Content uploaded by Catherine C Epkins
Author content
All content in this area was uploaded by Catherine C Epkins
Content may be subject to copyright.
Integrating Etiological Models of Social Anxiety and Depression
in Youth: Evidence for a Cumulative Interpersonal Risk Model
Catherine C. Epkins •David R. Heckler
Published online: 13 November 2011
Springer Science+Business Media, LLC 2011
Abstract Models of social anxiety and depression in
youth have been developed separately, and they contain
similar etiological influences. Given the high comorbidity
of social anxiety and depression, we examine whether the
posited etiological constructs are a correlate of, or a risk
factor for, social anxiety and/or depression at the symptom
level and the diagnostic level. We find core risk factors of
temperament, genetics, and parent psychopathology (i.e.,
depression and anxiety) are neither necessary nor sufficient
for the development of social anxiety and/or depression.
Instead, aspects of children’s relationships with parents
and/or peers either mediates (i.e., explains) or moderates
(i.e., interacts with) these core risks being related to social
anxiety and/or depression. We then examine various par-
ent- and peer-related constructs contained in the separate
models of social anxiety and depression (i.e., parent–child
attachment, parenting, social skill deficits, peer acceptance
and rejection, peer victimization, friendships, and loneli-
ness). Throughout our review, we report evidence for a
Cumulative Interpersonal Risk model that incorporates
both core risk factors and specific interpersonal risk factors.
Most studies fail to consider comorbidity, thus little is
known about the specificity of these various constructs to
depression and/or social anxiety. However, we identify
shared, differential, and cumulative risks, correlates, con-
sequences, and protective factors. We then put forth dem-
onstrated pathways for the development of depression,
social anxiety, and their comorbidity. Implications for
understanding comorbidity are highlighted throughout, as
are theoretical and research directions for developing and
refining models of social anxiety, depression, and their
comorbidity. Prevention and treatment implications are
also noted.
Keywords Children’s social anxiety Children’s
depression Parent–child relationships Peer relationships
Internalizing problems Comorbidity
Introduction
Etiological models of social anxiety and depression in youth
have been developed separately. As will be shown below,
similar etiological influences are posited in these models,
yet there has been very little focus on how the delineated
etiological influences are similarly or differentially related
to the development of social anxiety and depression, or the
comorbidity of social anxiety and depression. Our goal in
this paper is to examine and integrate the literature with
respect to the features in these models, with a careful eye
toward noting whether the relevant etiological constructs
have been shown to be a correlate or risk factor for social
anxiety and/or depression in youth at both the symptom
level and the diagnostic level. As such, we strive to advance
the integration of, and the empirical status of, theoretical
models of social anxiety and depression. As will be seen,
most studies fail to consider the substantial overlap in or
comorbidity of social anxiety and depression. As Starr and
Davila (2008) note, ‘‘For the purposes of identifying unique
etiological factors or determining how disorders may be
related to each other, partialing out potentially confounding
comorbid symptoms is critical’’ (p. 346). Moreover, iden-
tifying the unique, shared, and overlapping risk factors is
important for understanding the etiology of social anxiety,
depression, and comorbid social anxiety and depression and
C. C. Epkins (&)D. R. Heckler
Department of Psychology, Texas Tech University,
MS 42051, Lubbock, TX 79409-2051, USA
e-mail: catherine.epkins@ttu.edu
123
Clin Child Fam Psychol Rev (2011) 14:329–376
DOI 10.1007/s10567-011-0101-8
will enhance efforts in developing empirically- and theo-
retically relevant targets for prevention and treatment.
We begin by reviewing epidemiology, definition,
comorbidity, developmental aspects and temporal relations
of social anxiety and depression, at both the symptom level
and the diagnostic level. Then, we highlight the importance
of subthreshold or nonclinical social anxiety and depression
from both clinical and developmental literatures and high-
light principles within a developmental psychopathology
framework as they pertain to social anxiety and depression.
We then describe how both subthreshold and diagnostic
levels of social anxiety and depression are viewed as
interpersonal problems, and we provide an empirical and
theoretical context for the importance of examining whether
there are similar or differential interpersonal risk factors for
social anxiety and depression. Next, we review three core
risk factors for psychopathology that are noted in separate
models of social anxiety and depression (i.e., temperament;
genetics; and parent psychopathology, particularly depres-
sion and anxiety), and we examine whether they show
similar and/or differential relations to social anxiety,
depression, and their comorbidity at symptom and diag-
nostic levels. As we demonstrate, aspects of these core risk
factors are neither necessary nor sufficient for the devel-
opment of social anxiety and/or depression. Instead, a
number of constructs regarding children’s interpersonal
relationships with parents and/or peers either mediate (i.e.,
explains) or moderate (i.e., interacts with) these core risks
being related to social anxiety and/or depression. As such,
and based on interpersonal theoretical models of social
anxiety and depression, we then examine parent- and peer-
related interpersonal constructs and whether the literature
has demonstrated specific relations of these interpersonal
constructs to social anxiety and/or depression at the symp-
tom level and diagnostic level. The interpersonal constructs
we examine are parent–child attachment, parenting behav-
ior, social skill deficits, peer acceptance and rejection, peer
victimization, friendships, and loneliness. Throughout our
review, we highlight empirical evidence for a Cumulative
Interpersonal Risk model that incorporates both core risk
factors and specific interpersonal risk factors for social
anxiety and/or depression. Central to the notion of cumu-
lative risk is that multiple sources of risk, and their inter-
actions, contribute to negative outcomes, and the quantity
rather than the quality of risk factors is more influential
when multiple risk factors are considered simultaneously
(Rutter 1979; Sameroff 2000).
Epidemiology and Definition
Anxiety disorders are the most prevalent class of mental
disorders, with lifetime prevalence rates found to be 28.8%,
and major depressive disorder (MDD) is the most prevalent
lifetime disorder (16.6%; Kessler and Wang 2008). Epi-
demiological studies report a wide range of prevalence
estimates of social phobia (also called social anxiety dis-
order; SAD), likely due to cultural norms regarding social
anxiety in different countries (Heinrichs et al. 2006;
Kessler et al. 2009). In the USA, lifetime and 12-month
prevalence of SAD have been found to be 12.1 and 7.1%,
respectively (Ruscio et al. 2008).
Among youth, anxiety disorders are also the most com-
mon psychological disorders (Cartwright-Hatton 2006;
Costello et al. 2005). Epidemiological studies have found up
to 41.2% of children under 12 years of age have anxiety
disorders (see Cartwright-Hatton et al. 2006 for a review).
The prevalence of SAD in youth, however, has been found to
be lower, with lifetime prevalence of 1.6% for 12–17-year-
old German youth (Essau et al. 1999); 12-month prevalence
of 3.2% for 12–17-year-old Finnish youth (Ranta et al.
2009b); and lifetime prevalence of 13.6% in 18–29-year-
olds (Kessler and Wang 2008). Onset of SAD is typical in
adolescence (Kessler et al. 2005) although recent epidemi-
ological and other studies indicate the onset frequently
occurs in childhood (see Gazelle and Rubin 2010; Rapee
et al. 2009). The prevalence of MDD has been found to be
between .4 and 2.5% in children, and between 4.0 and 24.0%
in adolescents (Cummings and Fristad 2008). However, the
age of onset for depression is quickly decreasing, as 9% of
youth have experienced at least one severe major depressive
episode by 14 years of age (Abela and Hankin 2008).
The disorders of MDD and SAD are defined in the
Diagnostic and Statistical Manual of Mental Disorders,
fourth edition (DSM-IV, American Psychiatric Association
1994). MDD consists of the presence of one or more major
depressive episodes, which requires depressed mood (or
irritable mood in children) or loss of interest or pleasure
that persists at least 2 weeks. This is accompanied by at
least 4 other symptoms (or 3 if both loss of interest and
pleasure and depressed mood are present). These symp-
toms include low energy or fatigue; feelings of worth-
lessness or guilt; difficulty thinking, concentrating, or
making decisions; sleep problems (insomnia or hyper-
somnia); changes in weight or appetite; psychomotor agi-
tation or retardation; and thoughts of death or suicidal
thoughts or behavior. Also, the symptoms must cause
clinically significant distress or impairment in functioning
(e.g., social, school, work).
According to the DSM-IV, the essential feature of SAD
is a marked and persistent fear of one or more social or
performance situations where there are unfamiliar people or
possible scrutiny by others. The individual fears acting in an
embarrassing or humiliating way or showing anxiety. The
feared social and performance situations are either avoided
or endured with excessive anxiety or distress, and exposure
to the situation invariably creates anxiety. Children, unlike
330 Clin Child Fam Psychol Rev (2011) 14:329–376
123
adults, do not need to recognize that their fear is excessive
or unreasonable. Moreover, to be diagnosed with SAD in
childhood, the child needs to have age-appropriate social
relationships with familiar people and the anxiety must
occur in peer settings, not just with adults. In children and
adolescents, the duration needs to be at least 6 months.
Also, the avoidance behavior, anticipatory anxiety, or dis-
tress in the situation(s) must interfere significantly with the
individual’s normal routine, academic/work functioning, or
social relationships and activities.
Comorbidity
Extensive literature documents the co-occurrence or
comorbidity of depression and anxiety symptoms and dis-
orders in youth, community, population, school-based, and
clinical samples (Angold et al. 1999a; Brady and Kendall
1992; Seligman and Ollendick 1998). This is especially
true for the comorbidity of depression and social anxiety in
particular, both for symptoms of depression and social
anxiety (and subclinical SAD) and disorders of MDD and
SAD in youth (Crawley et al. 2008; Essau et al. 1999;
Ranta et al. 2009b; Viana et al. 2008) and in adults (Kessler
et al. 1999). For example, epidemiological studies have
found that 28–41% of youth with SAD also have comorbid
depressive disorders, including MDD (Chavira et al. 2004;
Essau et al. 1999; Ranta et al. 2009b; Wittchen et al. 1999).
In clinical samples of youth with SAD, 56% have been
found to have lifetime depressive disorders with 44%
having a lifetime history of MDD (e.g., Last et al. 1992). In
a sample of youth referred to an anxiety clinic, 55% of
those with a primary diagnosis of MDD were also found to
have concurrent comorbid SAD (Last et al. 1987). Thus,
there is substantial overlap in, and comorbidity of,
depression and social anxiety.
Developmental Aspects and Temporal Relations
The prevalence of depression and anxiety symptoms and
disorders, as well as their comorbidity, varies with respect
to children’s age and sex. Girls have higher rates of
depressive and anxiety symptoms and depression and anx-
iety disorders than boys, especially in adolescence and
continuing in adulthood (see Costello et al. 2005; Hankin
et al. 2008; Zahn-Waxler et al. 2008). Girls between 11 and
14 have also been found to have higher prevalence rates of
subsyndromal social anxiety than boys (Aune and Stiles
2009). In a number of nonclinical samples of children and
adolescents, girls have been found to report more social
anxiety symptoms than boys (La Greca 1999). Moreover,
the prevalence of depression and anxiety disorders escalates
in adolescence, when the sex differences become especially
prominent (Hankin 2009; Hankin et al. 2008; Hilt and
Nolen-Hoeksema 2009; Zahn-Waxler et al. 2008). Fur-
thermore, the comorbidity of depression and anxiety
symptoms and disorders is much more common in girls than
it is in boys (reviewed in Hankin et al. 2008; Zahn-Waxler
et al. 2008). The biological and environmental mechanisms
that account for the sex differences in depression and anx-
iety, and their comorbidity, have been reviewed elsewhere
and are beyond the scope of the present paper (e.g., Craske
2003; Hankin 2009; Hankin et al. 2008; Hilt and Nolen-
Hoeksema 2009; Zahn-Waxler et al. 2008). Nevertheless,
these data indicate that there are likely different etiologies
or risk factors for girls’ versus boys’ depression and anxiety.
In terms of the temporal relations, several longitudinal
studies find anxiety symptoms or disorders precede
depressive symptoms and disorders in children and ado-
lescents (Cole et al. 1998; Hankin et al. 2008; Seligman
and Ollendick 1998; Zahn-Waxler et al. 2008). Moreover,
anxiety disorders have been found to precede the onset of
MDD across three generations (Weissman et al. 2004).
Recent research has also shown social anxiety precedes
depression in youth. Children with a history of anxious
solitary withdrawal (and not concurrent) in 3rd or 4th
grade, relative to control children, were more likely to be
diagnosed with depressive disorders (Gazelle et al. 2010).
Moreover, 11–14-year-old youth level of social anxiety
symptoms was found to predict depressive symptoms
1 year later while controlling for initial depressive symp-
toms and depression did not predict later social anxiety,
suggesting social anxiety precedes depression (Aune and
Stiles 2009). In addition, in a clinical sample of anxiety-
disordered youth, SAD was found to precede the onset of
MDD in 74% of cases of youth with SAD and a lifetime
history of MDD (Last et al. 1992). Finally, a 10-year
prospective longitudinal study found that SAD was asso-
ciated with an increased risk of depressive disorders at all
ages of SAD onset, especially when the age of onset of
SAD was at ages 11 through 16 (Beesdo et al. 2007). These
data suggest that social anxiety and SAD precede depres-
sion symptoms and disorders. However, it is important to
note that some youth with onsets of SAD between ages 11
and 16 never do develop depression within 10 years
(range =36–47% for all ages of onset), and some youth
that do not have SAD diagnoses at ages 11 through 16 go
on to later develop depression (range =19–25% for all
ages of onset; Beesdo et al. 2007). Thus, SAD does not
always lead to later depression (c.f., Last et al. 1992), and
depression can develop without previous SAD.
