Volume of subcortical brain regions in social anxiety disorder: mega-analytic results from 37 samples in the ENIGMA-Anxiety Working Group.

There is limited convergence in neuroimaging investigations into volumes of subcortical brain regions in social anxiety disorder (SAD). The inconsistent findings may arise from variations in methodological approaches across studies, including sample selection based on age and clinical characteristics. The ENIGMA-Anxiety Working Group initiated a global mega-analysis to determine whether differences in subcortical volumes can be detected in adults and adolescents with SAD relative to healthy controls. Volumetric data from 37 international samples with 1115 SAD patients and 2775 controls were obtained from ENIGMA-standardized protocols for image segmentation and quality assurance. Linear mixed-effects analyses were adjusted for comparisons across seven subcortical regions in each hemisphere using family-wise error (FWE)-correction. Mixed-effects d effect sizes were calculated. In the full sample, SAD patients showed smaller bilateral putamen volume than controls (left: d = -0.077, pFWE = 0.037; right: d = -0.104, pFWE = 0.001), and a significant interaction between SAD and age was found for the left putamen (r = -0.034, pFWE = 0.045). Smaller bilateral putamen volumes (left: d = -0.141, pFWE < 0.001; right: d = -0.158, pFWE < 0.001) and larger bilateral pallidum volumes (left: d = 0.129, pFWE = 0.006; right: d = 0.099, pFWE = 0.046) were detected in adult SAD patients relative to controls, but no volumetric differences were apparent in adolescent SAD patients relative to controls. Comorbid anxiety disorders and age of SAD onset were additional determinants of SAD-related volumetric differences in subcortical regions. To conclude, subtle volumetric alterations in subcortical regions in SAD were detected. Heterogeneity in age and clinical characteristics may partly explain inconsistencies in previous findings. The association between alterations in subcortical volumes and SAD illness progression deserves further investigation, especially from adolescence into adulthood.

Prepandemic Risk Factors of COVID-19-Related Concerns in Adolescents During the COVID-19 Pandemic.

To identify adolescents who may be at risk for adverse outcomes, we examined the extent of COVID-19-related concerns reported by adolescents and investigated which prepandemic risk and protective factors predicted these concerns during the COVID-19 pandemic. Dutch adolescents (N = 188; Mage  = 13.49, SD = .81) were assessed before the pandemic and at eight and ten months into the pandemic. Results demonstrated that adolescents' most frequently reported COVID-19-related concerns were about social activities and getting delayed in school. Adolescents that have specific vulnerabilities before the pandemic (i.e., higher stress, maladaptive coping, or internalizing problems) experience more concerns during the pandemic, stressing the importance of guiding and supporting these adolescents in order to prevent adverse developmental outcomes.

Can Schools Reduce Adolescent Psychological Stress? A Multilevel Meta-Analysis of the Effectiveness of School-Based Intervention Programs.

Increased levels of psychological stress during adolescence have been associated with a decline in academic performance, school dropout and increased risk of mental health problems. Intervening during this developmental period may prevent these problems. The school environment seems particularly suitable for interventions and over the past decade, various school-based stress reduction programs have been developed. The present study aims to evaluate the results of (quasi-)experimental studies on the effectiveness of school-based intervention programs targeting adolescent psychological stress and to investigate moderators of effectiveness. A three-level random effects meta-analytic model was conducted. The search resulted in the inclusion of k = 54 studies, reporting on analyses in 61 independent samples, yielding 123 effect sizes (N = 16,475 individuals). The results indicated a moderate overall effect on psychological stress. Yet, significant effects were only found in selected student samples. School-based intervention programs targeting selected adolescents have the potential to reduce psychological stress. Recommendations for practice, policy and future research are discussed.

Impaired neural habituation to neutral faces in families genetically enriched for social anxiety disorder.

