Two dimensions of social anxiety disorder: a pilot study of the Questionnaire for Social Anxiety and Social Competence Deficits for Adolescents

Social anxiety disorder is one of the most challenging disorders in adolescence 1]–3]. During this age, the incidence of social anxiety increases notably 4]–6]. Adolescence is an important developmental stage with regard to emotional, cognitive,
biological, and social changes 7], 8] where youths are confronted with many psychologically relevant challenges. For example,
they have to deal with questions of identity and self-perception as well as with increasing
autonomy and responsibility. At the same time, relationships with peers and romantic
partners get more important and influence the development of self-esteem and social
competencies 9], 10]. In addition, the significance and frequency of achievement at school and during
leisure time also increases 11]. Since cognitive abilities increase in adolescence, reflections and self-evaluations
become more detailed and often more critical 12]. As a consequence, the time of adolescence is characterized by high self-awareness
and self-criticism and thus, can result in high vulnerability especially with regard
to social anxiety and social problems 7], 13].

Symptoms of social anxiety disorder are often stable through adolescence 14], 15] and can persist into adulthood 16]. Besides the risk of chronicity, there is a large amount of accompanying psychosocial
risk that can hinder the psychological, emotional, and social development of adolescents
16]–19]. Youths who suffer from social anxiety disorder often have problems at school or
work and difficulties that are related to interactions with peers and intimate partners
20]–25]. Moreover, comorbid disorders as depression, other anxiety disorders, and/or alcohol
abuse often develop 16], 26]–28]. As a consequence, socially anxious youths have a lower educational level, are more
often unemployed, are less socially integrated, and are less often in partnerships
compared to their healthy peers 16], 25], 29]. Because of these risks, an early and adequate identification as well as an appropriate
intervention for social anxiety are desirable.

Beyond the characteristic symptoms of social anxiety disorder like intensive fear
and avoidance of social situations on the basis of evaluation anxiety or anxiety of
being in the focus of attention 30], 31], some patients also suffer from social competence deficits 32]–35]. Social competence deficits can be unobservable, e.g., deficits in social cognition,
regulation of attention, decoding and interpretation of information, empathy, and
regulation of behavior, but can also be observable in motor and verbal behavior, e.g.,
frequency and duration of eye contact, gestures, and initialization of a conversation
36]. Adolescents with such deficits often worry about not meeting social expectations
21], 37]. Since peer relations are very important in adolescence 9], deficits in social competence might endanger important developmental progress by
leading to difficulties in establishing and maintaining adequate social contacts.

Several studies have shown that youths with social anxiety disorder have less social
competencies than healthy controls. These youths evaluated their own behavior worse
than their peers and were rated more incompetent by independent observers. For example,
Spence et al. 38] documented those children aged 7–14 years with social anxiety disorder seldom initialized
social interactions, interacted less with others, and gave short answers. Inderbitzen-Nolan
et al. 39] identified poorer evaluations of social anxious adolescents (12–16 years) than of
their healthy partners during role play in different categories, e.g., self-confidence,
social competence, and assertiveness. These results were replicated in the studies
of Alfano et al. 40], Beidel et al. 41], and Miers et al. 35]. Difficulties in empathy and interpretation of facial expressions also were found
in this group 40]. However, not all youths with social anxiety disorder showed social deficits 42]–45]. Hence, differences in the frequency and occurrence of social competence deficits
in youths with social anxiety disorder can be expected.

In clinical settings, the co-occurrence of social anxiety and social competence deficits
is often observed; however, the presence of deficits is not an integral part of the
diagnostic criteria for social anxiety disorder according to the ICD-10 or DSM IV
30], 31]. However, social competence deficits can maintain or exacerbate symptoms of this
disorder; therefore, they should not be disregarded 36]. Since a significant relationship between the constellation of symptoms and the severity
of the disorder must be assumed, an appropriate clarification about individually relevant
symptoms prior to therapy is required 46]. Thus, at the beginning of therapy, it should be assessed if—and if yes, what type
of—social deficits exist beyond symptoms of social anxiety. Only on this basis can
an adequate and individual therapy with regard to duration, focus, and intensity of
therapy be developed 47], 48], which in turn should lead to a better outcome.

