Social anxiety in late adolescence: The importance of early childhood language impairment

Anxiety Disorders 20 (2006) 915–930

Social anxiety in late adolescence: The importance of early childhood language impairment Sabrina C. Voci, Joseph H. Beitchman *, E.B. Brownlie, Beth Wilson Centre for Addiction and Mental Health, Toronto, Canada Received 31 May 2005; received in revised form 14 December 2005; accepted 21 January 2006

Abstract Social phobia is a common, highly comorbid, poorly understood and relatively understudied condition. The origins of social phobia share familial and biological features common with those of other anxiety disorders, but seldom have precursors of the fear of social communication been examined as a possible pathway to social phobia. Here we examine the role of early childhood language impairment as an antecedent to social phobia in late adolescence. Participants in a prospective longitudinal community study identified as having language impairment at age 5 and matched controls were followed up at age 19. Compared to normal language controls, individuals with a history of early language impairment had 2.7 times the odds of having a social phobia by age 19. Results suggest that early language impairment represents a distinct pathway to late adolescent social phobia. # 2006 Elsevier Ltd. All rights reserved. Keywords: Language impairment; Social phobia; Comorbidity; Language; Longitudinal study; Predictors

* Corresponding author at: Child, Youth and Family Program, Centre for Addiction and Mental Health, Clarke Site, 250 College Street, Toronto, Ont., Canada M5T 1R8. Tel.: +1 416 979 6813; fax: +1 416 979 6820. E-mail address: [email protected] (J.H. Beitchman). 0887-6185/$ – see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2006.01.007

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1. Introduction Epidemiological studies have identified social phobia as a common disorder among children, adolescents, and adults, with general population estimates of lifetime prevalence ranging from 1% to 13% (Benjamin, Costello, & Warren, 1990; Furmark, 2002; Kessler et al., 1994; Verhulst, Van der Ende, Ferdinand, & Kasius, 1997). Individuals with social phobia are at risk for considerable morbidity and impairment. Comorbidity includes a 3.5 times increased risk for depression with associated greater severity and persistence of depression (Stein et al., 2001). Social phobia is also associated with other anxiety disorders, substance use disorders and smoking and nicotine dependence (Carrigan & Randall, 2003; Kessler et al., 1994; Sonntag, Wittchen, Ho¨fler, Kessler, & Stein, 2000). Significant impairments in various domains include poor academic performance and early school drop out (Beidel, 1991; Last, Hersen, Kazdin, Orvaschel, & Perrin, 1991; Stein, Torgrud, & Walker, 2000). Distress and avoidance of social interaction contribute to impairment in social functioning and an increased sense of social isolation. Socially anxious youth report lower levels of perceived acceptance and support from peers (La Greca & Lopez, 1998) and demonstrate social skill deficits relative to non-anxious youth (Spence, Donovan, & Brechman-Toussaint, 1999). Despite the commonality of social phobia and an increased awareness of the seriousness of this disorder, the etiology of social phobia is poorly understood. In part, clarifying the development of social phobia may depend on our understanding of the nature of the disorder. For instance, social phobia viewed as a subtype of anxiety disorder would be expected to share similar roots and course with other anxiety disorders. However, evidence suggests that a cognitive bias leading to fear of social communication may be unique to social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997; Wilson & Rapee, 2005). Specifically, individuals with social anxiety in comparison to non-anxious individuals may overestimate the likelihood that negative outcomes and negative consequences will occur in social situations (Foa, Franklin, Perry, & Herbert, 1996; Gilboa-Schechtman, Franklin, & Foa, 2000). Therefore, in addition to common developmental pathways shared with other anxiety disorders, there may be unique developmental pathways to social phobia. Social anxiety arising through maladaptive interpretation of social events would seem to be, at least in part, associated with real or perceived difficulties in social interaction. Surprisingly, the issue of difficulties in interpersonal communication, such as would occur among those with language impairments, has been virtually neglected in the social anxiety literature. Children with language impairment exhibit communication deficits that may put them at an increased risk of developing anxiety around social interactions. A growing body of evidence has revealed that children with language impairment have numerous difficulties in their interactions with peers. Often, these children are not active participants in social interactions in school. Language impaired children have

