other than primary caregiver was

present, (2) parent or patient has a reading ability insufficient for completion of

measures, and (3) parent or patient has insufficient knowledge of English for

completion of measures. Full approval from the University of Arkansas for Medical

Sciences IRB was obtained prior to initiation of the project, and participating

children and their parent/legal guardian were asked for assent/consent for

participation during their initial visit to the clinic. All participants received a $10

Walmart gift certificate for participation.

The multidisciplinary clinic from which patients were approached treats

significantly obese youth utilizing medical, psychological, physical therapy, and

nutritional services. This clinic typically sees 58 % females and 52 % Caucasians,

42 % African American, 39 % less than 10 years old, 41 % between 10 and 14, and

19 % over 14-years old. We approached all new patients (n = 380) during thecourse of this study. Of those, 10.2 % (n = 39) declined and 10.3 % (n = 92) were

Social Anxiety and Obesity 39

123

ineligible. The resulting 249 represent the final sample. Over a 13-month period,

249 new patients were enrolled63 % were female, 49 % were Caucasian, 40 %

were African American, 32 % were less than 10 years old, 50 % were between 10

and 14, and 18 % were over 14-years old. The distribution of gender, race, and age

of subjects appears to reflect the distribution of patients at the clinic.

Measures

Subjects were asked to complete a battery of measures during the initial clinic visit.

This visit is typically half a day, due to visits with multiple disciplines (medical,

nutrition, and/or psychological) as well as various lab and physical fitness

assessments. There is ample downtime between these activities to complete the

measures. Administration of the self-report questionnaire measures took approxi-

mately 60 min for patients (perhaps a bit longer for younger patients) and 60 min

for parents (completed concurrently). All measures are pencil-and-paper self-report

questionnaires for parents or patients. Only the social anxiety scale (SAS) is reportedin this manuscript, including the childhood and adolescent versions: SASC-R

(revised) and the SAS-A. The SASC-R is a measure with 22 items, 18 are self-

statements and 4 are filler statements (e.g., I like to play sports). Each item is

rated on a five-point Likert scale according to how much the item is true for you,

ranging from 1 (not at all) to 5 (all the time). Analyses have suggested three factors

in both the SASC-R and SAS-A measures (La Greca 1999; La Greca and Lopez

1998; La Greca and Stone 1993). The first is FNE (eight items) which measures the

degree to which a child is concerned with others evaluations of him or her. The

second is SAD-General (four items) and involves the level of distress and

discomfort in social situations in general. The third is SAD-New (six items) which

focuses on SAD-New or unfamiliar peers. Items from each subscale are summed so

that high scores reflect greater social anxiety. Scores from the three subscales are

summed to form a total score.

There is a child version and adolescent version of this measure (SASC-R and SAS-

A), and both child and parent-report versions for each. The SAS-A is identical in

format to the elementary school version (i.e., 22 items; five-point rating scale), but the

item wording was modified slightly for an older age group. Specifically, items

containing the term other kids were reworded to peers, others, or people,

and references to playing with others were reworded to doing things with others.

Good internal and testretest reliability have been reported for both measures (La

Greca 1999). Internal consistencies for the SASC-R ranged from 0.69 (SAD-

General) to 0.78 (SAD-New) to 0.86 (FNE) and construct validity was supported by

patterns of relationships between SASC-R subscales and childrens self-appraisals,

as well as peer-rated sociometric status (La Greca and Stone 1993). Internal

consistencies (Cronbachs a) for the SAS-A were 0.91 (FNE), 0.83 (SAD-New), and0.76 (SAD-General) (La Greca and Lopez 1998; Harman et al., under review).

In addition to paper/pencil measures, height and weight status was assessed in

clinic by nursing staff. BMI was calculated as weight (kg) divided by height

(m) squared. BMI percentiles were obtained from the Center for Disease Control

standards [CDC] (2007) based upon the gender and age of the youth.


123

All data were entered into two separate datasets by two different research

assistants, and the two datasets were analyzed for differences. A third research

assistant investigated the raw data to identify the accurate entry. In this way, the

dataset is thought to be accurate in its data entry.

Statistical Analysis Plan

First, demographic variables will be described in frequency analyses of the sample.

All remaining analyses will involve the variables of interest including four

dependent variables: SAS total score and three subscales FNE, SAD-General, and

SAD-New. Any subjects with missing data were excluded from analyses. Parent-

report and youth-report versions of the measure will be analyzed separately in all

analyses.