Importance of Subthreshold MDD and SAD
A substantial amount of literature finds youth with sub-
threshold depressive symptoms (i.e., those who do not
meet all the criteria for having MDD in the DSM-IV) are
Clin Child Fam Psychol Rev (2011) 14:329–376 331
123
fairly similar to youth with MDD in their psychosocial
dysfunction, impairment in functioning, treatment-seeking,
and risk of future MDD (Avenevoli et al. 2008; Lewinsohn
et al. 1998). Dysthymic disorder (DD; which is sometimes
referred to a ‘‘minor depression’’) differs from MDD on
both acute–chronic and pervasiveness dimensions, yet
MDD and DD share similar features and symptoms (APA
1994). Research comparing youth with DD to youth with
MDD finds that they are similar on demographics, clinical
course, impairment in functioning, social competence and
problems with friends, persistence over time, poor social
and academic outcomes, comorbidity with other disorders,
and suicide and suicidal behaviors (Birmaher et al. 1996;
Flory et al. 2002; Goodman et al. 2000; Kovacs et al. 1993,
1997). DD has also been found to substantially increase the
risk of later MDD in youth (Birmaher et al. 1996; Flory
et al. 2002; Kovacs et al. 1994). Thus, subthreshold
depressive symptoms and DD have similar correlates and
features as MDD, and they have both been found to be risk
factors for subsequent MDD.
With regard to subclinical SAD, epidemiological studies
underscore the importance of nonclinical levels of social
anxiety. Youth with social fears have been found to: (1)
report their social anxiety or avoidance was unreasonable
or excessive (43%); (2) experience at least two physical
symptoms upon being exposed to the feared social situa-
tion (63%); and (3) engage in avoidant behavior (64%),
often lasting months to a few years (Essau et al. 1999).
These findings dovetail with research that finds youth with
subthreshold level of diagnostic symptoms (i.e., who fall
short of meeting the number of symptoms required for a
DSM diagnosis) do suffer from impairment in their psy-
chosocial functioning and are similarly as affected or
disturbed in various areas (e.g., comorbid symptoms and
disorders, specialist or school mental health-related service
use) as youth who do meet the number of symptom criteria
for a diagnosis but do not have the impaired functioning
that is required for a formal DSM diagnosis (Angold et al.
1999b; Knappe et al. 2009a). Thus, from the clinical lit-
erature, the importance of subthreshold MDD and SAD is
evident.
A large developmental literature has also accrued on
socially withdrawn or isolated children (see Rubin et al.
2009, for review). Indeed, a number of studies have found
early childhood social withdrawal or isolation is related to
later childhood depressive symptoms (see Rubin et al.
2009). Importantly, childhood social withdrawal/isolation
both is concurrently associated with and is a risk factor for
subsequent depression, social anxiety, and SAD (see Rubin
et al. 2009; Rubin and Coplan 2004). Thus, early social
withdrawal and isolation represents a subthreshold condi-
tion, and a risk factor, for both depression and social
anxiety.
Childhood shyness is another potentially important
subthreshold condition, or early manifestation, of social
anxiety or SAD. ‘‘Shy is a term used to describe a pattern of
reticence associated with social situations’’ (Beidel and
Turner 2007, p. 112). There is much overlap and similarity
between shyness and SAD. For example, studies examining
associations or comparing shy individuals to those with
SAD indicate that they appear similar on self-reported
sociability, fear or anxiety regarding negative evaluation,
self-reported anxiety and independent observer-rated anx-
iety during social-behavioral tasks, and somatic or physi-
ological responses in social situations (Heiser et al. 2009;
Turner et al. 1990). Although more shy individuals com-
pared to nonshy individuals have SAD, less than 50% of
shy individuals have been found to have SAD (Chavira
et al. 2002; Heiser et al. 2003), and the majority of shy
children do not develop SAD (Stein et al. 2001). However,
parent-reported childhood shyness has also been found to
be a strong predictor of adolescent social anxiety symp-
toms (as reported by parent and child; Hayward et al.
2008).
Another accruing literature by developmental research-
ers has focused on anxious solitary youth or anxious soli-
tude/withdrawal. This is defined as an affective–behavioral
profile (typically assessed via peer nominations and/or
behavioral observations in school) where children engage
in high rates of solitary behavior (play alone, shyness)
when around familiar peers due to social anxiety and social
evaluation concerns (Gazelle 2010; Gazelle and Rubin
2010). There are conceptual similarities between the anx-
ious solitude/withdrawal developmental classification and
the clinical DSM classification of SAD (i.e., social fears
and social anxiety).
An empirical linkage between anxious solitude/with-
drawal and SAD has also been established. Gazelle et al.
(2010) found that relative to control children, children
identified by their peers in school as anxious solitude/
withdrawal (or anxious solitary) in the 3rd or 4th grade
were more likely to self-report clinical levels of SAD
symptoms and receive more DSM-IV diagnoses of SAD
via a structured interview with parents (30% vs. 12.5% of
control children). Thus, anxious solitary youth exhibit
elevated rates of SAD symptoms and SAD diagnoses.
In sum, research on nonclinical subthreshold conditions
and symptoms discussed above (depressive symptoms, DD,
social fears, social withdrawal/isolation, shyness, and
anxious solitude/withdrawal) finds they are quite similar,
conceptually and empirically, to MDD and SAD full-syn-
drome disorders. However, it is very important to note that
the subthreshold symptoms or characteristics appear to be a
risk factor for the development of MDD or SAD, as not all
youth with these subthreshold characteristics will develop
MDD or SAD.
332 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Risk Factors and the Developmental Psychopathology
Framework
A developmental psychopathology framework is useful to
understand these common and impairing disorders and
subthreshold conditions, as well as the risk and resilience
factors over the life span (Cicchetti and Toth 2009). A
developmental psychopathology prospective provides an
overarching theoretical framework for integrating develop-
mental and clinical psychology. As such, the emphasis is on
both normal and abnormal development, the risk and pro-
tective factors that are involved in the development of psy-
chopathological disorders, and the developmental course
and outcome for children with these disorders. Although a
number of potential mechanisms are involved in the conti-
nuity and discontinuity of psychopathology over time (see
Rutter et al. 2006a), it is necessary to recognize the interplay
of, and interaction of, risk and protective factors over time
(Cicchetti and Toth 2009). Central to the notion of cumu-
lative risk is that multiple sources of risk contribute to
negative outcomes, whereas more protective factors con-
tribute to better outcomes (Rutter 1979; Sameroff 2000).
In thinking about continuity and discontinuity, it is also
important to consider both homotypic and heterotypic
development (Cicchetti and Toth 2009; Costello et al.
2005). Homotypic development refers to a given sub-
threshold condition developing into the full-syndrome form
of that disorder over time. Heterotypic development refers
to a given subthreshold condition developing into other
full-syndrome disorders over time. These principles may
explain why many youth with DD are not only at risk of
developing MDD, but also anxiety disorders, conduct dis-
order, and substance abuse (Birmaher et al. 1996; Flory
et al. 2002; Kovacs et al. 1997), and not all youth with
MDD have DD or history of DD (Goodman et al. 2000).
Also, Gazelle et al.’s (2010) study found children with a
history of anxious solitude not only showed elevated rates
of SAD in comparison with control children, but they also
had elevated rates of other anxiety disorders and higher
rates of MDD.
These examples indicate that disorders, as well as con-
tinuity and discontinuity, are multiply determined, which
reflects the principles of equifinality and multifinality in the
developmental psychopathology perspective (Cicchetti and
Rogosch 1996; Cicchetti and Toth 2009). Equifinality
refers to the fact that different pathways or risk factors may
lead to the same outcome. Multifinality refers to the fact
that a same or given risk factor may lead to different out-
comes. The principles of equifinality and multifinality are
important with respect to social anxiety (or SAD) and
depression (or MDD) because these two constructs and
disorders are not only highly comorbid, but they also have
many similar interpersonal risk and protective factors.
Depression and Social Anxiety as Interpersonal
Disorders and Problems
Interpersonal theories for depression and social anxiety
symptoms and disorders in youth are beginning to appear
in the literature. Interpersonal processes are implicated in
the development of social anxiety and depression, and there
are also interpersonal consequences of social anxiety and
depression. After all, leading scholars in the area note that,
‘‘social phobia is fundamentally an interpersonal disorder’’
(Ollendick et al. 2010, p. 72); ‘‘any model of child anxiety
must incorporate the role of the family’’ (Cartwright-Hatton
2006, p. 815); and ‘‘comprehensive models of social anx-
iety in childhood must include peer adversity…(e.g., peer
exclusion and peer victimization)’’ (Gazelle 2010, p. 73).
More recently, Kaslow and her colleagues put forth criteria
for a relational diagnosis of depression in youth (see Ka-
slow et al. 2009). In addition to meeting DSM-IV diag-
nostic criteria for a depressive disorder (including MDD or
DD), the child or adolescent must live in a family where
one or more of the following are present: ‘‘attachment
problems, low cohesion and low support, inappropriate
levels of family control, high levels of family conflict and
ineffective conflict resolution, family violence, affect reg-
ulation difficulties, transmission of depressive cognitions,
and impaired communication patterns’’ (Kaslow et al.
2009, p. 536). In addition, there also needs to be a con-
tinuous pattern of relationships with peers, teachers, or
other adults, which involves ‘‘social isolation, rejection, or
criticism of the youth, and which is associated with low
social self-esteem and/or difficulties in interpersonal
problem solving’’ (p. 536).
Kaslow et al.’s (2009) criteria contains constructs that
overlap with the interpersonal theory of depression for
youth that was put forth by Rudolph et al. (2008). They
suggested that a number of interpersonal disturbances serve
as risk factors, correlates, and consequences of youth
depression. Early family disruptions, such as insecure
attachment and parental depression, are noted as salient, as
are social-behavioral deficits (including ineffective inter-
personal problem solving and conflict negotiation). Rela-
tionship disturbances with peers noted are peer rejection
and peer victimization as well as poor-quality friendships,
and poor-quality family relationships include constructs
such as low parental warmth and support, and high parental
psychological control (Rudolph et al.).
Rubin et al.’s (2009) transactional model of social
withdrawal leading to social anxiety and then possibly
depression contains similar constructs as the above models.
They propose that ‘‘social withdrawal may be the product
of an inhibited temperament, and insecure parent–child
relationship, shared genetic vulnerabilities or traits with the
parents, overly directive and protective parenting, and peer
Clin Child Fam Psychol Rev (2011) 14:329–376 333
123
rejection and victimization, and the interactions among all
of the above’’ (p. 160). The consequences of the above are
conceptualized to result in social anxiety and loneliness,
and if the youngster is not able to establish and/or maintain
close interpersonal relationships, this may lead to depres-
sion. Thus, relationships with parents and peers are central.
When conceptualizing the development and mainte-
nance of social anxiety and SAD in youth, interpersonal
relationships with parents and peers are also highlighted.
For example, Kearney’s (2005) integrated etiological
model of SAD incorporates, in addition to genetic and
temperamental vulnerabilities, such interpersonal con-
structs as insecure parent–child attachment, parent–child
relationships that are low in warmth and/or high in rejec-
tion, and exposure to parents that are anxious; and then
negative peer experiences such as direct peer rejection.
Moreover, supportive parenting and the development of
friendships are noted to be protective factors. In addition,
Rapee and Spence (2004) developed a comprehensive
model explaining the etiology of social fears and social
phobia that included, in addition to important genetic and
temperament factors, parent and peer influences. In par-
ticular, they highlight parenting behavior characterized by
parental overprotection and control (‘‘and to a lesser extent
less warmth’’ p. 752); and aversive social experiences
(such as peer rejection, exclusion, or social failure), which
increase the risk of social anxiety even further for children
with poor social skills.
Importance for Examining Similar and/or Differential
Interpersonal Risk Factors
As shown above, the constructs in the models noted above
for depression and social anxiety symptoms and disorders
overlap substantially. Although these theoretical models
have been developed separately, they all contain risk fac-
tors or influences of temperament, genetics, and parental
depression or anxiety. In addition, they have many similar
interpersonal parent- and peer-related constructs that are
noted to be salient. Hence, we examine, and integrate, the
empirical literature on many of the constructs in the above
theories, with a careful eye toward noting whether the
construct has been shown to be a correlate of or a risk
factor for depression and/or social anxiety in youth, at both
the symptom level and the diagnostic level. Given the high
rates of comorbidity of depression and social anxiety, as
noted by Starr and Davila (2008), identifying specific and
unique risk factors, correlates, and consequences of
depression and social anxiety may facilitate and contribute
to the development of theoretically- and empirically based
models of depression, social anxiety, and their comorbid-
ity. Comorbidity may also have consequences for inter-
personal outcomes of depression and/or social anxiety.
In efforts to understand or explain the comorbidity
between depression and social anxiety, a number of dif-
ferent processes may be involved (see Angold et al. 1999a;
Seligman and Ollendick 1998). First, the two disorders may
share the same risk factor(s). Thus, there may be a risk
factor that is a common or shared risk factor for depression
and social anxiety. Second, the risk factors for the disor-
ders may be separate and independent, yet the risk factors
co-occur. That is, an individual may have risk factor X for
depression and risk factor Y for social anxiety and then end
up having both disorders because he/she has the both the
separate risk factors X and Y.
Important for a cumulative risk model is the fact that risk
factors often co-occur. It has been shown via latent class
analysis that 17 various risk factors fall into five distinct risk
classes (two low-, two medium-, and one high-risk class) and
that these classes have some predictive utility with respect to
specific behavioral and/or emotional disorders (Copeland
et al. 2009). Importantly, the one ‘‘high-risk’’ class was
characterized by family dysfunction risks and parental
risk characteristics (including mental illness). Moreover,
Copeland et al. found psychiatric DSM disorders (including
depression and anxiety disorders) were more common for
youth in this high-risk class relative to the other risk classes.
Our focus now turns to examining risk factors for
depression and social anxiety. The areas we review, based
on the above theoretical models of depression and social
anxiety, are three core risk factors for psychopathology,
focusing on depression and social anxiety in particular:
temperament, genetics, and parental psychopathology.
Then, we review interpersonal risk factors from the models
described above: parent–child attachment, parenting
behavior, social skill deficits, peer acceptance and rejec-
tion, peer victimization, friendships, and loneliness.