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been reported to interact with fewer peers (Fujiki, Brinton, & Todd, 1996), are perceived as less desirable playmates by other children (Gertner, Rice, & Hadley, 1994), and are rated by teachers as having poorer social skills (Fujiki et al., 1996). To our knowledge, no one has examined whether early language impairment is a risk factor for the development of social phobia. If early language impairment is identified as a risk for development of social phobia, children with these impairments would represent an important target for preventative efforts. Currently, the majority of individuals with social phobia go unrecognized by professionals, including school personnel and primary care physicians (Herbert, Crittenden, & Dalrymple, 2004; Sheeran & Zimmerman, 2002; Weiller, Bisserbe, Boyer, Lepine, & Lecrubier, 1996). Many professionals are unfamiliar with the disorder (Weiller et al., 1996) and may not appreciate its seriousness. Herbert et al. (2004) found teachers not only demonstrated overall lack of knowledge about social phobia, but also endorsed several misconceptions about social phobia such as that children outgrow social anxiety by puberty. Individuals with social phobia often do not seek treatment and report barriers to treatment such as an increased likelihood of being afraid of what others might think or say of seeking treatment (Olfson et al., 2000). A better understanding of the etiology, maintenance and course of social phobia could be used to educate teachers and other professionals to the early signs of social phobia and inform early intervention programs for youth at risk. The present paper examines whether early language impairment presents a risk for the development of social anxiety in late adolescence using data from a 14year prospective longitudinal study of a cohort of speech and language impaired children and matched controls, originally part of a one-in-three random representative survey in Ottawa, Ontario, Canada. We examine the relation between a history of early language impairment, assessed at age 5, and prevalence of social phobia and social fears at age 19. We also report results of exploratory analyses to investigate whether there are patterns of comorbidities or predictors of social phobia that differ according to age 5 language status (language impaired versus controls).

2. Method 2.1. Sample and design 2.1.1. Sample and design of initial study (age 5) In 1982, a one-in-three random sample of all 5-year-old English-speaking children in the Ottawa-Carleton region of Ontario, Canada (n = 1655) participated in an initial speech and language screening procedure. The response rate for the initial screening exceeded 94%. Children performing below specific cut points on the screening measures were selected for comprehensive speech and language

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assessment by qualified speech pathologists. In all, 142 children (90 boys, 52 girls) identified as speech and/or language impaired agreed to participate in the longitudinal study. Of these 142 speech and language impaired children, 39 had speech impairments only and 103 had language impairments (with and without speech impairments). A control group of 142 children, matched for age and gender and taken from the same classroom or school, was selected from the group of children who passed the speech and language screening. Detailed developmental/medical, cognitive, psychiatric, family/marital, and demographic data were collected through direct assessment, teacher and parent report, child self-report, and psychiatric interview. For complete details regarding the original study, see Beitchman, Nair, Clegg, and Patel (1986) and Beitchman, Nair, Clegg, Ferguson, and Patel (1986). 2.1.2. Sample at second follow-up (age 19) Of the 284 participants from the initial study, 258 (90.8%) agreed to take part in the second follow-up study. There was a loss to follow-up of 6.4%, a refusal rate of 2.1%, and two participants had died (0.7%). Of the 258 individuals who participated in the second follow-up study, 240 (84.5%) have data on social fears from the psychiatric interview. Due to the small number of participants from the speech impaired only group with social phobia, this paper reports on the language impaired (n = 76 [73.8%]) and control (n = 126 [88.7%]) groups only. The age range of the 202 participants (126 men, 76 women) at second followup was 18–20 years (M = 18.4, S.D. = .51). Socioeconomic ratings (Blishen, Carroll, & Moore, 1987) ranged from a low of 23.3 to a high of 79.2 (M = 49.4, S.D. = 14.4). Blishen and colleagues established occupational ratings based on the educational attainment, prestige and income level associated with various jobs. For families without paid employment, we assigned the lowest rating. For two-income families, we used the highest score of the two in analyses. The vast majority of participants were Caucasian. 2.1.3. Attrition Forty-three individuals who participated in the 1982 study either did not participate in the second follow-up study (n = 26) or did not have social fear data (n = 17). These participants, referred to as the attrition group, were compared on a number of age 5 measures to the 202 participants who did have social fear data, referred to as the follow-up group. The attrition group had lower IQ scores, were more likely to belong to the language impaired group, and were more likely to live in a single parent household compared with the follow-up group. These differences were significant at the 0.05 level. Groups did not differ statistically by gender or socioeconomic status, or by mother- or teacher-rated behavior problem scores. Thus, our sample may have been higher functioning than would have been the case with full, continued participation from the initial study.