To assess hypothesis 1 regarding the relationship between social anxiety and

BMI, Spearman correlations are planned comparing SAS total score and all three

subscale scores and BMI percentile. The non-parametric Spearmans correlation

coefficient was selected because the data did not follow a bi-variate Normal

distribution, an underlying assumption of the Pearson correlation coefficient. Tests

of the correlation coefficients being different from zero in these analyses were not

adjusted for simultaneous inference.

To assess hypothesis 2, multiple t test comparisons are planned comparing twogroups of BMI youth on the SAS total score and subscale scores. Non-parametric

analysis of variance and non-parametric independent t tests were used to comparesubjects in all these analyses as the data did not follow a Normal distribution.

Specifically, the KruskalWallis test and the Wilcoxon Rank Sum test were used.

A Holms adjustment for simultaneous inference was used when the number of post

hoc pair-wise comparisons following an ANOVA was two or more.

Hypothesis 3 will be assessed similarly, comparing SAS total score and subscale

scores among gender and racial groups. We also plan analyses separate for the

elementary and adolescent versions of our social anxiety measure. These measures

contain developmentally appropriate items but are thought to tap the same

underlying construct of social anxiety. Comparisons of mean scores on these

measures allow some understanding of age differences although comparisons based

on age were not planned.

Results

Subjects

Due to insufficient numbers of some minority racial groups, 19 subjects were

removed from the sample of 249 enrolled subjects (n = 230 final sample).Depending on patient age, the child or adolescent version of the measure was used.

The SASC-R has a parent report (n = 141) and youth report (n = 144). The SAS-Ahas a parent report (n = 90) and youth report (n = 86). Youth and parent-reportversions were obtained from each subject or their parent.


123

To assess hypothesis 1, Spearman correlation coefficients were calculated

between BMI percentile and the overall social anxiety score of the SASC-R and

SAS-A separately for parent and youth versions (see Table 1). A significant positive

correlation was found for the SASC-R only (both parent and child versions),

suggesting that for younger children, greater BMI is significantly associated with

greater social anxiety. This was true for all subscales of the SASC-R except one (the

SAD-General scale of the child report which approached significance). No

significant relationship was found for adolescents (SAS-A parent and self-report).

To investigate hypothesis 2, mean scores of overall social anxiety were compared

between BMI categories BMI status were investigated (see Table 2). BMI status is

arbitrarily defined as obese (9599th percentile) and extremely obese (99th

percentile and above). Interestingly, elementary-age children (self and parent report)

have significantly greater social anxiety if they are extremely obese as compared

to obese. Analyses for hypothesis 2 were done separately for the parent-report

and youth report versions of the SASC-R and SAS-A.

To investigate hypothesis 3, males versus females and Caucasians versus African

Americans were compared (see Table 2). Analyses for hypothesis 3 were also done

separately for the parent-report and youth report versions of the SASC-R and SAS-

A. For elementary-age children, the SASC-R parent version showed significantly

greater social anxiety for girls than boys, though not the self-report version. For

adolescents, the self-report SAS-A showed significantly greater social anxiety in

girls than boys but not the parent version. For adolescent self-report only,

Caucasians have greater social anxiety than African Americans.

As planned in hypothesis 4, for those analyses in Table 3 that showed significant

mean differences for overall social anxiety, the same analyses were performed for

Table 1 BMI percentile andSAS Spearman correlation

coefficients

SAS social anxiety scale,FNE fear of negative evaluation,SAD-General social avoidanceand distress (across many

situations), SAD-New socialavoidance and distress (in new,

unfamiliar situations)

* P \ 0.05

Spearman correlation

coefficients

P value

SAS-adolescents 0.100 0.373

FNE 0.102 0.363

SAD-General 0.123 0.273

SAD-New 0.050 0.653

SAS-adolescents for parents 0.091 0.403

FNE 0.078 0.470


SAD-New 0.050 0.650

SASC-R 0.290 \0.001*

FNE 0.274 0.001*


SAD-New 0.270 0.001*

SASC-R for parents 0.231 0.006*

FNE 0.216 0.010*

SAD-General 0.187 0.028*

SAD-New 0.170 0.045*


123

the subscales of social anxiety (see Tables 3, 4). Results found that for adolescent

girls there is greater FNE and SAD-New than boys, though no gender differences

for SAD-General. Conversely, for elementary girls (parent report) there is greater

SAD-General than boys, though no gender differences for FNE and SAD-New. For

adolescents, significant higher rates for Caucasians were found for FNE, SAD-

General, and SAD-New. For elementary children, significant higher rates for

extremely obese as compared to obese were found for FNE, SAD-New, and

SAD-General. For SASC-R (parent report), significantly higher rates for extremely

obese were found for FNE only.