Core Risk Factors
Temperament
‘‘Temperament is an ancient concept’’ (Clark and Watson
1999, p. 399) that has long been linked to psychopathology
(see Clark and Watson 1999,2008). Temperament gener-
ally refers to biologically based individual differences in
emotional reactivity and regulation that appear early in life
and can be shaped by the environment (Kagan 2008;
Rothbart and Bates 2006).
Emotional Reactivity and Affect
Contemporary models of temperament, in the personality
and clinical literature, suggest three higher-order temper-
amental traits: (1) Neuroticism/Negative Emotionality or
334 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Affectivity (NE/A); (2) Extraversion/Positive Emotionality
or Affectivity (PE/A); and (3) Disinhibition versus Con-
straint (Clark 2005; Clark and Watson 1999,2008). In
these models, NE/A reflects individual differences in
experiencing or reacting with distressing emotions, such as
fear, sadness, anger. PE/A refers to differences in social
engagement, fun-seeking, and experiencing or reacting
with positive emotions such as joy and enthusiasm. Dis-
inhibited individuals are impulsive, have difficulty delay-
ing gratification, and exhibit undercontrolled behavior.
Constrained individuals are more overcontrolled, avoiding
risk and danger. Disinhibition (versus constraint) is asso-
ciated with externalizing disorders in adults and youth
(Krueger et al. 2002,2007).
Contemporary theory regarding temperament and
depression and anxiety disorders posits that high NE/A
underlies depression and all anxiety disorders, and it may
account for their comorbidity. In contrast, low PE/A
underlies and is a specific vulnerability factor for depres-
sion and SAD (and not the other anxiety disorders; Clark
and Watson 2008; Mineka et al. 1998). Low PE/A thus is a
risk factor or a characteristic of social anxiety and
depression, which is not surprising given the social
engagement facet of PE/A and the interpersonal nature of
depression and social anxiety. This conceptualization is
supported in studies on adults (see Clark and Watson 2008;
Watson et al. 2005; Watson and Naragon-Gainey 2010).
Studies on samples of youth have focused more on
depression and/or general anxiety and have found, in
general, support for high NE/A being related to both
depression and anxiety, and low PE/A being specifically
related to depression (see Anderson and Hope 2008;
Tackett 2006 for reviews). More recently, lower PE/A (and
not NE/A) was found to predict higher levels of depressive
symptoms in adolescents 1 year later, after controlling for
earlier depression (Verstraeten et al. 2009). It should be
noted that all of these studies reviewed or referred to in this
paragraph used self-report measures of depression, anxiety,
and ‘‘temperament’’ constructs of NE/A and PE/A in older
children. However, a recent study found observational and
laboratory-based measures of 53 three-year-old children’s
PE/A predicted their depressive symptoms at age 10
(Dougherty et al. 2010), providing further evidence that
low PE/A is a risk factor for the development of
depression.
Another study by Dougherty et al. (2011) assessed a
large community sample of three-year-olds on laboratory
measures of temperament qualities and obtained caregiver
reports on DSM interviews. Interestingly, they found low
exuberance or low PE/A was common to both depression
and anxiety disorders in these preschoolers, when low PE/
A is noted to be related to social anxiety and not anxiety in
general (i.e., Clark and Watson 2008). Although 20% of
Dougherty et al.’s young sample had anxiety disorders,
SAD was not examined separately.
Studies examining social anxiety have found support for
social anxiety also being related to low PE/A as reported on
self-report measures, and this appears to be the case
especially in clinical samples or in youth with clinical
DSM diagnoses. For example, both depressive disorders
and SAD have been found to be associated with low PE/A
in clinic-referred youth (Chorpita et al. 2000). In a sample
of anxiety-disordered youth, higher NE/A and lower PE/A
were both associated with social anxiety and depression,
and additional analyses found PE/A scores were only
inversely related to social anxiety and not to other types of
anxiety (i.e., separation, worry; Hughes and Kendall 2009).
Moreover, in a nonclinical sample of adolescents, Anderson
et al. (2010) found self-reported social anxiety was related
to higher NE/A and lower PE/A. When they compared
those with SAD, elevated social anxiety, and a nonanxious
group, the SAD and socially anxious groups did not differ
from each other on NE/A, yet they each reported more NE/
A than the nonanxious group. On PE/A, a different pattern
emerged, with the SAD group reporting less PE/A than
both the socially anxious and nonanxious groups, with no
differences between the socially anxious and nonanx-
ious groups. As these authors noted, perhaps low PE/A
is only associated with diagnosed SAD and not social
anxiety symptoms. This notion is plausible, as findings on
our community sample of 198 8–12-year-olds revealed
PE/A was inversely related to children’s depressive
symptoms but was not related to their social anxiety, with
significantly stronger relations found between PE/A and
depression versus PE/A and social anxiety (Goodrich et al.
2008).
Consistent with a cumulative risk model, longitudinal
studies have noted the importance of the interaction of NE/
A with PE/A being pertinent for the development of
depression. Three studies using self-report measures have
found that the combination of high NE/A and low PE/A is
associated with: (1) depressive disorders, and changes over
time in depression, and not anxiety, in inpatient youth
(Joiner and Lonigan 2000); (2) 4th- through 11th-grade
youth changes in depressive symptoms over 7 months
(Lonigan et al. 2003); and (3) 6th- to 10th-grade adoles-
cents’ increases in anhedonic symptoms of depression over
a five-month period (Wetter and Hankin 2009). Another
longitudinal study that assessed 3-year-old children’s
temperament with parent report and laboratory and obser-
vational measures of NE/A and PE/A found neither NE/A
nor PE/A predicted depressive symptoms at age 7, yet the
interaction of mother-reported NE/A with PE/A predicted
depression at age 10, with high NE/A related to increases
in depression for children who were low in PE/A
(Dougherty et al. 2010). Thus, high NE/A and low PE/A,
Clin Child Fam Psychol Rev (2011) 14:329–376 335
123
together, have been found to be risk factors for the
development of depression.
To our knowledge, no studies have examined whether
NE/A and PE/A interact in their associations with, or are
related to the development of, social anxiety in youth. This
will be important for future research, especially with
respect to the PE/A dimension given the divergent findings
noted above with respect to PE/A being especially related
to social anxiety in clinical samples or youth with SAD.
Recent research on adult students and outpatients found
that various facets of PE/A show differential relations with
social anxiety and depressive symptoms (while controlling
for shared variance among the constructs; Naragon-Gainey
et al. 2009). Here, social anxiety was uniquely inversely
related to each of the four facets of PE/A: sociability,
positive emotionality, ascendance (i.e., assertiveness,
dominance), and fun-seeking. In contrast, depressive
symptoms only showed a strong inverse relation to positive
emotionality. Importantly, as these authors noted, their
findings indicate social anxiety is related to low positive
emotionality independent of depressive symptoms. Similar
research designs that examine various facets of NE/A and
PE/A (and their interactions) and their similar and/or dif-
ferential relations to depression and social anxiety are
clearly needed with youth.
Regulatory Processes
In addition to the reactive aspects of temperament, clinical
and developmental literature highlight the importance of
regulative aspects of temperament (Muris and Ollendick
2005; Rothbart and Bates 2006). One prominent regulative
temperament factor is effortful control (EC), which is ‘‘the
ability to inhibit a dominant response and/or to activate a
subdominant response’’ (Rothbart and Bates 2006, p. 129).
Attentional control, a component of EC, has been found to
be negatively related to children’s self-reported anxiety and
depression, after controlling for neuroticism or NE/A
(Muris et al. 2007). Thus, both reactive and regulatory
aspects of temperament are related to depression and
anxiety.
In line with a cumulative risk model, the interaction
between reactive and self-regulatory aspects of tempera-
ment may be critical in the development of psychopa-
thology (Lonigan et al. 2004; Muris and Ollendick 2005).
Here, EC is viewed as moderating the relation between NE/
A and psychopathology, such that high NE/A in combi-
nation with low EC, rather than merely high NE/A alone, is
associated with or yields risk of anxiety and depression.
Accruing research is consistent with this notion with
respect to anxiety (see Nigg 2006, Lonigan et al. 2004).
With regard to depression, NE/A was found to interact with
EC such that higher NE/A was associated with adolescents’
depression only at lower levels of EC (Verstraeten et al.
2009). Moreover, a similar pattern was found with PE/A,
yet only in girls, with lower PE/A associated with girls’
depression only at lower levels of EC. Thus, the combi-
nation of high NE/A and low EC is related to, and may
prove to be risk factors for, both depression and anxiety.
We know of no study that has examined social anxiety
with respect to EC and NE/A and PE/A, with the exception
of some work from our laboratory. Given that Muris et al.
(2004) found that EC did not moderate the relation between
NE/A and anxiety symptoms in 8–13-year-old children, we
examined mediation. We found that EC partially mediated
the relations between 8- and 12-year-old children’s NE/A
and each of anxiety, social anxiety, and depression, as well
as the relation between PE/A and depression (but not social
anxiety; Hoskinson et al. 2008). Additional studies are
clearly needed to examine the role of EC in social anxiety.
Behavioral Inhibition
Another large body of research has focused on behavioral
inhibition (BI), a behavior that has biological underpin-
nings (reviewed in Fox et al. 2005; Kagan 2008). BI is a
style of temperament that can be identified by 2 years of
age, and it involves being sensitive to novelty and threat in
the environment and the tendency to be shy, socially reti-
cent, and being wary of or withdrawing from unfamiliar
situations and unfamiliar peers (Fox et al. 2005; Fox 2010).
BI is considered to be a risk factor for the development of
anxiety disorders, particularly SAD. Overall, research has
shown that children who are behaviorally inhibited at a
young age are more likely to later develop anxious symp-
toms as well as anxiety disorders compared to children who
are uninhibited (Fox et al. 2005; Muris and Ollendick 2005;
Rapee 2002). Moreover, recent research has found that
early stable BI (reported by mothers over time) was related
to ongoing social anxiety symptoms, as well as lifetime
SAD diagnoses in adolescents (Chronis-Tuscano et al.
2009). The relation between BI and social anxiety (and
SAD) appears to be more substantial than the relation
between BI and any other anxiety disorder (Biederman et al.
2001; Chronis-Tuscano et al. 2009; Hirshfeld-Becker 2010;
Hirshfeld-Becker et al. 2007). Thus, BI has been found to be
a correlate and a risk factor for social anxiety and SAD.
BI has also been found to be a risk factor for developing
other anxiety disorders, as well as increased rates of MDD
and ADHD (Fox et al. 2005). Moreover, many anxious
solitude withdrawn youth and roughly half of youth with
SAD have no history of BI in childhood (see Gazelle
2010). As reviewed by Hirshfeld-Becker et al. (2008),
elevated levels of BI are also associated with depression
symptoms in children (e.g., Muris et al. 2001). Thus, BI is
also related to depression.
336 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Research also suggests that BI is a risk factor for
depression. Caspi et al. (1996) found that BI at the age of 3
was related to an increased risk of depression, and not
anxiety disorders, in young adulthood. However, BI may
have led to anxiety, which in turn contributed to later
depression, yet they did not assess lifetime diagnoses to
confirm this hypothesis. Utilizing SEM, Muris et al. (2001)
found tentative evidence that BI precedes anxiety, which
then leads to depression, although longitudinal research is
needed to corroborate these findings. Studies conducted by
Beesdo et al. (2007) and Gladstone and Parker (2006)
suggested that the relation between BI and MDD was
mediated by SAD, although both studies used retrospective
reports to assess BI.
Summary of Temperament and Evidence for Interpersonal
Relationships and a Cumulative Risk Model
High NE/A has been found to be related to both depression
and social anxiety in youth, and low PE/A has been found
to be a specific correlate of depression and a risk factor for
depression. Low PE/A has been found to be common to
depressive and anxiety disorders in very young children.
However, low PE/A appears especially related to social
anxiety or SAD in clinical samples or in youth with SAD,
although additional studies are needed. Consistent with the
notion of a cumulative risk model, a number of longitu-
dinal studies find that NE/A and PE/A interact such that the
combination of high NE/A and low PE/A is associated with
the development of, or increases of, depression over time.
No studies, however, have examined this with respect to
social anxiety. Regulatory processes, such as EC, need to
be considered in conjunction with emotional reactivity
(i.e., NE/A and PE/A), as the combination of high NE/A
and low EC has been found to be related to, and may prove
to be risk factors for, both depression and anxiety in youth.
However, no studies have examined this with respect to
social anxiety. Research indicates that BI is associated with
both depression and social anxiety, and BI has been found
to be a risk factor for depression and social anxiety (and
SAD).
Our review uncovered, as has been echoed in the liter-
ature (Nigg 2006), that various combinations of tempera-
ment constructs appear to place children at an increased
risk of depression and social anxiety, which is consistent
with the notion of a cumulative risk model. This indicates
the importance of future research to examine multiple
temperament factors, and their interactions, concurrently.
BI has been found to be related to children’s anxiety
symptoms, even after controlling for neuroticism or NE/A
(Muris et al. 2009). Thus, consistent with a cumulative risk
model, BI and NE/A may each contribute additively to or
interact with each other in the development of social
anxiety and/or depression, although future research is
needed to examine this possibility.
As others have noted, temperament may combine with
other risk factors or interact with other risk factors (Muris
and Ollendick 2005; Rothbart and Bates 2006). Interper-
sonal variables have been found to moderate the relation
between aspects of children’s temperament and depression
or social anxiety, or show additive effects, consistent with a
cumulative risk model. Adolescents’ PE/A has been found
to interact with their perceived support in relationships
with parents and peers, such that those with low PE/A and
low levels of perceived supportive relationships experi-
enced the greatest increase in depression over a 5-month
period (Wetter and Hankin 2009). Brendgen et al.’s (2005)
study of depressive symptom trajectories in youth aged
11–14 found that problematic relationships with parents (at
age 11–13) and children’s NE/A (assessed when the chil-
dren were age 6–7) were uniquely associated with
increasing and consistently high depression trajectories. In
contrast, sociometrically assessed peer rejection (at ages
11–13) predicted an increasing depression symptom tra-
jectory, but only for girls with high NE/A. Thus, the par-
ent–child relationships showed additive or unique effects
with NE/A, whereas interaction effects were found
between temperament and peer relationships. Similar
studies like this are needed to also include social anxiety.