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2.2. Measures 2.2.1. Age 5 language impairment During the initial 1982 study, language impairment was considered present if one or more of the following criteria were met: (i) Test of Language Development (TOLD; Newcomer & Hammill, 1977), Spoken Language Quotient, 1 S.D. below the mean; (ii) any TOLD language subtest (not including Word Articulation and Word Discrimination), 2 S.D. below the mean; (iii) Peabody Picture Vocabulary Test-Revised (PPVT-R; Dunn & Dunn, 1981), 1 S.D. below the mean; (iv) Goldman–Fristoe–Woodcock Auditory Memory Tests (Goldman, Fristoe, & Woodcock, 1974), 1 S.D. below the mean on both content and sequence subtests. The TOLD is a battery of subtests measuring expressive and receptive dimensions of semantics, syntax, and phonology, designed for children aged 4:0– 8:11. In the standardization sample, the TOLD correlated substantially with several other language tests and distinguished language impaired children from children with normally developing language. Five-day test re-test reliability coefficients for all subtests exceeded 0.80. The PPVT-R is a test of single word receptive vocabulary. Participants indicate which of four pictures correspond to each auditorily presented word. The correlation between alternate forms of the test administered to five- and six-year-olds within 14 days was 0.77. Split-half reliability coefficients for the five- and six-year age groups ranged from 0.73 to 0.84. The Goldman–Fristoe–Woodcock Auditory Memory Tests are among 12 tests in the Goldman–Fristoe–Woodcock Auditory Skills Battery. Two auditory memory tests were used to define language impairment: a test of short term memory for content, and a test of short term memory for sequence. Internal consistency for the 12 tests ranged from 0.78 to 0.97 for the youngest (age 3–8) normative sample. Test performance distinguished children with speech and language problems from children with normally developing language. In this report, language status is defined as follows: (1) language impaired (language impairment with or without speech impairment) and (2) control (no speech or language impairment). 2.2.2. Age 19 psychiatric status Age 19 psychiatric status was assessed using (1) the University of Michigan version of the Composite International Diagnostic Interview (UM-CIDI; Kessler et al., 1994), a modification of the Composite International Diagnostic Interview (World Health Organization, 1990) designed to improve its efficiency and assessment capability, and (2) the Global Assessment of Functioning scale (GAF; American Psychiatric Association, 1994). The UM-CIDI is a highly structured psychiatric interview designed for administration by trained lay interviewers in epidemiological studies. Trained interviewers administered the UM-CIDI with each study participant in private, face-to-face interviews. Using the UM-CIDI, the following psychiatric disorders based on DSM-III-R (American Psychiatric Association, 1987) criteria were assessed: affective