As an exploratory addition to the statistical plan, a three way ANOVA using

gender, race, and BMI category was calculated but not significant for parent or child

report on SASC-R or SAS-A. Results should be considered preliminary given the

small sample sizes in a few of the cells which would limit statistical power.

Discussion

This paper investigated social anxiety in an obese, pediatric clinical population.

Results suggest a strong positive correlation between obesity and social anxiety

and its componentsFNE and social avoidance/distress (in new situations and

generally). Furthermore, results showed that for elementary children (parent and

youth report), social anxiety and all its subcomponents are all higher for the

extremely obese as compared to obese patients. Youth reports suggest this

holds true across all three subcomponents of social anxiety. To our knowledge,

Table 2 Investigation of moderating variables effects on social anxiety

SASC-R SASC-R for parents SAS-adolescents SAS-adolescents

for parents

Gender

Female 44.5 (16.696) 95 45.5 (15.772) 94 45.0 (13.804) 53 45.3 (13.723) 53

Male 42.8 (16.928) 49 39.8 (13.834) 47 40.4 (19.102) 32 49.0 (17.331) 37

P value 0.523 0.040* 0.039* 0.352

Race

Caucasian 46.5 (17.081) 72 46.9 (14.904) 72 47.7 (16.945) 38 48.0 (15.860) 42

African American 40.6 (15.271) 54 41.5 (13.775) 52 37.2 (13.785) 38 45.9 (14.738) 39

P value 0.189 0.101 0.010* 0.689

BMI category

9599 % 36.8 (15.046) 46 39.8 (14.858) 45 39.5 (13.929) 18 46.8 (17.161) 18

More than 99 % 47.3 (16.679) 96 45.6 (15.389) 94 44.8 (16.645) 64 47.3 (15.130) 69

P value 0.000* 0.028* 0.248 0.773

M (SD) n

SAS social anxiety scale

* P \ 0.05


123

Table 3 SAS subscales and gender and race variables

Gender Race

SASC-R (parent)

FNE F = 21.4 (9.384) 94

M = 18.8 (8.314) 47

P = 0.119

SAD-General F = 8.3 (3.224) 94

M = 7.0 (3.286) 46

P = 0.013*

SAD-New F = 15.8 (5.349) 94

M = 14.1 (5.253) 47

P = 0.104

SAS-A

FNE F = 20.6 (7.507) 53 CA = 21.9 (9.128) 38

M = 17.8 (9.720) 32 AA = 16.3 (6.964) 38

P = 0.038* P = 0.004*

SAD-General F = 7.9 (3.842) 53 CA = 8.8 (4.068) 38

M = 8.0 (4.223) 32 AA = 6.8 (3.338) 38

P = 0.766 P = 0.019*

SAD-New F = 16.5 (4.250) 53 CA = 17.0 (5.243) 38

M = 14.6 (6.020) 32 AA = 14.1 (4.764) 38

P = 0.021* P = 0.010*

M (SD) n

CA Caucasian, AA African American, F females, M males, SAS social anxiety scale, FNE fear of neg-ative evaluation, SAD-General social avoidance and distress (across many situations), SAD-New socialavoidance and distress (in new, unfamiliar situations)

* P \ 0.05

Table 4 SAS subscales and BMI category variable

9599 % More than 99 % P value

SASC-R

FNE 16.3 (8.126) 46 21.7 (9.781) 96 0.002*

SAD-General 7.3 (3.625) 46 9.2 (4.166) 95 0.006*

SAD-New 13.2 (5.778) 46 16.5 (5.433) 96 0.001*

SASC-R (parent)

FNE 18.5 (8.918) 45 21.6 (9.041) 94 0.048*

SAD-General 7.2 (2.959) 45 8.2 (3.435) 93 0.109

SAD-New 14.1 (5.282) 45 15.8 (5.386) 94 0.120

M (SD) n

SAS social anxiety scale, FNE fear of negative evaluation, SAD-General social avoidance and distress(across many situations), SAD-New social avoidance and distress (in new, unfamiliar situations)

* P \ 0.05


123

social anxiety has never been investigated in the pediatric obese population, and

these results suggest a strong relationship for elementary-age youth.