BACKGROUND: Social anxiety disorder (SAD) is an incapacitating disorder running in families. Previous work associated social fearfulness with a failure to habituate, but the habituation response to neutral faces has, as of yet, not been investigated in patients with SAD and their family members concurrently. Here, we examined whether impaired habituation to neutral faces is a putative neurobiological endophenotype of SAD by using data from the multiplex and multigenerational Leiden Family Lab study on SAD. METHODS: Participants (n = 110; age, 9.2 - 61.5 years) performed a habituation paradigm involving neutral faces, as these are strong social stimuli with an ambiguous meaning. We used functional magnetic resonance imaging data to investigate whether brain activation related to habituation was associated with the level of social anxiety within the families. Furthermore, the heritability of the neural habituation response was estimated. RESULTS: Our data revealed a relationship between impaired habituation to neutral faces and social anxiety in the right hippocampus and right amygdala. In addition, our data indicated that this habituation response displayed moderate - to-moderately high heritability in the right hippocampus. CONCLUSION: The present results provide support for altered habituation as a candidate SAD endophenotype; impaired neural habitation cosegregrated with the disorder within families and was heritable. These findings shed light on the genetic susceptibility to SAD.

The effectiveness of school-based skills-training programs promoting mental health in adolescents: a study protocol for a randomized controlled study.

BACKGROUND: Adolescence is a period of elevated stress sensitivity, which places adolescents at increased risk of developing mental health problems such as burnout, depression, anxiety, and externalizing problems. Early intervention of psychological needs and low-threshold care addressing such needs may prevent this dysfunctional development. Schools may provide an important environment to identify and address psychological needs. The aim of this protocol is to describe the design of a study aiming to evaluate the effectiveness of low-threshold school-based skills-training programs promoting the mental health of adolescents and to examine moderators of the effectiveness. METHODS: A Randomized Controlled Trial will be conducted to examine the effectiveness of two school-based skills-training programs aiming to promote mental health by improving either skills to deal with performance anxiety or social skills. A multi-informant (i.e., students, parents, and trainers) and multi-method (i.e., questionnaires and physiological measurements) approach will be used to assess program targets (skills to deal with performance anxiety or social skills), direct program outcomes (performance or social anxiety) and mental health outcomes (i.e., stress, internalizing and externalizing problems, self-esteem and well-being), as well as specific moderators (i.e., student, parent and program characteristics, social support, perfectionism, stressful life events, perceived parental pressure, positive parenting behavior, treatment alliance and program integrity). DISCUSSION: The current study will provide information on the effectiveness of school-based skills-training programs. It is of crucial importance that the school environment can provide students with effective, low-threshold intervention programs to promote adolescents' daily functioning and well-being and prevent the emergence of mental health problems that negatively affect school performance. TRIAL REGISTRATION: Dutch Trial Register number NL7438 . Registered 12 December 2018.

The temporal association between emotional clarity and depression symptoms in adolescents.

INTRODUCTION: Low emotional clarity, that is, problems in understanding and identifying one's own emotions, is generally seen as related to depression. Most empirical studies on this topic focused on the link between low levels of emotional clarity predicting depression problems, fewer studies on depression symptoms predicting low emotional clarity. All studies were restricted to unidirectional associations. The present study evaluated the reciprocal associations between emotional clarity and depression symptoms. Additionally, we tested the role of rumination as a mediator of the links between depression symptoms and emotional clarity. METHODS: For the main analyses, data of 230 Dutch participants (Mage = 13.40, SD = 2.24; 48% girls) over three time points of a 5-year longitudinal study were used. Depression symptoms, emotional clarity, and rumination were self-reported. Cross-lagged panel analysis was used to test a model of reciprocal associations between depression symptoms and emotional clarity against models of unidirectional associations. The role of rumination as mediator and sex as moderator in the links between depression symptoms and emotional clarity were evaluated in separate analyses on a subsample (n = 151). RESULTS & CONCLUSIONS: A model of reciprocal associations where depression symptoms and low emotional clarity predict relatively high scores of the other over time offered a good representation of the data. Rumination mediated the link between depression symptoms predicting prospective emotional clarity for both sexes. These findings suggest a vicious cycle between depression symptoms and low emotional clarity. We discuss possible implications of these results for the treatment of depression in youth.

The Role of Performance Quality in Adolescents' Self-Evaluation and Rumination after a Speech: Is it Contingent on Social Anxiety Level?