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disorders (major depression [single episode or recurrent], dysthymia, bipolar disorder [manic, depressed, mixed subtype, or not otherwise specified]); anxiety disorders (social phobia, simple phobia, agoraphobia with and without a history of panic disorder, panic disorder with and without agoraphobia, generalized anxiety disorder); substance use disorders (alcohol, opioid, sedative, cocaine, cannabis, amphetamine, hallucinogen, phencyclidine, inhalant, psychoactive substance not otherwise specified [dependence or abuse]); eating disorders (anorexia nervosa, bulimia); and schizophrenia. The UM-CIDI was also used to assess antisocial personality disorder consistent with DSM-IV (American Psychiatric Association, 1994) criteria. In addition to meeting DSM-III-R criteria, we applied an extra functioning criterion. To meet diagnosis with a disorder, participants had to receive a GAF score of less than 70, reflecting at least mild functional impairment. The World Health Organization conducted field trials of the CIDI demonstrating good inter-rater reliability, test-retest reliability, and validity of all diagnoses excluding acute psychotic disorder (see Kessler et al., 1994, for details). In a review article, Wittchen (1994) reported that the CIDI is a widely used and reliable instrument with good to excellent k coefficients for most disorders. The three-day test-retest reliability k for the social phobia diagnosis was 0.64, and the inter-rater reliability k was 0.97, based on three independent field trials (Wittchen, 1994). Further details regarding the UM-CIDI and diagnostic criteria are described in Beitchman et al. (2001). The UM-CIDI collects information about onset and recency of each disorder. Unless otherwise specified, we report on 1-year rather than lifetime psychiatric disorders, where participants experienced symptoms within the 1-year period preceding the interview. The following psychiatric disorder categories are used in this paper: (1) social phobia; (2) other anxiety disorder (includes all anxiety disorders listed above except social phobia); and (3) other psychiatric disorder (includes all affective disorders, substance use disorders, eating disorders, schizophrenia, and antisocial personality disorder; does not include other anxiety disorders or social phobia). 2.2.3. Cigarette smoking Cigarette smoking status was derived from a participant interview during which participants were asked if they smoked cigarettes and were questioned regarding onset. 2.2.4. Treatment for social phobia The UM-CIDI includes the following questions regarding treatment of social phobia: (1) Did you ever tell a doctor other than a psychiatrist about your unreasonably strong fear(s)? (2) Did you ever tell any other professional about (it/ them)? (3) Did you take medication more than once because of (this/these) fear(s)? In addition, during the interview participants were asked if they were currently receiving ‘‘counselling, therapy, or other treatment for any personal problems (they) were currently having, or problems concerning (their) feelings or behavior.’’

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2.2.5. Age 5 predictors of social phobia To determine which psychosocial factors assessed at age 5 predict social phobia in late adolescence, the following variables were included in analyses: social competency scores assessed through maternal Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983) ratings; maternal psychiatric symptomatology assessed using the Brief Symptom Inventory (BSI; Derogatis & Spencer, 1982), General Symptom Index and Phobic Anxiety subscale; birth order (firstborn or not); and family socioeconomic status.

3. Results 3.1. Prevalence and age of onset of social phobia Table 1 presents the prevalence of current and lifetime social phobia and age of onset of current social phobia. Grouped according to age 5 language status, 16.0% of the language impaired group and 6.5% of the controls met criteria at age 19 for social phobia occurring within the past year (x2 (1) = 4.43, OR = 2.76, 95% CI = 1.07–7.11). The lifetime prevalence of social phobia was 22.7% among the language impaired group, and 11.3% among controls (x2 (1) = 4.44, OR = 2.30, 95% CI = 1.06–5.00). Severity of language impairment (based on TOLD composite scores) among the language impaired group was not related to the prevalence of social phobia. There were no significant gender differences in the lifetime and current rates of social phobia among the entire sample and when examined separately by age five language group. Language impaired and control groups did not differ significantly in age of onset of current social phobia. Mean age of onset for the entire sample was 11.60 years (S.D. = 3.25 years). 3.2. Comorbidity Participants with social phobia, irrespective of language group, were significantly more likely to be diagnosed with at least one other psychiatric Table 1 Rates of social phobia grouped according to age 5 language status a

Lifetime social phobia , n (%) Current social phobiab, n (%) Age of onset Gender (% female)

LI

Control

p

17 (22.7) 12 (16.0) 12.50 (3.34) 50.0

14 (11.3) 8 (6.5) 10.25 (2.77) 37.5

<0.05 <0.05 n.s. n.s.

Note: Unless otherwise indicated, means and standard deviations are presented. LI: language impaired. a x2 (1) = 4.44, OR = 2.30, 95% CI = 1.06–5.00. b x2 (1) = 4.43, OR = 2.76, 95% CI = 1.07–7.11.

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Table 2 Comorbidity of age 19 social phobia Age 19 diagnostic category

Social phobia (%)

No social phobia (%)

x2

OR

Other psychiatric disorder Major depression Substance use disorder

80.0 45.0 40.0

18.1 6.8 10.6

23.94*** 20.00*** 11.14**

18.13 11.18 5.61

5.68–57.85 3.88–32.20 2.04–15.46

Control group only Other anxiety disorder

62.5

1.7

19.82***

94.14

12.73–696.15

CI

Note: Subjects with social phobia were almost four times more likely to report they smoked cigarettes, x2 (1) = 8.00, p < 0.01, OR = 4.26, CI = 1.56–11.63. OR: odds ratio; CI: 95% confidence interval. ** p < 0.01. *** p < 0.001.