With regard to social anxiety, research on 11–15-year-
old youth found that child-reported BI, attachment quality
with parents, and parental control and anxious rearing each
contributed unique variance to children’s SAD symptoms
(van Brakel et al. 2006). Thus, BI, insecure parent–child
attachment, and parental control contribute independent or
additive relations to children’s social anxiety. Moreover,
2-year-olds’ inhibited temperament predicted their social
reticence (i.e., wariness and anxiety) in unfamiliar nonso-
cial and social situations at age 4 only if their mothers were
intrusively controlling and overprotective and/or made
high levels of derisive or critical comments about the child
(Rubin et al. 2002). Indeed, evidence that temperament
interacts with parent and peer relationships is building (i.e.,
Brendgen et al. 2005; Degnan et al. 2010).
Genetic Aspects of Depression and Social Anxiety
In addition to temperament, etiological models of social
anxiety and depression (reviewed earlier) contain genetic
influences. Anxiety and depressive disorders and symp-
toms, in general, tend to aggregate in families. In terms of
depression, findings from quantitative genetic studies sup-
port a genetically inherited liability for MDD and depres-
sive symptoms in childhood, adolescence, and adulthood.
However, genetic influences are moderate, and there are
substantial shared and nonshared environmental influences
Clin Child Fam Psychol Rev (2011) 14:329–376 337
123
as well (for reviews see Lau and Eley 2008,2009,2010).
Shared environment encompasses factors that make twins
or family members similar to one another (e.g., family
socioeconomic status, parenting styles), whereas nonshared
environmental influences encompass factors that make
twins or family members different from one another (e.g.,
peer relationships, outside-of-family-life experiences).
Twin studies have found heritability estimates for
depression in childhood to be between 30 and 80%
(Avenevoli et al. 2008). Heritability estimates or genetic
effects appear to be larger in adolescence versus childhood
or adulthood (Lau and Eley 2010). Several studies find
smaller shared environmental effects in adolescents than in
children (Lau and Eley 2008,2009). Thus, environmental
influences in depression may vary with respect to youth age.
In terms of anxiety disorders, there is also familial
aggregation as well as modest yet significant genetic
influences (see Rapee et al. 2009). Findings with respect to
genetic influences on anxiety in children show that anxiety
is heritable, yet both shared and nonshared environment
factors likely play a role and ‘‘environmental factors are at
least of equal importance’’ (reviewed by Gregory and Eley
2007; p. 209). As noted by Gregory and Eley (2007),
studies on adult anxiety do not find significant shared
environmental influences, while shared environmental
influences are significant for anxiety disorders in youth.
Twins and family members are more likely to share envi-
ronments early in life and not in adulthood, thus shared
environment factors, such as parenting, would likely exert
more influence in early to middle childhood. In contrast,
nonshared environmental influences, such as the peer
group, might likely exert more influence on anxiety, and
depression, in adolescence, given that parents and adoles-
cents spend less time together as adolescents begin to
spend more time with peers (Hill et al. 2007).
In terms of social anxiety, there is familial aggregation
of shyness, social anxiety, and SAD (reviewed by Bogels
et al. 2010; Hirshfeld-Becker 2010). As concluded by
Rapee and Spence (2004) ‘‘genetic factors play a modest
but significant role in the development of social phobia and
social anxiety, in both children and adults’’ (p. 744). Twin
studies find the heritability estimates for SAD to range
from 30 to 50% (Hirshfeld-Becker 2010). However, one
recent twin study found only nonshared environment was
found to have a significant influence on SAD in early
childhood, and nonsignificant influences of genes and
shared environment (Eley et al. 2008), which is in contrast
to some other studies. The findings by Eley et al. (2008)
highlight the importance of nonshared environmental
influences on SAD.
There are also shared/common genetic influences on
depression and anxiety symptoms and disorders, which
may also explain the comorbidity between depression and
anxiety (Lau and Eley 2010; Rapee and Spence 2004). In
fact, with respect to social anxiety, ‘‘No study has dem-
onstrated specific transmission of social anxiety within
families that is independent from this broader liability to
mood and anxiety problems’’ (Bogels et al. 2010, p. 181).
What is genetically inherited appears to be a broader
genetic predisposition or risk factor for depression and
anxiety problems, and then disorder specificity (or not
developing a disorder) is determined by environmental
influences (Bogels et al. 2010; Lau and Eley 2010; Rapee
and Spence 2004). This is conveyed by research that shows
that different types of anxiety disorders and anxiety-related
behaviors in youth (including SAD and social anxiety)
have been found to have different contributions of genetic
influences, as well as shared and nonshared environmental
influences (Eley et al. 2008; Hallett et al. 2009). Impor-
tantly, nonshared environmental influences (e.g., peer and
parent relationships) differentiate anxiety subtypes and are
particularly salient for social anxiety and SAD (Eley et al.
2008; Hallett et al. 2009).
In considering the extent of genetic influences, it is
important to note that heritability estimates contain gene–
environment interactions, and therefore heritability
estimates minimize or underestimate the effects of envi-
ronmental influences (Rutter et al. 2006b). Gene–environ-
ment interactions ‘‘refer to the situation where genetic
factors influence individual sensitivity or response to envi-
ronmental adversity or context’’ (Thapar et al. 2007, p. 989).
Thus, genetic characteristics (e.g., high/low genetic liability,
presence/absence of certain genes) influence or moderate the
relation between environmental risk and psychopathology,
such that the relation between environmental risk and out-
come is stronger or greater in the presence of high versus low
genetic liability (Rutter et al. 2006b). For example, in a
longitudinal study using twins (aged 5–15), the influence of
family conflict in predicting depression varied with respect
to genetic risk of depression, and youth with a genetic vul-
nerability to depression, relative to those without, were more
likely to develop depression in response to family conflict
(Rice et al. 2006). Consistent with a cumulative risk model,
family interpersonal risk factors for depression may be more
salient for youth with a genetic liability for depression ver-
sus youth without a genetic liability.
Summary of Genetics and Evidence for Interpersonal
Relationships and a Cumulative Risk Model
Findings from quantitative genetic studies indicate that
genetic factors play a modest, yet significant, role in each of
depression, anxiety, and social anxiety. Shared or common
genetic influences may explain, at least in part, the comor-
bidity between depression and anxiety (Lau and Eley 2010).
However, shared (e.g., parenting styles) and nonshared (e.g.,
338 Clin Child Fam Psychol Rev (2011) 14:329–376
123
peers) environmental influences are both critical in social
anxiety and depression. Importantly, nonshared environ-
mental influences have been found to differentiate social
anxiety from other types of anxiety (Hallett et al. 2009), and
to be the only influence on SAD in early childhood (Eley
et al. 2008). Thus, nonshared environmental influences may
be especially pertinent for social anxiety. Moreover, genetic
liability has been found to moderate the relation between a
interpersonal risk factor (i.e., family conflict) and depression
(Rice et al. 2006). Thus, family interpersonal risk factors for
depression may be more salient for youth with a genetic
liability for depression versus youth without a genetic lia-
bility. It is also important to note that offspring of a parent
with SAD or MDD are genetically and environmentally at
risk of MDD and/or SAD.
Parental Depression, Anxiety, and SAD
A large literature has accrued documenting a wide range of
outcomes for children of depressed mothers (see Goodman
and Gotlib 1999,2002; Goodman and Tully 2008). A
20-year prospective study found maternal depressive
symptoms in infancy predicted children’s depression in
middle childhood and in adolescence, even after controlling
for maternal concurrent and recurrent depression (Bureau
et al. 2009). Children of depressed mothers are not only at
risk of depression, but for a range of problems including
anxiety and conduct disorder (Goodman 2007; Shanahan
et al. 2008). Indeed, three-generation studies have found: (1)
high-risk grandchildren (i.e., those with at least one grand-
parent with MDD), regardless of their parents’ depression
status, have higher rates of mood disorders (including MDD)
and anxiety disorders than low-risk grandchildren and (2)
MDD in both grandparent and parent was associated with the
highest rates of depression in offspring (Weissman et al.
2004). Similar findings were echoed in another three-gen-
eration study, where 97% of the grandchildren were under
the age of 10 and parent-reported grandchildren’s internal-
izing behavior and anxious/depressed behavior were asses-
sed on the CBCL (Pettit et al. 2008). Pettit et al. found
grandparent MDD interacted with parent MDD in predicting
grandchildren’s internalizing behavior, with greater anx-
ious/depressed symptoms reported for grandchildren with
both depressed parents and grandparents. Thus, grandparent
MDD and parent MDD is associated with grandchildren’s
MDD and anxiety disorders, and associated with young
grandchildren’s anxious/depressed behavior. Furthermore,
adolescent offspring of parents with MDD have been found
to have over three times greater risk of SAD relative to
offspring of parents with no disorder (Lieb et al. 2000).
Compared to depression, far less research has focused
on anxiety in parents. However, a recent meta-analysis
conducted by Micco et al. (2009) revealed similar patterns
that have emerged with parental depression. Micco et al.
found offspring of parents with an anxiety disorder, com-
pared to offspring of normal control parents, have (1)
almost four times greater risk of anxiety disorders and over
two and a half times greater risk of depressive disorders
(MDD or DD) and (2) greater odds of having each type of
anxiety disorder (including SAD) and MDD. Thus, parental
anxiety disorders are associated with elevating risk of
children to have anxiety disorders, SAD, and MDD.
However, Olino et al. (2010) found parental MDD and not
anxiety disorders was related to parents’ reports of 2-year-
olds’ internalizing behaviors. Methodological and age
differences could account for these different findings, as
Olino et al. had very young children who were assessed via
parent-reported symptoms and not diagnostic interviews.
As Micco et al. (2009) note, very few studies have
examined the transmission of specific types of anxiety
disorders from parent to child, including SAD. However,
children with anxiety disorders, relative to children with no
disorders, have been found to have almost three times
higher rates of having mothers with SAD, and children
with SAD, relative to those without SAD, were over twice
as likely to have mothers with SAD (Hughes et al. 2009).
Moreover, adolescent offspring of parents with SAD have
been found to have over four and a half times greater risk
of SAD relative to offspring of parents with no disorder
(Lieb et al. 2000). Thus, parental SAD is associated with
elevated risk of anxiety disorders and SAD.
Comorbid Depression and Anxiety in Parents
The meta-analysis by Micco et al. (2009) compared off-
spring of four groups: parents with (1) anxiety disorders
alone; (2) MDD alone; (3) comorbid anxiety disorder and
MDD; and (4) no disorders. Although all three psychiatric
offspring groups had higher odds of developing a depressive
disorder and any anxiety disorder compared to the offspring
of nonpsychiatric control parents, the three psychiatric off-
spring groups did not differ significantly from one another in
the odds of developing either any anxiety disorder or any
depressive disorder. Thus, parents with comorbid depression
and anxiety do not confer additional risk of offspring
depression or anxiety, beyond the risk of either depression or
anxiety disorders alone. These findings dovetail with a
recent study involving parents with anxiety disorders (not in
Micco et al.’s meta-analysis) that found after accounting for
parental anxiety, parental depressive symptoms had no
additive effects on the relation between parental anxiety and
6–14-year-old children’s depressive or anxiety symptoms
(Burstein et al. 2010). Likewise, in a 20-year follow-up of
offspring of parents with MDD (not in the Micco et al.’s
meta-analysis), the three times higher risk of anxiety dis-
orders in offspring of depressed parents, relative to offspring
Clin Child Fam Psychol Rev (2011) 14:329–376 339
123
having no parent with MDD, was not explained by parental
comorbid anxiety disorders (Weissman et al. 2006). Thus,
offspring of parents with MDD, anxiety disorders, and
comorbid depression and anxiety are at similar risk of
depression and anxiety disorders (including SAD).
Mechanisms of Risk
A number of mechanisms underlying the transmission of
risk of depression from mother to child have been proposed
and examined (see Goodman 2007; Goodman and Gotlib
1999; Joormann et al. 2009). One such mechanism includes
exposure to a mother who models negative or depressive
behavior, affect, and cognitions, and literature is accruing
in support of this mechanism (see Blount and Epkins 2009;
Goodman 2007). Another possible mechanism is the neg-
ative effects that depression has on parenting and the par-
ent–child relationship. Depression in mothers is associated
with more negative and less positive parenting behaviors,
such as increased hostility, more negative parent–child
interactions, and less responsiveness (Wilson and Durbin
2010). Studies show support for aspects of mothers’ par-
enting and the mother–child relationship mediating the
relation between mothers’ depression and depression and
other problems in children (see Goodman 2007).
Similar to depression, parents with anxiety disorders
have some different parenting behaviors than parents that
do not have anxiety disorders (e.g., Turner et al. 2003).
Moreover, a number of learning mechanisms have been
documented with respect to the transmission of anxiety
from parent to child. Children can learn fears and anxiety
through observational learning and parental modeling of
anxiety, and parents reinforcing anxious and/or avoidant
behaviors in their children (see Fisak and Grills-Taquechel
2007). Modeling has also been used to explain the linkages
between child and mother, and not father, specific anxiety
disorders (including SAD) that have been found (Hirshfeld-
Becker 2010; Hughes et al. 2009). The notion here is that
mothers may be the main caregiver, and thus children may
spend more time observing mothers’ versus fathers’
behaviors. Children can also learn anxiety from their par-
ents via information transfer, which refers to parents
communicating information about threat or harm-provok-
ing situations. Research is accruing in support of the
information transfer mechanism of children learning anxi-
ety from their parents, and from anxious parents (Fisak and
Grills-Taquechel 2007; Lester et al. 2009; Muris et al.