Nowadays, social competence training is often provided as an optional part in manuals
for the therapy of social anxiety disorder and as a consequence, is often integrated
into therapy 47]–49]. However, some studies have shown that such trainings are not always effective 50]. One reason for this finding can be seen in the general behavioral focus of social
competence trainings 51], although different types of social problems in patients with social anxiety disorder
(e.g., cognitive deficits, communication deficits, performance deficits) occur 36]. Moreover, the diagnostic basis of the decision to include or not to include a module
with focus on social competence is difficult since an adequate measure of social deficits
has not been available 52]. There are some well-accepted questionnaires for social anxiety disorder in youth
53], 54], for example the Social Anxiety Scale for Adolescents (SAS-A) 55], the Social Anxiety Scale for Children-Revised (SASC-R; La Greca) 55], the Social Phobia and Anxiety Inventory for Children (SPAI-C) 56], and the Social Anxiety and Avoidance Scale for Adolescents (SAASA) 57]. All of these mainly measure symptoms of anxiety, avoidant behavior, and dysfunctional
cognitions; however, items regarding deficits in social competence are neglected.
Thus, a questionnaire that explicitly measures such deficits and separates them from
social anxiety has not yet been developed. Such an instrument would be essential for
clinicians to be able to improve their decisions on whether competence training is
warranted and if yes, what competencies should be emphasized. Hence, this type of
instrument could improve current practices regarding therapeutic decisions.

A few years ago, Kolbeck and Maß 36] published the Questionnaire for Social Anxiety and Social Competence Deficits (SASKO)
for adults as the component of deficits had also been lost 37]. The key feature of the SASKO is the separate measurement of social anxiety and social
competence deficits as two distinct dimensions. The authors argued that social anxiety
and social deficits interact with each other and thus cannot be regarded isolated.
Rather, they should be considered as different components of social anxiety disorder
36]. This assumption aligns with the model of Wlazlo (1989; cited in Kolbeck and Maß
36]) who described social anxiety and social deficits as central components of the disorder.
In addition, through the differentiation of behavioral and cognitive competencies
within the deficit dimension, the SASKO allows a deeper insight into possible deficits
36].

As the SASKO has proved consistently good psychometric properties 36], it was adapted for use with adolescents (SASKO-J) 58]. The conceptual separation and the underlying five-factor structure of the questionnaire
for adults (i.e., two anxiety scales, two deficit scales, and one additional scale
that measures loneliness) has been confirmed for the SASKO-J 58]. The results of an unselected sample of 228 German students showed satisfactory to
good consistencies (0.77 ? ? ? 0.94) and retest-reliabilities (0.56 ? r _tt
 ? 0.87) for the subscales and the total scale 58]. Additionally, in a sample of 115 German students, good convergent (0.39 ? r ? 0.80) and divergent (0.19 ? r ? 0.31) validity of the SASKO-J was documented for the total scale and the majority
of subscales 58]. Thus, there is strong evidence that the questionnaire can be used with adolescent
samples. However, because the SASKO-J was predominantly developed for application
in patients, evaluation of its feasibility and diagnostic quality in clinical samples
is still lacking.

In the first step of the present pilot study, the reliability and validity of the
SASKO-J was tested in a mixed clinical sample¹
of adolescents aged 12–19 years. Since the SASKO-J is supposed to improve the diagnosing
of social anxiety disorder, it is important to examine its accuracy in differentiating
individuals with or without social anxiety disorder. Thus, in the second step, we
tested the sensitivity and the specificity of the SASKO-J. For this purpose, a specific
clinical sample was recruited consisting only of adolescent patients who suffered
from social anxiety disorder. Furthermore, a sample of non-selected high school students
was assessed that provided the comparison sample. On this basis, a cutoff was computed
to determine the critical value that allows an accurate classification and differentiation
of adolescents with and without a possible social anxiety disorder diagnosis.

With regard to the first aim and based on the results from previous studies on the
SASKO-J 58], we expected good reliability (internal consistency) of the SASKO-J in the mixed
clinical sample. Furthermore, we assumed good convergent and divergent validity of
the SASKO-J in this sample. We expected that the anxiety scales would be more strongly
associated with the convergent measurement of social anxiety disorder than the deficit
scales due to their conceptual similarity. With regard to the second aim, when comparing
high school students (non-clinical sample) with adolescent patients (clinical social
anxiety disorder sample), we assumed that the patients would have significantly higher
scores on all scales of the SASKO-J than the students. Concerning the accuracy, we
expected that the questionnaire would adequately discriminate between these two groups
and present high sensitivity and specificity.