disorder, and were significantly more likely to report they smoked cigarettes than participants without social phobia (see Table 2). A significant interaction between age 5 language status and the diagnosis of a comorbid anxiety disorder was found (x2 (1) = 6.39, p < 0.05), such that control participants diagnosed with social phobia were more likely to meet criteria for at least one other anxiety disorder compared to language impaired participants diagnosed with social phobia. The most frequent comorbid psychiatric disorder was major depression, with individuals with social phobia more than 11 times more likely to be diagnosed with major depression compared to individuals without social phobia. Only two participants with social phobia did not have any other psychiatric disorder. Among the 18 participants with current social phobia and an additional disorder, 7 (39%) reported onset of social phobia prior to or concurrent with the onset of another psychiatric disorder or cigarette smoking. Eleven (61%) reported onset of social phobia after the onset of another disorder or cigarette smoking. Of these, five reported a simple phobia, three reported an affective disorder, one reported a substance use disorder, one reported a conduct disorder, and one reported smoking as their first psychiatric disorder. Participants who experienced the onset of social phobia prior to or accompanying the onset of another disorder or cigarette smoking were significantly more likely to experience the onset of social phobia at a younger age than participants who developed social phobia after the onset of another disorder or cigarette smoking (M = 9.43, S.D. = 1.99 versus M = 12.82, S.D. = 3.55; t (16) = 2.30, p < 0.05). There was no significant association between onset pattern and language status. 3.3. Age 5 predictors of social phobia Table 3 presents results of logistic regression analyses, with means and standard deviations, for each age 5 psychosocial variable. Lower socioeconomic

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Table 3 Age 5 predictors of social phobia

First-born (%) Maternal global severity index (BSI) Mother-rated social competence (CBCL) SES Control group only Maternal phobic anxiety (BSI)

Social phobia

No social phobia

x2

OR

CI

25.0 50.5 (10.6)

50.0 48.9 (9.9)

4.17* n.s.

0.33

0.12–0.96

42.9 (11.0)

47.9 (12.9)

n.s.

38.2 (11.7)

48.0 (14.8)

7.21**

0.95

0.91–0.99

53.6 (11.6)

48.0 (5.3)

4.77*

1.12

1.0–1.2

Note: Unless otherwise indicated, means and standard deviations are presented. OR: odds ratio; CI: 95% confidence interval; SES: socioeconomic status; CBCL: child behavior checklist; BSI: brief symptom inventory. * p < 0.05. ** p < 0.01.

status and being second or later born were significantly associated with age 19 social phobia. Mother-rated CBCL social competence and maternal BSI global severity index were not significant predictors of social phobia. There was a significant interaction between age 5 language status and maternal BSI phobic anxiety scores (x2 (1) = 3.90, p < 0.05), such that maternal phobic anxiety was a significant predictor of social phobia among controls only. 3.4. Lifetime social fears Table 4 presents frequency of lifetime social fears among the age 5 language impaired and control groups regardless of social phobia diagnostic status. Participants from the language impaired group were significantly more likely to Table 4 Lifetime social fears by age 5 language status Lifetime social fear

LI, n (%)

Control, n (%)

Any social feara Speaking in publicb Having to use the toilet when away from home Eating or drinking in public Talking to people because you might have nothing to say or might sound foolish Writing while someone watches Talking in front of a small group of peoplec

48 32 8 7 17

46 32 14 5 22

(63.2) (42.1) (10.5) (9.2) (22.4)

13 (17.1) 21 (27.6)

Note: LI: language impaired; OR: odds ratio; CI: 95% confidence interval. a x2 (1) = 13.14, p < 0.001, OR = 2.98, CI = 1.65–5.38. b x2 (1) = 6.01, p < 0.05, OR = 2.14, CI = 1.16–3.92. c x2 (1) = 10.51, p < 0.01, OR = 3.63, CI = 1.67–7.90.