2010). No study has examined parents’ information transfer
to children regarding social fears (c.f., Field et al. 2003,
who examined social fears with information given by tea-
cher and peers). However, other research has found that
parents of anxiety-disordered children (18% with SAD),
relative to parents of control youth, reported lower or more
pessimistic expectations of their children (in social/peer
and other areas), consistent with the notion of information
transfer (Eisen et al. 2004).
Fathers
In recent years, fathers’ depression and anxiety has
received more research attention. Meta-analyses find that
paternal depression is related to children’s internalizing
problems and disorders (Kane and Garber 2004). In addi-
tion, three-generation studies do not find differences in
maternal versus paternal MDD, or grandmother versus
grandfather MDD, impacting young children’s internaliz-
ing behavior (Pettit et al. 2008). Less research has been
done on fathers’ anxiety, although some have found ele-
vated lifetime rates of anxiety disorders in both mothers
and fathers of children with anxiety disorders, relative to
parents of children with no disorder (Cooper et al. 2006).
Consistent with a cumulative risk model, Merikangas et al.
(1988) found that when both mothers and fathers have
anxiety disorders (and to a lesser extent MDD), the com-
bination substantially increased the risk of MDD and
anxiety disorders in children. Moreover, they found that
comorbid MDD and anxiety in both mothers and fathers
appear associated with increased risk of offspring comorbid
MDD and anxiety, relative to risk with only one parent
with comorbid MDD and anxiety. Thus, having two parents
(versus one parent) with anxiety disorders, or having two
parents with comorbid MDD and anxiety disorders, confers
additional increased risk for offspring to have anxiety
disorders and comorbid MDD and anxiety.
The mechanisms underlying the transmission of risk
from father to offspring appear similar as to the mechanisms
discussed above with respect to mothers. Paternal depres-
sion has been found to have effects on fathers’ decreased
positive and increased negative parenting behaviors, with
similar effect sizes that have been found for mothers
(Wilson and Durbin 2010). Meta-analyses also find paternal
depression is related to conflict in the father–child rela-
tionship (Kane and Garber 2004). Moreover, a recent pro-
spective study found that after controlling for mothers’
depression, fathers’ depression was related to adolescents’
depression only for girls who perceived low closeness in the
father–child relationship (Reeb and Conger 2009).
Summary of Parental Depression, Anxiety, and SAD
and Evidence for Interpersonal Relationships
and a Cumulative Risk Model
Parental depression, anxiety, and SAD have each been
found to be a risk factor for each of youth depression,
anxiety, and social anxiety (or SAD). Offspring of parents
with MDD, anxiety disorders, and comorbid depression and
340 Clin Child Fam Psychol Rev (2011) 14:329–376
123
anxiety disorders are at similar risk of depression and
anxiety disorders (including SAD). Thus, parents with
comorbid depression and anxiety do not confer additional
risk of offspring depression or anxiety, beyond the risk of
either depression or anxiety disorders alone (Micco et al.
2009). Importantly, parenting and aspects of the mother–
child relationship have been found to explain (mediate) the
relation between maternal depression and youth depression
(Goodman 2007), and similar findings are beginning to
emerge with respect to paternal depression. Parental
behaviors and aspects of parent–child relationships have
also been found to explain the linkages between parent and
child anxiety, and parent and child social anxiety (Fisak and
Grills-Taquechel 2007, Hirshfeld-Becker 2010; Hughes
et al. 2009).
In support of a cumulative risk model, it appears that the
combination of two parents (versus one parent) with anxiety
disorders, or the combination of two parents with comorbid
MDD and anxiety disorders, confers additional increased
risk for offspring to have anxiety disorders and comorbid
MDD and anxiety. Thus, in future studies, it will be
important to assess both the maternal and paternal psy-
chopathology, and their combined relation to youth
depression and social anxiety. Moreover, grandparent MDD
and parent MDD, together, also appear to result in a
cumulative, additional, risk of grandchildren’s MDD, anx-
iety disorders, and young grandchildren’s anxious/depres-
sed behavior (Pettit et al. 2008; Weissman et al. 2004).
Overall Summary on Core Risk Factors and Evidence
for a Cumulative Risk Model
Temperament, genetics, and parents’ psychopathology are
each noted as risk factors in etiological models of depres-
sion and social anxiety. Our review uncovered that they are
indeed risk factors. Importantly, as we have demonstrated,
these risk factors interact with, or depend on, the presence
or absence of other risk factors or protective factors, pri-
marily aspects of children’s relationships with parents and
peers. These findings highlight the interpersonal nature and
aspects of children’s depression and social anxiety and are
in line with a cumulative risk model.
These three core risk factors have been shown to be
interrelated and/or interact with each other in conferring
risk. For example, the relation between temperament and
risk of depression and/or social anxiety may be related to, or
interact with, parents’ psychopathology (see Hirshfeld-
Becker 2010). A 20-year follow-up study of offspring with
parental MDD found offspring temperament (as assessed by
late adolescents’ self-report) partially mediated the relation
between parental MDD and offspring MDD (Bruder-
Costello et al. 2007), indicating one core risk factor (tem-
perament) may partially explain the relation between
another core risk factor (parental MDD) and youth
depression. Aspects of 3-year-old children’s laboratory-
assessed temperament (NE/A and BI) have been found to be
associated with increased probability of having parents with
depression and not with anxiety disorders or SAD (Olino
et al. 2010). Thus, parental depression (vs. anxiety or SAD)
may be more related to child temperament. Longitudinal
research has also found that infant BI was only related to
children’s later social wariness (a composite of shyness,
anxiety, and social reticence) for children with mothers
high, and not low, on negativity (a composite of neuroticism
and depression; Degnan et al. 2008). When mothers were
low on negativity, infant temperament was not related to
children’s later social wariness. Thus, consistent with a
cumulative risk model, one core risk area (i.e., parents’
psychopathology) moderates or interacts with another core
risk area (i.e., temperament). Now we turn to specific par-
ent-related interpersonal risks, including parent–child
attachment, parenting, and parent–child relationships.
Parent-Related Interpersonal Relationship Problems
Parent–Child Attachment
Insecure attachment between the child and primary care-
giver has been noted to be a contributing factor to anxiety
and social anxiety (Hudson and Rapee 2009; Kearney 2005)
and depression (Rudolph et al. 2008). As reviewed by
Brumariu and Kerns (2010b), three types of insecure attach-
ment have been identified: ambivalent, avoidant, and disor-
ganized. Ambivalently attached children display fearfulness,
heightened negative emotions, and dependence as a way to
gain attention of their caregiver because of the caregiver’s
inconsistent availability. Avoidantly attached children mask
negative emotions and work to be self-reliant because they
have historically experienced frequent rejection from their
caregiver when trying to elicit comfort after being distressed.
Children who have disorganized attachment exhibit ‘‘con-
tradictory, bizarre, and incoherent behaviors’’ (p. 178)
because they view the caregiver as a secure base yet also
psychologically unavailable and a source of apprehension. If
a child unsuccessfully predicts an attachment figure’s avail-
ability, particularly when in distress or separated from the
figure, the child will in turn feel anxious. Also, a caregiver’s
lack of availability can cause the children to believe they are a
failure, and can lead to depression.
Parent–Child Attachment and Subclinical/Clinical Social
Anxiety
Longitudinal studies have found ambivalent attachment is a
risk factor for social anxiety. Boys who were ambivalently
Clin Child Fam Psychol Rev (2011) 14:329–376 341
123
attached at 12 months of age, compared to boys who were
securely attached, had significantly more SAD symptoms
when they were 11 years old (Bar-Haim et al. 2007).
Similarly, ambivalent attachment in the 3rd grade predicted
three different aspects of social anxiety (fear of negative
evaluation, social avoidance in new situations, and gen-
eralized social avoidance) in the 5th grade (Brumariu and
Kerns 2008). Finally, Warren et al. (1997) found ambiva-
lent attachment in infancy predicted anxiety disorders in
the youth 16 years later. At 17 years of age, 26 (15%)
developed an anxiety disorder, and the majority of these 26
youth developed SAD (38.5%) versus other anxiety
disorders.
In addition to ambivalent attachment, there is support
for disorganized subtype of insecure attachment being
associated with social anxiety. Brumariu and Kerns
(2010a) found that children between the ages of 10 and 12
with more disorganized attachment representations repor-
ted more SAD symptoms, while children with ambivalent
attachment representations were more likely to report
separation anxiety, not SAD symptoms. Studies have found
nonsignificant relations between avoidant attachment and
social anxiety (Brumariu and Kerns 2008,2010a).
Parent–Child Attachment and Subclinical/Clinical
Depression
Rudolph et al. (2008) theorized that insecure attachment
and/or parental depression can lead to relationship distur-
bances within peer and family networks, which may ulti-
mately contribute to depression. Mothers with MDD are
more likely to develop insecure attachments with their
children than their mildly depressed or nondepressed
counterparts (Goodman and Tully 2008).
As reviewed by Brumariu and Kerns (2010b), studies
have demonstrated a relation between insecure attachment
and depression whether assessed concurrently or longitu-
dinally. According to their review, four studies (two lon-
gitudinal and two concurrent) have examined attachment
and MDD, with only one longitudinal study yielding
insignificant results.
Similar to studies on social anxiety, few studies have
examined specific forms of attachment. Thus far, disorga-
nized attachment has been linked to concurrent and future
childhood depression, while ambivalent attachment has
only been found to be concurrently related to preadoles-
cent/adolescent depression (Brumariu and Kerns 2010b).
Parent–Child Attachment and Both Social Anxiety
and Depression
No study has examined attachment and social anxiety and
depression, and to the best of our knowledge, only one
longitudinal study has examined attachment and anxiety
and depression. In a sample of 6th to 10th graders, Lee and
Hankin (2009) measured attachment along two dimensions:
anxious and avoidance. Those who score high on anxious
dimension have a fear of rejection while those who score
high on avoidance are uncomfortable getting close to oth-
ers. Adolescents completed self-report measures at four
time points, within a 5-month period, and approximately
5 weeks apart. Even after controlling for initial levels of
depression and anxiety, anxious and avoidant attachment
styles each uniquely predicted changes in depressive and
anxious symptoms over time. Thus, attachment is a risk
factor for developing depressive and anxious symptoms.
Similar studies are needed with younger children, and to
examine social anxiety and depression.
Summary of Parent–Child Attachment and Evidence
for a Cumulative Risk Model
As seen in Table 1, ambivalent attachment is related to
depression and not to social anxiety; yet, it has been
repeatedly shown to be a risk factor for social anxiety.
Disorganized attachment is related to social anxiety and
depression and is a risk factor for depression. Avoidant
attachment is not associated with social anxiety and has not
been examined with depression. However, an anxious/
avoidance attachment style has been found to predict
changes in anxious and depressive symptoms over time in
adolescents (Lee and Hankin 2009). Consistent with the
notion of cumulative risk, attachment dysfunction (secure
versus insecure) has also been found to moderate the
relation between social withdrawal (a risk factor for
depression) and depressive symptoms, such that social
withdrawal was more robustly related to depression for
children with higher versus lower level of attachment
dysfunction (Gullone et al. 2006).
Paternal attachment has largely been neglected in
research, despite evidence of its importance. Paternal
attachment with adolescent sons and daughters has been
found to be a better predictor of adolescents’ depression
than was maternal attachment (Liu 2008). Moreover,
secure maternal and paternal attachment has been found to
be related to children having higher levels of perceived
peer acceptance compared to children with a secure
attachment with only one caregiver (Diener et al. 2008).
Thus, the combination of paternal and maternal attachment
should be considered in future research on depression and
social anxiety.
Parenting and Parent–Child Relationships
Parental rejection and control (both autonomy granting and
psychological control) have been theorized to be linked to
342 Clin Child Fam Psychol Rev (2011) 14:329–376
123
depression and social anxiety. More specifically, Rudolph
et al. (2008) theorized that family relationships character-
ized by a lack of warmth and intimacy and an abundance of
hostility, criticism, and psychological control contribute to
depression. While Kearney (2005) suggested both parental
rejection and control are related to SAD, Rapee and Spence
(2004) emphasized parental overprotection and control.
Rubin et al. (2009) emphasized parental overprotection,
intrusiveness, and psychological control in a model of
social withdrawal.
In large part, factor analyses reveal two main parenting
constructs: rejection and control (Rapee 1997). Both parent-
ing constructs can be viewed as being on a continuum. On one
continuum, parental rejection and criticism are on one side,
while acceptance and warmth are on the reverse. Parental
rejection is defined as ‘‘excessive disapproval, criticism, and
lack of contact with the child’’ (McLeod et al. 2007a,p.987).
Conversely, parental acceptance can be described as the
parent expressing warmth and being responsiveness to the
child’s feelings and behaviors (Wood et al. 2003). In terms of
parental control, overprotection and autonomy are on
opposing sides of the continuum (Rapee 1997). Controlling
parents are overinvolved in their child’s activities and deci-
sions, encourage dependence, and attempt to influence chil-
dren’s thoughts and feelings (McLeod et al. 2007a).
Importantly, some researchers contend that parental
psychological control and behavioral control are unique
constructs. According to Barber (1996), psychological
control is defined as ‘‘control attempts that intrude into the
psychological and emotional development of the child
(e.g., thinking processes, self-expression, emotions, and
attachment to parents),’’ while parental behavioral control
is defined as the ‘‘attempt to control or manage children’s
behavior’’ (p. 3296).
Table 1 Summary of findings on relations of aspects of attachment and parenting to social anxiety and depression
Attachment Parenting
Insecure attachment
DEP (Brumariu and Kerns 2010b, CR and RF, mixed
findings)
Ambivalent attachment
SANX (Bar-Haim et al. 2007, RF, boys; Brumariu and
Kerns 2008, RF; Warren et al. 1997, RF)
NOT SANX (Brumariu and Kerns 2010a, CR)
DEP (Brumariu and Kerns 2010b, CR)
Avoidant attachment
NOT SANX (Brumariu and Kerns 2008, CR; Brumariu
and Kerns 2010a, CR)
Disorganized attachment
SANX (Brumariu and Kerns 2010a, CR)
DEP (Brumariu and Kerns 2010b, CR and RF)
High anxious/high avoidance
ANX and DEP (Lee and Hankin 2009, RF)
Low warmth/acceptance/support
SANX (Knappe et al. 2009a, RF; Knappe et al. 2009b, RF) (same sample, used
retrospective self-report of parenting)
NOT SANX (Bogels et al. 2001, CR; La Greca and Lopez 1998, CR; Lieb et al.