BACKGROUND: Cognitive behavioural therapy (CBT) has relatively poor outcomes for youth with social anxiety, possibly because broad-based CBT is not tailored to their specific needs. Treatment of social anxiety in youth may need to pay more attention to negative social cognitions that are considered a key factor in social anxiety development and maintenance. AIMS: The aim of the present study was to learn more about the role of performance quality in adolescents' cognitions about their social performance and, in particular, the moderating role social anxiety plays in the relationship between performance quality and self-cognitions. METHOD: A community sample of 229 participants, aged 11 to 18 years, gave a speech and filled in questionnaires addressing social anxiety, depression, expected and self-evaluated performance, and post-event rumination. Independent observers rated the quality of the speech. The data were analysed using moderated mediation analysis. RESULTS: Performance quality mediated the link between expected and self-evaluated performance in adolescents with low and medium levels of social anxiety. For adolescents with high levels of social anxiety, only a direct link between expected and self-evaluated performance was found. Their self-evaluation was not related to the quality of their performance. Performance quality also mediated the link between expected performance and rumination, but social anxiety did not moderate this mediation effect. CONCLUSIONS: Results suggest that a good performance does not help socially anxious adolescents to replace their negative self-evaluations with more realistic ones. Specific cognitive intervention strategies should be tailored to the needs of socially anxious adolescents who perform well.

Frontal delta-beta cross-frequency coupling in high and low social anxiety: An index of stress regulation?

Cross-frequency coupling (CFC) between frontal delta (1-4 Hz) and beta (14-30 Hz) oscillations has been suggested as a candidate neural correlate of social anxiety disorder, a disorder characterized by fear and avoidance of social and performance situations. Prior studies have used amplitude-amplitude correlation (AAC) as a CFC measure and hypothesized it as a candidate neural mechanism of affective control. However, using this metric has yielded inconsistent results regarding the direction of CFC, and the functional significance of coupling strength is uncertain. To offer a better understanding of CFC in social anxiety, we compared frontal delta-beta AAC with phase-amplitude coupling (PAC) - a mechanism for information transfer through neural circuits. Twenty high socially anxious (HSA) and 32 low socially anxious (LSA) female undergraduates participated in a social performance task (SPT). Delta-beta PAC and AAC were estimated during the resting state, as well as the anticipation and recovery conditions. Results showed significantly more AAC in LSA than HSA participants during early anticipation, as well as significant values during all conditions in LSA participants only. PAC did not distinguish between LSA and HSA participants, and instead was found to correlate with state nervousness during early anticipation, but in LSA participants only. Together, these findings are interpreted to suggest that delta-beta AAC is a plausible neurobiological index of adaptive stress regulation and can distinguish between trait high and low social anxiety during stress, while delta-beta PAC might be sensitive enough to reflect mild state anxiety in LSA participants.

Adolescents' increasing stress response to social evaluation: pubertal effects on cortisol and alpha-amylase during public speaking.

Stress responses to social evaluation are thought to increase during adolescence, which may be due to pubertal maturation. However, empirical evidence is scarce. This study is the first to investigate the relation between pubertal development and biological responses to a social-evaluative stressor longitudinally. Participants performed the Leiden Public Speaking Task twice, with a 2-year interval (N = 217; age at Time 1: 8-17 years). The results support an increase in sensitivity to social evaluation during adolescence. The overall cortisol and alpha-amylase responses increased-both between and within participants-and were more strongly related to self-reported pubertal development than to age. The cortisol response shifted from speech delivery toward anticipation. The alpha-amylase response increased in both phases.

The relation between social anxiety and audience perception: examining Clark and Wells' (1995) model among adolescents.

BACKGROUND: Clark and Wells' cognitive model of social anxiety proposes that socially anxious individuals have negative expectations of performance prior to a social event, focus their attention predominantly on themselves and on their negative self-evaluations during an event, and use this negative self-processing to infer that other people are judging them harshly. AIMS: The present study tested these propositions. METHOD: The study used a community sample of 161 adolescents aged 14-18 years. The participants gave a speech in front of a pre-recorded audience acting neutrally, and participants were aware that the projected audience was pre-recorded. RESULTS: As expected, participants with higher levels of social anxiety had more negative performance expectations, higher self-focused attention, and more negative perceptions of the audience. Negative performance expectations and self-focused attention were found to mediate the relationship between social anxiety and audience perception. CONCLUSIONS: The findings support Clark and Wells' cognitive model of social anxiety, which poses that socially anxious individuals have distorted perceptions of the responses of other people because their perceptions are coloured by their negative thoughts and feelings.