(36.5) (25.4) (11.1) (4.0) (17.5)

10 (7.9) 12 (9.5)

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report at least one social fear, specifically fear of speaking in public and fear of speaking to small groups, compared to those from the control group. Among participants with social phobia, 5% had speaking fears only (e.g., public speaking), 25% had non-speaking social fears only (e.g., eating or drinking in public), and 70% had both speaking and non-speaking social fears. There was no significant association between age 5 language status and type of social fears among participants with social phobia. Among the entire sample with complete onset data, mean age of onset of social fears was 10.47 years (S.D. = 3.20 years). There was no significant difference in the mean age of onset of social fears by age 5 language status. The age of onset of social fears did not differ between the social phobia group and those who did not reach criteria for diagnosis of social phobia. 3.5. Treatment for social phobia Among participants with social phobia, 35% reported they told a medical doctor or other professional about their unreasonably strong social fears. Among those participants, 43% were from the language impaired group and 57% were from the control group. Although 35% of participants told a doctor or professional, only 8% with social phobia reported currently receiving treatment for emotional or behavioral problems.

4. Discussion 4.1. Early language impairment and prevalence of social phobia in late adolescence Findings presented suggest that adolescents with a history of language impairment are at greater risk for the development of social phobia in late adolescence compared to peers with a history of typically developing language ability (controls). With a 16% 1-year prevalence rate for social phobia, adolescents with a history of language impairment have one of the highest rates of social phobia reported within the community epidemiological literature. In contrast, the rates found among the control group are comparable to findings from other community studies utilizing the UM-CIDI with DSM-III-R diagnostic criteria (Kessler et al., 1994; Offord et al., 1996). The diagnostic criteria for social phobia (social anxiety disorder) were equivalent in DSM-III-R and DSM-IV, except for the exclusionary criteria of symptoms due to the effects of a substance (e.g., a drug of abuse), or a general medical condition or better accounted for by another mental disorder. Prevalence rates are similar for social phobia based on the two sets of criteria (Furmark, 2002). Some models of social phobia propose that negative expectancies and evaluations regarding social performance may reflect a history of negative

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outcomes in social situations due in part to poor performance (e.g., Stopa & Clark, 1993; Turner, Beidel, Cooley, Woody, & Messer, 1994). Perhaps in the case of children with language impairment, experiences of exclusion and peer rejection may promote a hypersensitivity to negative feedback or expectations of negative outcomes in social situations. Early negative experiences may have a lasting impact on expectations and behavior regarding social interactions that may not be easily ameliorated by improvements in language or communicative ability. Recent studies provide empirical support for non-generalized (also referred to as pure speaking) and generalized (also referred to as complex) subtypes of social phobia (Kessler, Stein, & Berglund, 1998; Stein & Kean, 2000). Nongeneralized or pure speaking phobias exclusively involve unreasonably strong fears of public speaking. Generalized or complex phobias involve additional social fears and are associated with greater levels of functional impairment and comorbidity. In this study, language impaired and control groups did not differ according to rates of social phobia subtype. Among participants with social phobia, only 5% reported pure speaking fears only, which is comparable to the 3% rate reported by Stein et al. (2000). This finding suggests that individuals with a history of language impairment are at risk for social phobia beyond a fear of public speaking alone. Community studies (DeWit et al., 2005; Kessler et al., 1994; Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996;) report higher rates of social phobia among women compared to men. Although women in our sample showed a higher rate than men (12% versus 8.9%), this difference was not significant. The lack of a significant difference may be due to lack of power to detect a difference or perhaps it may be as DeWit et al. (2005) suggest, that the increased probability of developing a pure social phobia in women may not be fully expressed until later in adulthood. 4.2. Comorbidity and treatment of social phobia Onset of social phobia in late childhood to early adolescence and substantial comorbidity are consistent with findings from the social phobia and social anxiety disorder literature (DeWit, Ogborne, Offord, & MacDonald, 1999; Dunner, 2001; Kessler, Stang, Wittchen, Stein, & Walters, 1999; Kushner, Sher, & Beitman, 1990; Last, Perrin, Hersen, & Kazdin, 1992; Sonntag et al., 2000; Wittchen, 2000). In this sample, social phobia was associated with the presence of other psychiatric disorders and cigarette smoking. Among the control group, but not the language impaired group, social phobia was also associated with the presence of other anxiety disorders. This suggests that among the normal language cohort, the development of a social phobia may be part of a more general anxiety disorder diathesis, whereas among the language impaired group there appears to be a more specific association between social phobia and language impairment. The relation between maternal scores of phobic anxiety on the BSI, to the extent they reflect