2000, CR; Rork and Morris 2009, CR)
NOT SANX after controlling for DEP (Hutcherson and Epkins 2009, CR, girls)
DEP (McLeod et al. 2007a, meta-analysis, CR, medium effect; Sheeber et al. 2007,
CR; Dallaire et al. 2006, CR; Hipwell et al. 2008, RF and Weak CQ, girls; Sheeber
et al. 1997, RF but not CQ; Stice et al. 2004, RF but not CQ, girls)
DEP after controlling for SANX (Hutcherson and Epkins 2009, CR, girls)
Rejection
SANX (Knappe et al. 2009a, RF; Knappe et al. 2009b, RF; Lieb et al. 2000, CR)
(all same sample, used retrospective self-report of parenting)
NOT SANX (Bogels et al. 2001, CR; Festa and Ginsburg 2011, CR; Greco and
Morris 2002, CR, fathers)
DEP (McLeod et al. 2007a, meta-analysis, CR, medium effect)
Controlling/overinvolved/overprotective
SANX (Festa and Ginsburg 2011, CR, self-report; Greco and Morris 2002, CR,
fathers; Lieb et al. 2000, CR; Rork and Morris 2009, CR, mothers and boys only);
(Knappe et al. 2009a, RF; Knappe et al. 2009b, RF; same sample, used
retrospective self-report of parenting)
NOT SANX (Bogels et al. 2001, CR; Festa and Ginsburg 2011, CR, behavioral
observation; Rork and Morris 2009, CR, fathers only)
DEP (McLeod et al. 2007a, meta-analysis, CR, small effect)
More negative commands (parental aversive behavior/conflict)
SANX (CR: Hummel and Gross 2001; Rork and Morris 2009 mothers only)
NOT SANX after controlling for DEP (Starr and Davila 2008, CR, girls)
DEP (McLeod et al. 2007a, meta-analysis, CR, medium effect) Dallaire et al. 2006,
CR; Sheeber et al. 2007, CR; Sheeber et al. 1997, RF but not CQ; Hipwell et al.
2008, RF and Weak CQ, girls)
DEP after controlling for SANX (Starr and Davila 2008, CR, girls)
DEP depression, SANX social anxiety, CR correlate, RF risk factor, CQ consequence
Clin Child Fam Psychol Rev (2011) 14:329–376 343
123
Parenting and Subclinical/Clinical Social Anxiety
Bogels et al. (2001) examined 8–18-year-old children’s and
parents’ report of parental rejection, overprotection, and
warmth in a socially anxious clinic group, a clinic control
group, and a normal control group. The socially anxious
clinic youth differed from the normal control group on five
of the six scales (exception being child-reported overpro-
tection), yet they did not differ significantly from the clinic
control group on any child- or parent-reported measure.
Thus, as they noted, these aspects of parenting were not
specific to social anxiety versus psychopathology in gen-
eral. Using the same child self-report measure as Bogels
et al., Festa and Ginsburg (2011) found 7–12-year-old
children’s self-reported social anxiety was related to their
perceived parental overprotection and not rejection
(warmth was not examined). The difference between these
two studies with respect to child-reported overprotection
may be due to the nature of the samples. As Bogels et al.’s
clinic sample was clinic-referred youth, half of Festa and
Ginsburg’s sample had parents with an anxiety disorder
and none of the children had any disorder.
Using a similar self-report questionnaire on parenting
constructs, Lieb et al. (2000) examined a large sample of
14–17-year-old adolescents. They found perceived parental
overprotection and rejection were associated with
increased odds of having a SAD diagnosis (at baseline or
20-month follow-up). Parental warmth was not related to
increased odds of having SAD. Continued follow-ups of
this sample at 4 and 10 years after baseline have examined
how the earlier-obtained (at 20-month follow-up) per-
ceived parenting constructs relate to cumulative lifetime
SAD as well as subthreshold SAD (Knappe et al. 2009a,b).
Their findings indicated that those with subthreshold SAD
reported more parental rejection and overprotection rela-
tive to those without SAD. Similar findings were found
with respect to SAD versus no SAD, yet the SAD group
also reported less parental warmth than those with no SAD.
As these authors noted, the retrospective self-report mea-
sure of parenting for these late adolescents (completed
when they were Mage 19.7 months) may not tap actual
parenting per se and their perception of negative parenting
may also be a result of psychopathology.
Hummel and Gross (2001) found parents of 9–12-year-
old children with high SAD symptoms used more negative
statements compared to parents of control children while
working on a puzzle. Similar findings emerged in a study
by Rork and Morris (2009) that used a direct observation
task with both parents and preadolescent children. They
found that maternal negative commands were related to
children’s social anxiety. In addition, child-reported
maternal overprotection (not paternal overprotection) was
related to boys’, but not girls’, social anxiety. Conversely,
parental warmth was not related to either boys’ or girls’
social anxiety. These findings dovetail with those of La
Greca and Lopez (1998) who found adolescents’ self-
reported social anxiety was not related to their perceived
parental support, and Lieb et al.’s (2000) finding that
parental warmth was not associated with having a SAD
diagnosis in adolescents.
Consistent with these findings, a meta-analysis by
McLeod et al. (2007b) found parental warmth explained
less than 1% of the variance in child anxiety. Moreover,
they found that parental control had a significantly stronger
association with childhood anxiety (a medium effect)
compared to parental rejection (a small effect). In fact,
autonomy granting (a dimension of control) accounted for
18% of the variance of children’s anxiety (a large effect).
However, a recent study used a behavioral observation task
and found a variable combining overprotection/overcontrol
and granting autonomy was not related to 7–12-year-old
children’s self-reported social anxiety or to an independent
evaluator ratings’ of children’s social anxiety, in a sample
where half of the mothers had an anxiety disorder (Festa
and Ginsburg 2011).
Importantly, youth anxiety has been found to influence
parental behavior (e.g., Eley et al. 2010; van der Bruggen
et al. 2010). For example, Hudson et al. (2009) paired
mothers of clinically anxious children and mothers of
nonclinical children with their own child, an anxious child,
and nonanxious child in preparing a speech. Overall,
mothers were more overinvolved with clinically anxious
children compared to nonanxious children. Furthermore,
children’s social wariness has been found to influence
parental overprotection, as Rubin et al. (1999) found that
parents who perceived their children as shy at the age of 2
were significantly more overprotective when the child was
4 years old compared to mothers who did not view their
children as shy. In light of these findings, it is likely that
children’s social anxiety influences parenting behavior as
well.
Parenting and Subclinical/Clinical Depression
In a meta-analysis, McLeod et al. (2007a) compared parental
rejection and control and found that parental rejection had a
significantly stronger association with depression (a medium
effect) than did parental control (a small effect). When the
subcategories of both control (i.e., autonomy granting and
overinvolvement) and rejection (i.e., warmth, withdrawal,
and aversive parental behavior) were examined, they found
the absence of parental warmth and the presence of parental
aversive behavior had the strongest associations with
depression (both medium effects).
Studies done since that meta-analysis are consistent with,
and extend, those correlational findings. In a sample of
344 Clin Child Fam Psychol Rev (2011) 14:329–376
123
7–11-year-olds, both low positive (supportive/engaged,
warmth, acceptance) and high negative (hostile and coer-
cive) parent-reported parenting behaviors were found to be
uniquely, and cumulatively, related to both parent- and
child-reported depression (Dallaire et al. 2006). Hipwell
et al. (2008) found both parent-reported warmth and use of
harsh punishment uniquely and independently predicted
7–12-year-old girls’ self-reported depression over the
course of several years. Parental support (i.e., warmth,
support, approval, and closeness) and conflict (i.e., criti-
cism, anger, and conflict) have also been linked to adoles-
cent MDD. Sheeber et al. (2007) constructed support and
conflict variables with a combination of multiple-informant
reports and behavioral observations. They found adoles-
cents with subthreshold depression as well as those with
MDD experienced lower levels of maternal and paternal
support and higher conflict relative to a control group.
In terms of bidirectional or reciprocal relations between
parenting and youth depression, there is more support for
aspects of parenting being a risk factor for later depression,
than for depression leading to interpersonal consequences
in terms of parenting and the parent–child relationship.
Sheeber et al. (1997), using again constructs defined by
multiple informants and observational methods, found that
less family support and more conflict was associated with
adolescent depression one year later, but depression was
not predictive of later family support or family conflict.
Likewise, Stice et al. (2004) found 11–15-year-old girls’
perceived low social support from parents predicted
increases in depressive symptoms and the onset of MDD
over a 2-year period, but initial depression and MDD did
not predict decreases in perceived social support from
parents. Similarly, although Hipwell et al. (2008) found a
reciprocal relationship between low levels of parent-
reported parental warmth and use of harsh punishment and
7–12-year-old girls’ self-reported depressive symptoms
over several years, the effect was very small for girls’
depression decreasing parental warmth and increasing
harsh punishment over time. In contrast, Branje et al.
(2010) found bidirectional relations between changes in
adolescents’ self-reported depressive symptoms and chan-
ges in their perceived quality of the parent–child relation-
ship over 4–5 years. Their results may have differed from
the other three studies as it was the only one to use youth
self-report measures of both depression and parenting.
Parenting and Both Social Anxiety and Depression
In an observational study examining fathers, Greco and
Morris (2002) compared high and low socially anxious
children’s perceptions of paternal parenting behaviors and
fathers’ actual behavior when working on an origami task
with their child. After controlling for children’s depressive
symptoms, the two groups did not differ on their percep-
tions of fathers’ parenting and observed rejecting behavior
(high criticism or low praise). However, the fathers of
children in the high socially anxious group displayed more
physical and behavioral controlling behaviors compared to
fathers in the low socially anxious group. Thus, paternal
control, and not rejection, was related to social anxiety.
Starr and Davila (2008) found that adolescent girls’
social anxiety was associated with their perceptions of
conflict with parents and parent report of parental alien-
ation and trust. However, after controlling for depression,
none of these associations remained significant. Con-
versely, depression was associated with the parenting-
related variables even after controlling for social anxiety.
Later, Hutcherson and Epkins (2009) echoed these find-
ings, with a sample of preadolescent girls. They found that
girls’ and mothers’ report of lower maternal acceptance
and girls’ report of parental support were more strongly
related to girls’ depression versus social anxiety. After
controlling for depression, none of these three parenting-
related variables were related to girls’ social anxiety. In
contrast, after controlling for social anxiety, all three
variables remained significantly associated with girls’
depression. Finally, Johnson et al. (2005) found that three
of the four aspects of family environment that they
examined (perceived concern about others’ opinions,
shame, and family sociability) were more strongly related
to 9–17-year-olds’ depression versus social anxiety.
Summary of Parenting and Evidence for a Cumulative
Risk Model
As seen in Table 1, low parental warmth/acceptance/sup-
port is related to depression and not to social anxiety and is
a risk factor for and not a consequence of depression in
several studies. Parental rejection is associated with
depression, and many studies find it is not associated with
social anxiety. Controlling/overprotective parenting has
been found in some but not all studies to be related to
social anxiety, and it is not strongly related to depression.
Findings on one large sample found parental warmth,
rejection, and overprotection to be risk factors for SAD, yet
retrospective self-reports of parenting were used. Parental
negative commands/aversive behavior/conflict is related to
social anxiety and is associated with, a risk factor for, but
not a consequence of, depression.
Studies examining both social anxiety and depression
highlight the importance of examining the role of comorbid
symptoms. These studies find that parenting-related vari-
ables, including acceptance/support and conflict, are more
salient to depression versus social anxiety and that these
constructs were not significantly related to social anxiety
when depressive symptoms were controlled for. Thus,
Clin Child Fam Psychol Rev (2011) 14:329–376 345
123
parental acceptance/support and conflict appear more
important in depression versus social anxiety. However,
Greco and Morris (2002) found observed fathers’ physical
and behavioral controlling behaviors were associated with
social anxiety after controlling for children’s depression.
Consistent with a cumulative risk model, Lieb et al.
(2000) found adolescents’ perceived parental rejection
interacted with parental psychopathology. Here, if a parent
was diagnosed with any disorder, the relation between
perceived parental rejection and adolescent SAD was
greater than if the parent had no diagnosis. Moreover, sig-
nificant associations between perceived parenting and SAD
remained after controlling for parental psychopathology
over a number of assessment periods (Lieb et al. 2000;
Knappe et al. 2009a,b). Thus, parent psychopathology and
parenting are independent risk factors for SAD.
Aligned with a cumulative risk model, both positive and
negative aspects of parenting have been found to be
uniquely and cumulatively related to children’s depression
(Dallaire et al. 2006), and to predict girls’ depression over
several years (Hipwell et al. 2008). Parenting constructs
can also interact with one another. Caron et al. (2006)
found that high psychological control, when coupled with
low parental warmth, was related to more internalizing
problems in children. Yet, when parental warmth was high,
there was no relation between control and internalizing
problems, suggesting that parental warmth may be a pro-
tective factor. Future work is needed to examine these
possibilities with social anxiety and depression.
Peer-Related Interpersonal Relationship Problems
In addition to children’s relationships with parents, chil-
dren’s relationships with peers have been long viewed as
having a vital influence on children’s normal and abnormal
development (see Kingery et al. 2010; Rubin et al. 2010,
for a review). Indeed, developmental aspects of peer rela-
tionships are critical. As Dodge and Putallaz appropriately
sum up, ‘‘During adolescence, parents lose influence over
their sons and daughters while peers gain influence’’ (p. ix,
Prinstein and Dodge 2008). In adolescence, peer networks
begin to expand, and what crowd one affiliates with
becomes increasingly important (La Greca and Moore
Harrison 2005). There are also sex differences in peer
relationships and processes (see Rose and Rudolph 2006,
for a review).