Does gaze anxiety predict actual gaze avoidance and is it more informative than social anxiety?

BACKGROUND AND OBJECTIVES: In recent years eye-tracking studies have provided converging evidence that socially anxious individuals avoid looking at other people's faces in social situations. In addition to these objective measures, the Gaze Anxiety Rating Scale (GARS) has increasingly been used as a self-report measure of gaze avoidance. However, extant results concerning its predictive validity were inconsistent. Moreover, no study has considered social anxiety and gaze anxiety together to examine their relative contributions to actual gaze behavior. METHODS: To address these two questions, eye-tracking data collected from 81 female students during the initial 6 min of a face-to-face conversation with a female confederate were analyzed. Gaze anxiety and social anxiety were measured via the GARS and the Leibowitz Social Anxiety Scale. RESULTS: The results revealed that gaze anxiety was associated with reduced face gaze while speaking. Social anxiety was not only associated with decreased face gaze during speaking, but also across the initial conversation. Moreover, there was no evidence that gaze anxiety made an additional contribution to social anxiety in predicting face gaze behavior. LIMITATIONS: This study examined face gaze instead of eye gaze. Additionally, the self-report data were not collected on the same day as the eye-tracking data. CONCLUSIONS: The findings indicate that, in a community sample, gaze anxiety does predict actual gaze behavior during a face-to-face initial encounter, but social anxiety is a stronger predictor.

Cognitive mediation of cognitive-behavioural therapy outcomes for anxiety-based school refusal.

BACKGROUND: Cognitive-behavioural therapy (CBT) has proven to be effective for anxiety-based school refusal, but it is still unknown how CBT for school refusal works, or through which mechanisms. AIMS: Innovative statistical approaches for analyzing small uncontrolled samples were used to investigate the role of self-efficacy in mediating CBT outcomes for anxiety-based school refusal. METHOD: Participants were 19 adolescents (12 to 17 years) who completed a manual-based cognitive-behavioural treatment. Primary outcomes (school attendance; school-related fear; anxiety) and secondary outcomes (depression; internalizing problems) were assessed at post-treatment and 2-month follow-up. RESULTS: Post-treatment increases in school attendance and decreases in fear about attending school the next day were found to be mediated by self-efficacy. Mediating effects were not observed at 2-month follow-up. CONCLUSIONS: These findings provide partial support for the role of self-efficacy in mediating the outcome of CBT for school refusal. They contribute to a small body of literature suggesting that cognitive change enhances CBT outcomes for young people with internalizing problems. Regarding methodology, the product of coefficient test appears to be a valuable way to study mediation in outcome studies involving small samples.

Associations between Autonomic and Endocrine Reactivity to Stress in Adolescence: Related to the Development of Anxiety?

Internalizing disorders in adolescence have been associated with disturbances in autonomic and endocrine functioning. Because the prefrontal cortex and the limbic system play a central role in regulating both the autonomic and the endocrine systems, their joint functioning is hypothesized to provide information about the potential development of internalizing symptoms throughout adolescence, notably in the preclinical stage. This hypothesis was tested in a sample of 198 adolescents from the general population. Heart rate variability (HRV) and skin conductance levels (SCLs) were measured before, during, and after a public speaking task. These autonomic parameters were associated with cortisol response to the task in the complete sample as well as in low- and high-anxiety adolescents separately. Self-reported social anxiety, low HRV, and high SCL recovery values were predictive of cortisol response. Importantly, in low-anxiety adolescents, only HRV during the task predicted the cortisol response, whereas, in their highly anxious peers, both HRV and SCL were strongly associated with this response. In the latter finding, age was a prominent factor. Additional analyses supported the idea that the interaction of autonomic and endocrine reactivity is subject to natural development. These findings provide evidence that adolescence might be a period of highly interactive emotional-neurobiological development, particularly with respect to the development of stress management skills.

Social anxiety is related to reduced face gaze during a naturalistic social interaction.