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maternal anxiety, and social phobia exclusively in the control group and not the language impaired group lend further support to this idea. Consistent with the literature that indicates a low rate of help seeking among individuals with social phobia, only 35% of participants with social phobia told a doctor or other mental health professional about their fears. Only 8% of participants with social phobia reported they were currently receiving treatment, and that treatment may have been sought for a problem other than social phobia. It is possible that practitioners either did not recognize (Weiller et al., 1996) social phobia, or did not understand the clinical implications of having social phobia, and consequently did not refer or provide treatment. Alternatively, these participants may not have sought further assistance from professionals due to their fears of scrutiny and judgment. The exact reasons are not known, but are worthy of investigation as it may lead to innovative approaches to those suffering with social phobia. 4.3. Age 5 predictors of social phobia Few studies have prospectively examined the precursors of social phobia. Our results revealed that family socioeconomic status and being second or later in birth order were significant age 5 precursors of social phobia among both language impaired and normal language cohorts. Although the mechanism by which low socioeconomic status is associated with social phobia is not known, it is conceivable that this relation could be due to early experiences of social isolation more common among lower SES groups than among those with higher SES (e.g., Patterson, Vaden, Griesler & Kupersmidt, 1991) and/or the increased prevalence of language impairment among children in lower income households. Our finding that being second or later in birth order was a precursor for diagnosis of social phobia is not consistent with past findings that first and only children have a greater tendency to be shy (Bruch, 1989). However, second or later birth was also associated with greater likelihood of language impairment (Beitchman, Peterson, & Clegg, 1988). In addition, Chartier, Walker, and Stein (2001) found that being second or later born was positively related to social phobia in males only. Further research will need to clarify what role, if any, birth order plays in the development of social phobia. In contrast with the retrospective and family history literature (Chartier et al., 2001; Lieb et al., 2000), maternal mental health measures were not associated with social phobia in their offspring with the exception of maternal phobic anxiety among control participants. Specific to the control group only, maternal phobic anxiety scores at age 5 predicted social phobia. Among the maternal symptomatology measures, phobic anxiety most closely approximated a diagnosis of social phobia. This suggests the importance of maternal transmission of social phobia among those without language impairment. Although the relative contributions of genetic and environmental influences cannot be ascertained from this data, it is a subject worthy of continued research. These results suggest a

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differential pattern of associations or possibly etiology for social phobia among adolescents on the basis of early language impairment and that future studies of the environmental and genetic precursors of social phobias should identify at least two phenotypes: one with a history of language impairment and one without. 4.4. Lifetime social fears Participants from the language impaired group were more likely than normal language controls to report social fears, particularly fears of speaking in public and speaking in front of a small group. Given the centrality of language competence to effective communication, it is not surprising to find that individuals with a history of communication-related deficits are more likely to experience fears related to public speaking. What is surprising is that this finding had not to our knowledge previously been reported, thereby neglecting a potentially critical risk and treatment variable. 4.5. Limitations and future directions Small cell sizes prevented us from considering the role of early speech impairment. The rate of social phobia at age 19 among the 38 participants with age 5 speech impairments only (no concurrent language impairments) was 13.2%, compared to 6.5% among controls. This difference did not reach significance. Future research should address the possibility that speech only impaired children may be at increased risk for the development of social anxiety. Small cell sizes also prevented us from testing multivariate models in the prediction of social phobia. We were unable to conduct analyses to determine whether language impairment continued to predict social phobia after controlling for other early childhood risk factors. In addition, although the sample was representative of Ottawa, Ontario in 1982, the majority of participants are Caucasian. As such, results have limited generalizability to diverse communities. Finally, selective attrition resulted in a higher functioning sample than would have been the case if all the children in the initial 1982 study had participated at age 19. Given the pattern of differences between continuing participants and participants with incomplete data, it is likely that the effects of attrition underestimated the impact of language impairment on social anxiety, highlighting the importance of further study with this group.

Acknowledgements This study was supported by Grant 6606-5639-102 awarded to Joseph H. Beitchman from Health Canada, National Health and Research Development Program. We would like to extend our gratitude to the youth and their families for their continued participation in this study. We would also like to acknowledge the

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