Various peer relationship constructs are included in
models of social anxiety and depression (e.g., Kearney
2005; Rudolph et al. 2008). We next review peer-related
aspects within these models, including social skill deficits,
peer acceptance and rejection, peer victimization, friend-
ships, and loneliness, with a focus on examining whether
these are correlates of, or causal risk factors (or protective
factors) for, depression and/or social anxiety.
Social Skill Deficits
Social skill deficits have been long noted in behavioral
(Lewinsohn 1974) and interpersonal models of depression
(Rudolph et al. 2008). As noted by Segrin (2000), poor social
skills may represent a vulnerability factor or a diathesis for
developing depression. This notion is consistent with Rapee
and Spence’s (2004) model of SAD, whereby they are
careful to note that they ‘‘do not believe that lack of social
skills on their own are a major cause of social anxiety’’
(p. 758), but aversive social experiences (such as peer rejec-
tion, exclusion, or socialfailure) will increase the risk of social
anxiety even further for children with poor social skills.
Social Skill Deficits and Subclinical/Clinical Social Anxiety
SAD symptoms have been found to be related to teacher-
reported social skill deficits (Greco and Morris 2005).
Many studies find youth with SAD have social skill, social
competence, and performance deficits relative to control
groups as judged by independent observers, other infor-
mants, and/or behavioral observations (Alfano et al. 2006;
Beidel et al. 1999,2007b; Inderbitzen-Nolan et al. 2007;
Spence et al. 1999). Stronger relations have been found
between social skill deficits (as reported or observed by
others) and social anxiety for girls than for boys, in both
nonclinical (Morgan and Banerjee 2006) and anxiety-dis-
ordered youth (Ginsburg et al. 1998).
Observer-rated social skill deficits have also not been
found in 8–12-year-old socially anxious youth, yet these
youth self-reported they had poorer social skills relative to
nonsocially anxious youth (Cartwright-Hatton et al. 2003,
2005). These findings dovetail with cognitive models of
social anxiety (Rapee and Heimberg 1997) that emphasize
the role of individual’s negative beliefs as being primary.
Social Skill Deficits and Subclinical/Clinical Depression
Substantial research documents that social-behavioral def-
icits and poor social skills are associated with depression
and MDD (Rudolph et al. 2008; Segrin 2000). These
studies have found social skill deficits when they are
assessed through direct observations as well as via child,
teacher, parent, and peer reports (Bell-Dolan et al. 1993;
Rudolph et al. 2008; Segrin 2000).
Depressive symptoms have also been found to be
associated with children’s actual social skill deficits and
interpersonal problems in addition to negatively biased or
distorted thinking that extends beyond their actual inter-
personal experiences (Krackow and Rudolph 2008;
346 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Rudolph and Clark 2001). These findings dovetail with
cognitive models of depression (Clark and Beck 1999) and
the competence-based model of depression (Cole 1991),
which both highlight the role of individual’s negative
beliefs about themselves, or their skills, as being primary.
The few longitudinal studies that have been conducted
have not shown strong support for social skill deficits being
an antecedent or a consequence of depression (see Segrin
2000), with two exceptions. In a small sample of forty-six
8–14-year-old children, Wierzbicki and McCabe (1988)
found parent and child reports of children’s social skills
were related to increasing depressive symptoms 1 month
later. In addition, lower levels of kindergarten children’s
teacher-reported social skills were found to be modestly,
yet significantly, related to increases in their teacher-
reported depressive symptoms 1 to 2 years later (Perren
and Alsaker 2009).
Social Skill Deficits and Both Social Anxiety
and Depression
We located only one study that examined both depression
and social anxiety. Stednitz and Epkins (2006) found 9–12-
year-old girl- and mother-reported girls’ social skill deficits
showed significantly stronger relations to girls’ depression
in comparison with their social anxiety. Socially anxious
girls also differed from nonsocially anxious girls on both
informants’ reports of social skills, yet after controlling for
depression, the social anxiety group differences were no
longer significant.
Summary of Social Skill Deficits and Implications
for Cumulative Risk Model
As shown in Table 2, social skill deficits have been found
to be concurrently associated with social anxiety and
depression, as well as SAD and MDD. No longitudinal
studies have been conducted to examine whether social
skill deficits are a risk factor for social anxiety or SAD. The
few longitudinal studies on depression are mixed, but there
is not strong support for social skills being either an
antecedent to or a consequence of depression. Stednitz and
Epkins’ (2006) findings on preadolescent girls highlight the
importance of considering comorbid depression and social
anxiety when examining social skills, as they found social
skill deficits were no longer related to girls’ social anxiety
after controlling for depression.
Greco and Morris (2005) found that the relation between
8- and 12-year-old children’s peer nomination–based peer
rejection and their self-reported SAD symptoms was par-
tially mediated by children’s teacher-reported social skills.
Thus, further studies are needed to examine the moderating
or mediating role of social skills in the context of other
peer-related interpersonal risk factors, including peer
rejection.
Peer Acceptance and/or Rejection
A number of constructs that capture children’s acceptance
or rejection by their peers are noted in criteria for a rela-
tional diagnosis of depression and in interpersonal models
of depression, including poor peer social status such as low
popularity and high rejection and isolation (Kaslow et al.
2009; Rudolph et al. 2008). In models of social anxiety,
peer rejection and peer exclusion/neglect are noted
(Kearney 2005; Rapee and Spence 2004). Thus, both peer
rejection and peer exclusion/isolation/neglect are common
to models of depression and social anxiety. Peer neglect
and exclusion are viewed as conceptually similar (La Greca
1999).
Two very different methodologies have been used to
assess these constructs: (1) sociometric peer nomination
assessments, typically done in school classrooms, and (2)
rating scales completed by the child or others informants
(i.e., parents, teachers, or peers). We describe each of these
methodologies before we summarize findings on social
anxiety and depression.
Characteristics of children falling in peer sociometric
status groups have been a focus of research for almost three
decades (Coie et al. 1982). With this methodology, children
nominate, typically on a class roster, those peers that they
like the most (LM) and those peers that they like the least
(LL). From these LM and LL nominations, after they are
tallied and standardized across grade/classrooms, chil-
dren’s peer social status is assessed along two dimensions:
social preference and social impact. As Coie et al. (1982)
describe, social preference is defined as LM -LL (i.e.,
acceptance minus rejection), and social impact is defined as
LM ?LL (i.e., acceptance plus rejection). Then, based on
where children stand relative to other children on these
dimensions (as well as LM and LL), they are categorized as
falling into one of five peer social status groups: popular,
rejected, neglected, controversial, and average (Coie et al.).
As described by Coie et al. (1982), children in the
‘‘rejected’’ peer social status group are those low on social
preference, defined as social preference score less than
-1.0, in addition to LL greater than 0 and LM less than 0.
Thus, relative to their peers, children in the ‘‘rejected’’ peer
social status group have a lot of LL and few or no LM
nominations; hence, they are disliked by many peers (high
on rejection) and not liked by many (low on acceptance).
Children in the ‘‘neglected’’ peer social status group are
those who are low on social impact, defined by Coie et al.
as social impact score less than -1.0, as well as an LM
score of 0. Thus, they receive no LM and no or few LL
nominations, so they are both low on acceptance and low
Clin Child Fam Psychol Rev (2011) 14:329–376 347
123
Table 2 Summary of findings on relations of aspects of peer relationships to social anxiety and depression
Social skill deficits
SANX (observational or observer-rated, CR in clinical samples: Alfano et al. 2006; Beidel et al. 1999,
2007b; Inderbitzen-Nolan et al. 2007; Spence et al. 1999)
(Youth self-reported, CR in nonclinical samples; Cartwright-Hatton et al. 2003,2005; Teacher-reported,
CR, nonclinical sample, Greco and Morris 2005)
NOT SANX (observer-rated, CR in nonclinical samples; Cartwright-Hatton et al. 2003,2005)
NOT SANX after controlling for DEP (Stednitz and Epkins 2006, CR, nonclinical girls)
DEP (observational and other-reported, CR, in clinical and nonclinical samples: Bell-Dolan et al. 1993;
Rudolph et al. 2008, review; Segrin 2000, review)
(Weak RF: Wierzbicki and McCabe 1988; Perren and Alsaker 2009; Weak RF and Weak CQ: Segrin
2000 review)
Youth perceived social acceptance
SANX (CR: Ginsburg et al. 1998
b
; La Greca and Lopez 1998
b
; La Greca and Stone 1993
b
)
(Vernberg et al. 1992, RF but not CQ)
SANX after controlling for depression (Starr and Davila 2008
b
, CR, adolescent girls; Hutcherson and
Epkins 2009
b
, CR, girls)
DEP (CR: Cole et al. 1996
b
; Epkins 1998
b
; Kistner 2006, review) (RF and CQ: Kistner 2006, review;
Rudolph et al. 2007
b
, CQ)
NOT DEP after controlling for SANX (Starr and Davila 2008
b
, CR, adolescent girls; Hutcherson and
Epkins 2009
b
, CR, girls)
Friendships and friendship quality (FQ)
SANX (few or no friends, CR: Beidel et al. 1999; La Greca and Lopez 1998; Shanahan et al. 2008)
SANX (low pos and neg FQ, CR, especially girls: Greco and Morris 2005, Hutcherson and Epkins 2009;
La Greca and Lopez 1998, adolescents; La Greca and Moore Harrison 2005, adolescents; Ginsburg et al.
1998, Neg but not low Pos FQ)
(Low pos FQ, CQ, Vernberg et al. 1992, girls only, high pos FQ protective)
(Neg FQ: Borelli and Prinstein 2006, Weak RF and Weak CQ)
NOT SANX after controlling for DEP (Low Pos FQ, Hutcherson and Epkins 2009, CR, girls)
DEP (few or no friends, CR: Shanahan et al. 2008, children and not adolescents; Rudolph et al. 2007,
CQ, girls only, children)
(Less stable: Birmaher et al. 2004, CR, Rudolph et al. 2008, review, CR; Prinstein et al. 2005, CQ,
adolescents)
(Low pos FQ, adolescents: Lewinsohn et al. 1997, CR; Prinstein et al. 2005, RF)
(Neg FQ, adolescents: Prinstein et al. 2005, CQ, girls only; Borelli and Prinstein 2006, Weak RF and
Weak CQ)
(Low pos and high neg FQ: Oppenheimer and Hankin 2011, CQ, but neither RF, adolescents; Rudolph
et al. 2007, CQ, girls only, children)
DEP after controlling for SANX (low Pos FQ, Hutcherson and Epkins 2009, CR, preadolescent girls)
NOT DEP (low Pos FQ, CR: La Greca and Moore Harrison 2005, adolescents)
Low peer acceptance (peer-assessed)
NOT SANX (3rd through 5th grade; CR: Bell-Dolan et al. 1995, girls; Crick and Ladd 1993; Greco and
Morris 2005)
SANX (2nd to 6th grade and adolescent samples; CR: Inderbitzen et al. 1997; La Greca et al. 1988;La
Greca and Stone 1993) (RF: Gazelle and Ladd 2003
c
, Gazelle and Rudolph 2004
c
)
NOT DEP (Newcomb et al. 1993, meta-analysis, CR; Cole et al. 1996
a
not RF, 3rd graders, not CQ)
DEP (RF: Cole et al. 1996
ab
, 6th graders; Gazelle and Ladd 2003
c
; Gazelle and Rudolph 2004
c
)
Peer rejection (peer-assessed)
SANX (3rd through 5th grade; CR: Bell-Dolan et al. 1995, girls; Crick and Ladd 1993; Greco and Morris
2005)
SANX (2nd to 6th grade, CR: La Greca et al. 1988; La Greca and Stone 1993; adolescents: Inderbitzen
et al. 1997, CR; Borelli and Prinstein 2006, Weak RF and Weak CQ)
DEP (Newcomb et al. 1993, meta-analysis, CR; Nolan et al. 2003
a
, adolescents, RF and not CQ; Prinstein
and Aikins 2004, adolescents, RF, girls only; Borelli and Prinstein 2006, adolescents, Weak RF and Weak
CQ)
Peer victimization
SANX (CR: Hawker and Boulton, 2000, meta-analysis; Ranta et al. 2009b)
(CR, direct/overt and indirect/relational: Kingery et al., 2010, review)
(CR, indirect/relational controlling for Direct/Overt, adolescents: La Greca and Moore Harrison, 2005,
Siegel et al., 2009; Storch et al. 2003a)
(Relational and not overt, adolescents: Storch et al., 2005, RF and not CQ; Siegel et al., 2009, RF girls
only, and CQ)
DEP (CR: Hawker and Boulton 2000, meta-analysis; Birmaher et al. 2004; Cuevas et al. 2009)
(CR, direct/overt and indirect/relational: Storch and Ledley 2005, review)
(CR, indirect/relational controlling for direct/overt, adolescents: La Greca and Moore Harrison 2005,
Prinstein et al. 2001; children: Cole et al. 2010; Kawabata et al. 2010)
(RF and Weak CQ: Reijntjes et al. 2010, meta-analysis; Sweeting et al. 2006)
SANX or SANX AND DEP (vs. DEP alone; CR, Ranta et al. 2009a, adolescents)
Loneliness
SANX (CR, clinical samples: Beidel et al. 1999,2007b, adolescents; nonclinical samples: Prinstein and La
Greca 2002, adolescents; Crick and Ladd 1993, girls only, children)
SANX (Weak RF and Weak CQ, Prinstein and La Greca, 2002)
SANX after controlling for DEP (CR, Girls: Hutcherson and Epkins, 2009, children; Starr and Davila,
2008, adolescents; Stednitz and Epkins, 2006, children)
DEP (CR: Prinstein and La Greca 2002, adolescents; Storch et al. 2003b, stronger for girls then boys,
children)
DEP (Weak RF and Weak CQ, Prinstein and La Greca 2002; RF, Joiner et al. 2002, adolescents)
DEP after controlling for SANX (CR, Girls: Hutcherson and Epkins, children; Starr and Davila 2008,
adolescents)
DEP depression, SANX social anxiety, CR correlate, RF risk factor, CQ consequence
a
Used multiple-informant-defined constructs, including peers
b
Used the self-perception profile for children social acceptance scale (and/or its other-informant versions)
c
Used teacher report of peer exclusion
348 Clin Child Fam Psychol Rev (2011) 14:329–376
123
on rejection. As Coie et al. note, neglected children ‘‘dif-
fered from the rejected children in that the rejected children
received many nominations of liked least, whereas the
neglected children did not’’ (p. 564). Thus, neglected and
rejected children are both low on their overall acceptance
by the peer group, and they differ only on whether peers
dislike them (i.e., rejection).
