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INTRODUCTION: Environmental, specifically familial behaviors and parenting styles are particularly significant in the development of social phobia (SP). The development of anxiety in children seems especially affected by parental behaviors, genetic inheritance, prevention of social initiative, and role modeling1 . Retrospective studies have described parents of SP patients as people with limited socialization and isolated, with disconnected relationships. In addition to parental behaviors, an increased parental anxiety level is another variable related to SP. Parents who show anxiety disorders like SP, agoraphobia, and panic disorder are at greater risk to have children with anxiety disorders like SP. On the other hand, published studies also reported that these symptoms as not related specifically to SP but to all kinds of anxiety disorders and identified no differences in parenting styles in families of patients diagnosed with SP2 . Early childhood adverse experiences have also been commonly observed among the developmental risk factors for SP. Experiences that increase risk for SP include parental psychopathology, conflicts within the family, divorce, emotional, physical, and sexual abuse, loss of a parent, and early separation from parents. These risk factors increase not only the likelihood of SP but are also implicated in the development of other types of psychopathology. Our study examines the developmental effects of parenting style, parental anxiety levels, and childhood adverse life events in the manifestation of various modes of SP. We compared patients diagnosed with SP and their parents with a control group and their parents.
METHODOLOGY:
Sample: The research sample consisted of 60 (n=60) individuals aged between 14 and 24 years diagnosed and treated at S.B. Ankara Dışkapı Y.B.E.A.H. Psychiatry Outpatient Clinic Adolescence Unit. The control group consisted of 30 (n=30) healthy individuals between 14 and 24 years of age who volunteered to be part of the study. In both groups, parents who agreed to participate in the study were included (SP parents n=45; control parents, n=30). This study utilized the data from a master’s thesis titled “Parental child rearing attitude in social anxiety development”. All participants in the study provided informed consent, and approval was obtained from the local ethical board.
METHOD: The SCID-1 was administered to all patients who were admitted to the clinic as well as to all controls, and a sociodemographic questionnaire was given to the parents for family interview. Liebowitz’s Social Anxiety Scale (LSAS) was used to evaluate the severity of social anxiety experiences and avoidance behaviors. The Parent Attitude Research Instrument (PARI) was completed separately by all participants in order to evaluate perceived parenting attitudes for all. The subjects were requested to complete the forms with attention to their own parenting practices and family experiences. Because of parent loss, separation or divorce, failure to contact, and lack of time, only 45 parents in the SP group were able to participate in the study. All parents of the healthy control group were also evaluated using the PARI and the LSAS.
Scales: The Parent Attitude Research Instrument was developed in 1958 by Schaefer and Bell. Children complete a 1-4 Likert-type scale to evaluate the scale’s reliability and validity. The subjects complete scales rating child rearing attitudes using 5 subscales. Over-Protective Mothering (Factor 1) particularly shows mothers’ over-protectiveness and interference. Democratic behaviors and definitions of equality (Factor 2) show supportiveness and participatory relationships. Mothers’ refusal of the housewife role (Factor 3) shows tension and anger in parents, especially the mothers’ relationship with the children. Husband and wife incompatibility (Factor 4) shows the effects of conflict between the spouses on child rearing attitudes. Harsh Discipline (Factor 5) describes punishing, harsh mothers’ and fathers’ attitudes. The Liebowitz Social Anxiety Scale was developed in 1985 by Liebowitz, and the validity and reliability of the Turkish version has been demonstrated by Dilbaz. This is an inventory developed to measure levels of social anxiety and is constructed with two subscales: anxiety and avoidance. Statistical Analysis: The SPSS 15 package was used to complete the
Statistical Analysis. Data were analyzed using statistical methods that compared the patient and control groups and the male and female groups using single direction variation analysis, and risk factor effects were evaluated using a multi-linear regression analysis. The significance factor for results was found to be p<0.05.
RESULTS: The SP and control groups were compared with regard to their age, gender, SES status, educational levels, professions and other variables and no significant statistical differences found. Also no other statistically significant sociodemographic factors were identified between the parents of those diagnosed with SP and the control group, with the exception of the mothers’ educational levels (χ²=14.02, p<0.05). Early childhood adverse life events were reported significantly higher in the SP group, reaching 20% against the controls at 1.1% incidence of early childhood adverse life experiences (χ²=8,540, p<0,05). When compared according to rates of separation anxiety, the SP group showed a 28.3% rate and the control group a rate of 13.3% (χ²=2,52, p=0,91). The scores of patients’ parents on the Liebowitz anxiety and avoidance subscales were significantly higher than the controls’. According to results of the univariate variation analysis of 2 (patients and controls) X 2(males and females), PARI subscale scores showed significant group difference in the over-protective mothering group; adolescents from the SP group showed higher scores on the protective mother scales than controls (F(3.256)= 3.05; p<0.03). Gender differences were not found between the groups. When we analyzed the parents’ experiences, PARI subscales showed significant differences for PARI1 (over-protective mothers) subscale, for mothers (F(3.163)= 2.73, p<0.05) and for fathers (F(3.256)= 3.05, p<0.03). They were significantly higher than those of the control group’s mothers and fathers. Also, a significant gender difference was found for fathers (F(1, 377)= 7.27; p<0.009); the fathers of both the SP and control groups scored significantly higher for girls on the PARI1 over-protective mothering scales. No significant differences were identified with relation to the other subscales.
DISCUSSION: This study aimed to consider the roles of variables like family parenting styles, parents’ levels of anxiety, avoidance behaviors, and childhood adverse events in individual risk for the development of SP. For those diagnosed with this disorder, rates of parental divorce, separation and death of a parent were found higher than in the control group. In the literature, some studies showed a relationship between incidence of this kind of traumatic experience and the development of this disorder while others did not. The results of this study showed that the mothers and fathers of those diagnosed with SP showed higher levels of anxiety and avoidance behaviors in social situations than controls. Studies examining the genetic inheritance for SP show a concordance for monozygotic twins of 24% and for dizygotic twins of 15%; for close relatives, the frequency of the disorder is also 15%. The high levels found for social anxiety and avoidance behaviors among the parents of our patient group are in agreement with Bandura’s model, suggesting that children’s anxious thinking and avoidant behaviors are socially learned. Stemberger’s study described patients’ parents as having limited social relationships and being avoidant. Bruch et al. suggest in their study that patients took parental behavior assessed as socially anxious as a model and thus learned the disorder. It is also possible that when parents limit children’s initiative, discourage alternative behaviors for initiative, or abuse them, the way may be paved for the development of the disorder. Studies in the literature show a relationship between parental attitudes toward initiative and encouragement of initiative, and the development of SP3 . Another important finding of this study was that the patient group scored higher on the over-protective parent style (PARI 1) scale in comparison with the control group. In the literature, when parenting approaches have been examined retrospectively, SP patients’ parents have generally been described as over-protective, rejecting, or neglectful4 . This study was limited in the range of anxiety disorders that it examined and was cross-sectional. We would recommend studies considering other anxiety disorders and with a longitudinal design that examine the reciprocal parent-child relationships in this area. In conclusion, we determined that when compared with a control group, SP is related to specific family characteristics like parental anxiety levels, avoidance levels and parental attitudes. In future studies, larger sample sizes and groups drawn from broader diagnostic categories would be useful. Prospective, qualitative studies will help to determine the etiological factors that contribute to the development of SP.