BACKGROUND: Social anxiety has long been related to reduced eye contact, and this feature is seen as a causal and a maintaining factor of social anxiety disorder. The present research adds to the literature by investigating the relationship between social anxiety and visual avoidance of faces in a reciprocal face-to-face conversation, while taking into account two aspects of conversations as potential moderating factors: conversational role and level of intimacy. METHOD: Eighty-five female students (17-25 years) completed the Leibowitz Social Anxiety Scale and had a face-to-face getting-acquainted conversation with a female confederate. We alternated conversational role (talking versus listening) and manipulated intimacy of the topics (low versus high). Participants' gaze behavior was registered with Tobii eye-tracking glasses. Three dependent measures were extracted regarding fixations on the face of the confederate: total duration, proportion of fixations, and mean duration. RESULTS: The results revealed that higher levels of social anxiety were associated with reduced face gaze on all three measures. The relation with total fixation duration was stronger for low intimate topics. The relation with mean fixation duration was stronger during listening than during speaking. CONCLUSION: The results highlight the importance of studying gaze behavior in a naturalistic social interaction.

The Effectiveness of School-Based Skills-Training Programs Reducing Performance or Social Anxiety: Two Randomized Controlled Trials.

Background: Given that high levels of stress during adolescence are associated with negative consequences, it is important that adolescents with psychological needs are supported at an early stage, for instance with interventions at school. However, knowledge about the potential of school-based programs targeting adolescents with psychological needs, aimed at reducing school or social stress, is lacking. Objective: The current study aimed to investigate the effectiveness of two targeted school-based skills-training programs, addressing either skills to deal with performance anxiety or social skills. Methods: Two randomized controlled trials were performed with participants who self-selected to one of the programs. The sample comprised of N = 361 adolescents (M age = 13.99 years, SD = 0.83) from various educational levels and ethnic identity backgrounds. The performance anxiety program included N = 196 participants (N = 95 in the experimental group), while the social skills program included N = 165 participants (N = 86 in the experimental group). MANCOVA's were performed. Results: The performance anxiety program had a small effect on reducing adolescents' test anxiety. Furthermore, for adolescents who attended more than half of the sessions, the program had small effects on reducing test anxiety and fear of failure. The program did not improve adolescents' coping skills or mental health. The social skills program was not effective in improving social skills, social anxiety, and mental health. Conclusions: A relatively short, targeted program addressing skills to deal with performance anxiety can have the potential to reduce adolescents' performance anxiety. Trial registration: International Clinical Trials Registry Platform (Netherlands Trial Register, number NTR7680). Registered 12 December 2018. Study protocol van Loon et al., (2019). Supplementary Information: The online version contains supplementary material available at 10.1007/s10566-023-09736-x.

The role of cognition in school refusal: an investigation of automatic thoughts and cognitive errors.

AIMS: The purpose of this study was to investigate the cognitions of anxious school refusers. The cognitive constructs under investigation included negative cognition commonly linked to youth anxiety (i.e. negative automatic thoughts and cognitive errors) and positive automatic thoughts. METHOD: The cognition of school refusers (n = 50) and youth from a community sample (n = 181) was assessed with the Children's Automatic Thoughts Scale-Negative/Positive and the Children's Negative Cognitive Error Questionnaire-Revised. RESULTS: When controlling for anxiety, school refusers were found to report more negative automatic thoughts concerning personal failure, fewer negative automatic thoughts concerning hostility, and fewer positive automatic thoughts. Negative automatic thoughts concerning personal failure and hostility, and the negative cognitive error of overgeneralizing were found to independently predict school refusal. CONCLUSIONS: The findings underscore the importance of further researching the role of cognition in the development, maintenance, and treatment of anxiety-based school refusal.

Self-concept and ego development in deaf adolescents: a comparative study.

Self-concept and ego development, two intertwined aspects of self-indicating well-being and social-cognitive maturation, respectively, were examined in a representative sample of deaf adolescents of normal intelligence (N = 68), using translated and adapted versions of Harter's (1988, Manual for the self-perception profile for adolescents. Denver, CO: University of Denver) multidimensional measure of self-concept and Loevinger's (1998, Technical foundations for measuring ego development. Mahwah, NJ: Lawrence Erlbaum) measure of ego development. Compared to hearing norm groups, deaf adolescents showed lower levels of self-perceived social acceptance, close friendships and ego development and higher physical appearance. Hierarchical multiple regression analyses controlling for sociodemographic variables showed positive associations of global self-worth with support for signing during childhood and quality of parent-child communication and of ego development with attending a regular school. Cluster analysis identified three social competence profiles: uniformly low competence, uniformly high competence, and low social acceptance with high physical appearance. Cluster membership was associated with school type, ego development, and (past) neurological disorder. The results are discussed in reference to interventions aimed at the well-being of deaf youth.