In contrast to results with children, results for adolescents did not show a

correlation between social anxiety and obesity nor was there greater risk of higher

social anxiety for the extremely obese. It is possible that in the pre-teen and

teenage years, social anxiety may be a more complicated construct. In fact, this

weakening relationship between social anxiety and obesity may be related to the

phenomenon of adolescenceincreased rates of peer rejection, social isolation,,

peer pressure, academic stress, and tensions with parents (La Greca and Lopez

1998; Siddique and DArcy 1984) which may exert increasing influence on social

anxiety rates in addition to concerns about physical appearance and the social

stigma of obesity. Our findings are curious and warrant further investigation.

It is important to highlight the fact that the present study includes only

correlational data. Therefore, it is unclear from this study whether social anxiety

worsens obesity (social anxiety leading to social withdrawal thereby reducing

physical activity, increasing food intake with greater time at home, etc). Equally

possible is the negative impact being obese has on social anxiety given the social

rejection and peer teasing that often occurs (Falkner et al. 2001; Strauss and Pollack

2003; Hayden-Wade et al. 2005). There may be a number of factors that mediate

this relationship as well, which were not addressed in the present study. Clearly

longitudinal data can assist in understanding the directional nature of the

relationship and the impact of development and the emergence of adolescence on

this relationship.

Another important result from this study is an understanding of the racial and

gender differences in social anxiety in an obese, pediatric clinical population. Social

anxiety in community samples with a full range of BMIs (not clinic-based, obese

samples) is higher for girls (Crick and Ladd 1993; La Greca and Stone 1993) and

Caucasians (Himle et al. 2009). In the present study, results consistently followed

similar trends though differences were not always significant. The tentative conclusion

is that similar racial and gender differences in social anxiety hold true for the obese,

pediatric clinical population as are present in community, normal-weight samples

though replication of these findings would further strengthen this conclusion.

These results have important clinical implications. For elementary-age patients,

social anxiety may be an important comorbid condition worthy of assessment and

treatment along with depression, low self-esteem, and other psychological issues.

Further, social anxiety may represent an important barrier for treatment of these

young obese patients. Research should investigate the role of social anxiety on

eating patterns (e.g., skipping meals in the cafeteria), physical activity behaviors

(e.g., avoiding physical activity options that are peer-based), motivation to change,

drop out rates from pediatric clinical programs, BMI change and/or successful

change toward eating or activity goals, and the development of comorbid health

conditions, as well as whether social anxiety reduces as BMI declines with

treatment. Similarly, research should also investigate the role of obesity on the

development of social anxiety (peer rejection, peer teasing, social isolation), as well

as documenting any changes in social anxiety with reduction in BMI due to

successful clinical treatment.


123

The present study has several limitations. The present study had insufficient sample

size to address racial groups other than Caucasian and African American. Hispanics,

for instance, may have cultural mores that impact the nature and prevalence of social

anxiety in obese individuals that warrant careful study. An additional limitation is the

clinic-based sample used in the present study and thus a restricted range in BMI on the

extreme end. The sample chosen was purposeful as it allowed for greater numbers of

obese and extremely obese patients and the study of social anxiety in these high-

risk patients. However, research has typically found a greater incidence of

psychological symptomatology and lower quality of life in clinic-based than

community-based samples (Williams et al. 2005), possibly due to heightened anxiety

from being brought to the clinic OR youth with higher anxiety are identified as

needing help and brought to clinic more often than non-anxious youth. Clearly, future

research should investigate social anxiety and obesity in a community sample.

Further, investigation of social anxiety in a sample that includes a full range of BMI

would be helpful in further understanding gender differences, racial differences, and

BMI differences in social anxiety. One additional limitation is that different versions

of the social anxiety measure were available for elementary versus adolescent youth.

This allowed for some comparisons, but it is not clear whether these differences are

based on age itself or the differences among the two measures. While they are widely

considered to be measuring the same underlying construct and simply contain

developmentally appropriate items, it is possible that measure differences rather than

age differences per se created the results in this study and caution should be used in

interpreting results.

Conclusion

Social anxiety and obesity are found to be positively correlated in this pediatric

clinic-based population. For elementary-age patients, extremely obese patients

are at greater risk than obese patients for social anxiety and its various

symptomsFNE, SAD-New, and SAD-General. Results for adolescents were less

clear. The relationship between social anxiety and obesity was discussed along with

clinical implications and future directions for research.

Acknowledgments Investigators would like to thank Annette La Greca, PhD, for her permission to usethe SAS and its versions for the purposes of this research. This study was funded by an intramural CUMG

grant.

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