Child Adolesc Soc Work J (2013) 30:3747

DOI 10.1007/s10560-012-0274-0

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 anxiety
in 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 administered (including parent-report and self-report scales for both elementary and adolescent 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 community 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: wward@uams.edu
K. Thomas
Department of Psychiatry, University of Arkansas for Medical Sciences, College of Medicine,
Little Rock, AR, USA

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Keywords

J. E. Thompson et al.

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

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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)

(2)

(3)

(4)

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).
We further hypothesize that extremely obese youth (those with [99th
percentile BMI) would have higher levels of social anxiety than obese youth
(9599th percentile BMI) in this clinic population.
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.
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 the
course of this study. Of those, 10.2 % (n = 39) declined and 10.3 % (n = 92) were

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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 approximately 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 reported
in 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 selfstatements 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 SASA), 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 (SADGeneral) 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), and
0.76 (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.

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41

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. Parentreport 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 two
groups 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 compare
subjects 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-A
has a parent report (n = 90) and youth report (n = 86). Youth and parent-report
versions were obtained from each subject or their parent.

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Table 1 BMI percentile and

SAS Spearman correlation
coefficients

Spearman correlation
coefficients
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

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 value

0.091

0.403

FNE

0.078

0.470

SAD-General

0.179

0.097

SAD-New

0.050

0.650

SASC-R

0.290

\0.001*

FNE

0.274

0.001*

SAD-General

0.150

0.075

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*

* P \ 0.05

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 SASA. 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

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Table 2 Investigation of moderating variables effects on social anxiety

SASC-R

SASC-R for parents

SAS-adolescents

SAS-adolescents
for parents

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

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

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

Gender

Race

BMI category

M (SD) n
SAS social anxiety scale
* P \ 0.05

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, SADGeneral, 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,

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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

SAD-General

SAD-New

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*

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*

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 negative evaluation, SAD-General social avoidance and distress (across many situations), SAD-New social
avoidance 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*

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

SASC-R (parent)

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

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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.

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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 highrisk 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 use
the SAS and its versions for the purposes of this research. This study was funded by an intramural CUMG
grant.

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