Concurrent and Prospective Associations Between Social Anxiety and Responses to Stress in Adolescence.

Several studies have investigated the relationship between adolescents' responses to stress and general anxiety and depression, but only few studies addressed the relationship between responses to stress and social anxiety. The current three-wave longitudinal study, that covered a period of 5 years with a time interval of on average two years between waves, examined concurrent as well as prospective relations between adolescents' self-reported stress responses, including coping responses, and self-perceived social anxiety. Both the predictive power of social anxiety for different stress responses and, reversely, of stress responses for social anxiety were evaluated. Participants were 331 youth (170 boys) aged 9 to 17 years old at Wave 1. Self-report questionnaires were used to measure social anxiety, responses to social stress, and depressive symptoms. Results showed significant concurrent relations between social anxiety and maladaptive stress responses. Moreover, the study yielded evidence for social anxiety predicting stress responses across time as well as stress responses predicting social anxiety, although evidence for the former link is stronger. The findings suggest that a relative lack of adaptive stress responses may heighten social anxiety and social anxiety in turn may trigger maladaptive as well as adaptive responses to social problems. The relevance of these findings for social anxiety prevention and intervention purposes are discussed.

Trajectories of adolescent perceived stress and symptoms of depression and anxiety during the COVID-19 pandemic.

Adolescents might be particularly affected by the drastic social changes as a consequence of the COVID-19 pandemic, given the increased stress-sensitivity and importance of the social environment in this developmental phase. In order to examine heterogeneity during the pandemic, the current study aimed to identify whether subgroups of adolescents could be distinguished based on their levels of perceived stress and symptoms of depression and anxiety. In addition, we examined which prepandemic factors predicted these trajectories. Adolescents were assessed before the pandemic (N = 188, Mage = 13.49, SD = 0.81) and at three timepoints during the pandemic (i.e., eight, ten, and 15 months after the start of the pandemic in the Netherlands). Results showed no support for distinct trajectories of perceived stress, adolescents experienced stable moderate levels during the pandemic. In contrast, results showed three trajectories for depression and anxiety. The majority of adolescents reported stable low or moderate levels and one small subgroup reported high levels of depression and anxiety that decreased during the pandemic. Certain prepandemic factors predicted higher initial levels of stress and symptoms of depression and anxiety during the pandemic. To support adolescents with prepandemic vulnerabilities, strategies could be developed, for instance enhancing adolescents' social support.

The effects of school-based interventions on physiological stress in adolescents: A meta-analysis.

Chronic stress is associated with dysregulations in the physiological stress system, resulting in diverse negative developmental outcomes. Since adolescence is a period characterized by increased stress-sensitivity, and schools are an important environment for the developing adolescent, school-based interventions promoting psychosocial functioning are of particular interest to prevent adverse outcomes. The present study therefore aimed to investigate the effectiveness of such interventions on hypothalamic pituitary adrenal-axis (i.e., cortisol) and cardiovascular (i.e., blood pressure [BP] and heart rate [HR]/heart rate variability [HRV]) parameters of stress in adolescents, and examined moderators of effectiveness. The search resulted in the inclusion of k = 9 studies for cortisol, k = 16 studies for BP, and k = 20 studies for HR/HRV. The results indicated a significant small overall effect on reducing BP, but no significant effect for HR/HRV. For cortisol, large methodological variation in the few primary studies did not allow for quantitative analyses, but a qualitative review demonstrated inconsistent results. For BP and HR/HRV, larger effects were observed for intervention programs with a mindfulness and/or meditation component, for interventions without a cognitive-behavioural component and for interventions with a higher intensity. Providing adolescents with techniques to improve indicators of physiological stress may prevent emerging mental health problems.