Another body of research has used questionnaire or
rating scale methods to assess children’s peer social
acceptance and/or rejection, as assessed by children, par-
ents, teachers, or peers. The social acceptance subscale of
the Self-Perception Profile for Children (SPPC; Harter
1985) and the other-informant versions of the SPPC are
often used. As noted by Kistner et al. (2006), this ‘‘is one of
the most commonly used measures of children’s perceived
peer acceptance’’ (p. 352). The six items on this subscale
include two items that tap acceptance or rejection (e.g.,
being popular or unpopular, and extent of being liked by
others their age). The remaining four items tap ease or
difficulty in making friends, having or not having many
friends, wanting or not wanting more friends, and doing
things with other children versus by themselves. The parent
and teacher versions of the social acceptance subscale
contain three items: ease or difficulty in making friends,
having or not having many friends, and being popular or
unpopular. Therefore, some items on the social acceptance
subscale of the SPPC tap acceptance/rejection yet most tap
aspects of children’s friendships. As we describe in a
section below, children’s friendships represent a separate
aspect of children’s peer relationships than does peer
acceptance and/or rejection. Nevertheless, many studies
use the SPPC social acceptance subscale to assess ‘‘social
acceptance.’’
Peer Acceptance and/or Rejection and Subclinical/Clinical
Social Anxiety
In a meta-analysis regarding characteristics associated with
the five peer social status groups, the rejected social status
group was associated with increased anxiety relative to
other status groups (Newcomb et al. 1993). However, the
neglected status group was associated with lower anxiety
than average social status group. Given the definitional and
conceptual differences between rejected and neglected peer
social status groups noted above, these findings suggest that
it is peer rejection (i.e., dislike) and not low acceptance per
se that is related to increased anxiety, although social
anxiety was not specifically examined in this meta-analysis.
Subsequent cross-sectional research using the same Coie
et al. (1982) methodology seems to corroborate the above
meta-analysis findings with respect to social anxiety, at
least for elementary school-aged children. For example, in
a sample of 3rd through 5th graders, Crick and Ladd (1993)
found the neglected group self-reported significantly less
social anxiety than both rejected and average youth (and
neglected children did not differ significantly from popular
or controversial groups). In a similar vein, Greco and
Morris (2005) found 8–12-year-old school children’s self-
reported SAD symptoms were related to their social pref-
erence peer nominations (LM -LL, like/dislike; rejection)
but not related to their social impact scores (LM ?LL;
neglect/low acceptance). Thus, for elementary school-aged
youth, peer rejection (dislike) and not low acceptance
(neglect) per se has been found to be related to increased
social anxiety.
La Greca et al. (1988) used a slightly different peer
nomination procedure to define the five social status groups
in 2nd- through 6th-grade children. Instead of using nom-
inations of ‘‘like least,’’ La Greca et al. had children rate
how much they would like to play with each same-sex
classmate on a 1- to 5-point scale ranging from 1 (not at
all) to 5 (very, very much). Ratings of ‘‘1’’ were tallied for
each child, and this was used to reflect disliking or LL in
their calculating social preference and social impact scores.
La Greca et al. found neglected and rejected youth did not
differ significantly on their self-reported social anxiety,
although both groups reported more social anxiety than the
popular group. Then, using their same modified procedure
in lieu of negative nominations described above with a
sample of 4th through 6th graders, La Greca and Stone
(1993) also found no differences between rejected and
neglected groups on fear of negative evaluation (an aspect
of social anxiety), and they both differed from average or
popular groups. The difference between La Greca and
colleagues’ findings and those of Crick and Ladd (1993)
and Greco and Morris (2005) may be due to including older
6th graders in the sample and/or differences in their peer-
obtained measures. As La Greca and Stone note, data
indicate the modified method they used ‘‘may underiden-
tify neglected children relative to traditional classification
methods that use negative nominations’’ (p. 20). However,
other research on 6th through 9th graders used the standard
Coie et al. (1982) nominations (LM and LL) and found
results similar to the La Greca studies (Inderbitzen et al.
1997). In this study, no differences emerged between the
rejected and neglected peer social status groups’ self-
reported social anxiety, yet they both reported more social
anxiety than the other groups.
Collectively, the findings on social anxiety and peer
social status groups suggest that for adolescents, and not
for children in several studies, low acceptance (i.e.,
neglected status) as well as rejection (being disliked) is
associated with social anxiety. As discussed and reviewed
by Sentse et al. (2010), when children move into adoles-
cence, there is a need to belong and to be accepted by
peers. This may explain why for adolescents, and not
Clin Child Fam Psychol Rev (2011) 14:329–376 349
123
children in some studies, that low acceptance and rejection
are associated with social anxiety.
Using questionnaire methods, anxiety-disordered chil-
dren’s (Ginsburg et al. 1998) and child and adolescent
students’ (e.g., La Greca and Lopez 1998; La Greca and
Stone 1993) social anxiety have been found to be related to
lower perceived social acceptance on the SPPC. Moreover,
in 12–14-year-old recently relocated youth, Vernberg et al.
(1992) found that more perceived peer exclusion (on a
5-point rating scale for the item ‘‘being excluded from peer
activities’’) early in the school year predicted increases in
fear of negative evaluation a few months later, as well as
increases of social avoidance and distress in new situations
later for girls, but not boys. Greater frequency of peer
exclusion also predicted increasing general social avoid-
ance and distress over the course of the school year.
Conversely, social anxiety did not predict subsequent
perceived peer exclusion. Thus, youth perceived peer
exclusion is associated with increases in social anxiety over
time.
Studies have also used other methodologies to shed light
on peer acceptance and/or rejection in social anxiety. In
Chansky and Kendall’s (1997) sample of anxiety-disor-
dered youth, children’s social anxiety, and not their per-
ceived social acceptance on the SPPC, was related to their
expectations to be disliked/rejected in a new social situa-
tion with a group of unfamiliar peers. Verduin and Kendall
(2008) found that children with SAD were rated as less
liked (by unfamiliar peers) than children with other anxiety
disorders, and unfamiliar peers’ liking of anxiety-disor-
dered youth was inversely related to anxiety-disordered
youth social anxiety.
Peer Acceptance and/or Rejection and Subclinical/Clinical
Depression
A meta-analysis regarding characteristics associated with
the five peer social status groups found the rejected social
status group was associated with increased depression
relative to other status groups (Newcomb et al. 1993).
However, the neglected status group was associated with
lower depression than average social status group. These
findings, similar to those on anxiety, suggest that it is peer
rejection (i.e., dislike) and not low acceptance per se that is
related to depression.
Several prospective longitudinal studies have recently
been conducted, using the Coie et al. (1982) peer nomination
methodology but not looking at peer social status groups per
se. Early childhood social preference (LM -LL, rejection)
was found to be both concurrently and prospectively related
to adolescents’ anxious/depressed behavior (as assessed
by multiple informants; Fontaine et al. 2009). In separating
out peer acceptance and rejection (and omitting social
preference and impact scores), low peer acceptance in early
adolescents was found to be related to internalizing prob-
lems 2 years later, but peer rejection was only related to later
internalizing problems in girls, and not boys (Sentse et al.
2010). These findings dovetail with Prinstein and Aikens’s
(2004) study. They found that peer-assessed peer rejection
(LM -LL) was found to be prospectively related to ado-
lescent girls’ depression 17 months later only when girls
placed high (and not low) importance to their peer social
status. For boys, peer rejection was not related to their later
depression, whether they placed high or low importance on
their peer social status. Thus, peer acceptance and rejection
(especially for girls) is concurrently and prospectively
related to adolescents’ anxious/depressed and internalizing
behavior, as well as depression.
Using questionnaire methods, studies have found that
children’s depressive symptoms are related to lower per-
ceived social acceptance on the SPPC, as well as lower
mother-, father-, and teacher-reported social acceptance on
the SPPC scales (e.g., Cole et al. 1996; Epkins 1998).
Youth with MDD have also been found to receive low
unfamiliar peer ratings of their popularity and likeability
(i.e., Connolly et al. 1992). In addition, girls’ depressive
symptoms have been found to be related to their expected
acceptance and expected rejection from unfamiliar hypo-
thetical peers (Romero and Epkins 2008).
Cognitive models of depression (Clark and Beck 1999)
and the competence-based model of depression (Cole 1991)
stress the role of individuals’ beliefs about themselves as
being primary. Indeed, much correlational and longitudinal
research finds children’s self-perceptions of their social
acceptance, as opposed to others’ (i.e., peer, teacher, or
parent) perceptions of their social acceptance or rejection,
are more saliently related to depression symptoms. Using
the child and parent versions of the SPPC, Epkins (1998)
found 8–12-year-old children’s perceptions of social
acceptance was related to their depressive symptoms after
controlling for mother- or father-rated social acceptance. A
correlational study found the relation between peer dislike
and depressive symptoms in 9–13-year-old youth was
mediated by the children’s perceived social acceptance (on
the SPPC; Zimmer-Gembeck et al. 2007). A study with 3rd
and 6th graders found children’s self-evaluations in many
areas (including their social acceptance on the SPPC)
mediated the relation between others’ perceptions of them
(assessed via SPPC social acceptance versions) and their
depressive symptoms 6 months later (Cole et al. 1997).
Finally, in a study of 4th and 5th graders, followed up in
11th and 12th grade, children’s perceived social acceptance
(on the SPPC) and not their actual social preference (i.e.,
LM -LL; like/dislike, rejection) predicted dysphoria
7 years later (Kistner et al. 1999). Thus, children’s self-
perceptions of social acceptance on the SPPC have been
350 Clin Child Fam Psychol Rev (2011) 14:329–376
123
found to be concurrently and prospectively more saliently
related to children’s depression than other informants’
reports of children’s social acceptance on the SPPC, peer
dislike, and peer rejection.
Kistner (2006) concluded in her review that children’s
negative perceptions of their social acceptance have been
found to be both a cause and a consequence of depression.
Since that review, Rudolph et al. (2007) found, in youth
assessed repeatedly in the 3rd through 6th grade, that
parent-reported youth depression predicted decreases in
both boys’ and girls’ perceived social acceptance (on the
SPPC). Thus, reciprocal or bidirectional relations have
been found between children’s self-perceptions of their
social acceptance and their depression.
In contrast, when measures of acceptance or rejection
are not based exclusively on children’s self-perceptions,
the limited prospective studies have found evidence for
unidirectional and not bidirectional relations, in adoles-
cents. For example, Cole et al. (1996) obtained child, peer,
parent, and teacher reports of 3rd and 6th graders’
depression and these informants’ reports of children’s peer
social acceptance (on versions of the SPPC) in the fall and
spring of the school year. They found that after controlling
for fall depression, social acceptance in the fall was related
to depression in the spring only for 6th graders and not for
3rd graders. These findings are consistent with social
acceptance being more salient for adolescents than children
as discussed previously. In contrast, after controlling for
social acceptance in the fall, depression in the fall did not
predict social acceptance in the spring. Their findings are
consistent with Nolan et al.’s (2003) study of 6th graders
(also assessed in 7th and 8th grades), which focused on
multiple-informant-based constructs of both peer rejection
and youth depression. They found peer rejection predicted
later depression, yet depression did not predict later peer
rejection across any time span examined. Thus, in adoles-
cents, both acceptance and rejection (when defined by
multiple-informant-based constructs) have been found to
be prospectively linked to later depressive symptoms and
depression was not related to later acceptance or rejection.
Peer Acceptance and/or Rejection and Both Social Anxiety
and Depression
Bell-Dolan et al. (1995) examined social anxiety and
depression in 3rd- through 5th-grade girls. They found
rejected girls reported more social anxiety and had more
self- and teacher-reported depression than other groups.
However, neglected girls did not differ from any of the
other social status groups. Thus, consistent with others who
have examined peer social status and social anxiety in this
age-group (e.g., Crick and Ladd 1993; Greco and Morris
2005), peer rejection (dislike) and not low acceptance
(neglect) was related to both depression and social anxiety.
However, depression and social anxiety were not examined
simultaneously in this study, so the role of comorbid
symptoms or the unique associations of peer neglected and
rejected social status to depression and/or social anxiety
could not be determined.
Only one study on an anxiety-disordered sample of
youth has considered comorbid depression and anxiety
with respect to peer social status groups (Strauss et al.
1988). Although there were no youth with SAD in their
anxiety-disordered sample, Strauss et al. found the anxiety-
disordered group had significantly less LM nominations
and lower social impact scores than a nonreferred control
group, but no differences emerged between these groups on
LL nominations and social preference scores. Those with
comorbid depressive and anxiety disorders had lower LM
and social preference scores than those with anxiety dis-
orders only, and these two groups did not differ on LL
nominations or social impact. Thus, lower acceptance (i.e.,
low LM) in anxiety-disordered youth appeared to be a
function of comorbid depression. Examining peer social
status correlates of socially anxious youth with and without
comorbid depression remains an important area of inquiry.
Using questionnaire methods, Epkins (1996) examined
four groups were formed based on cutoffs on self-report
measures: dysphoric, socially anxious, mixed (both dys-
phoric and socially anxious), and control. Children in the
symptomatic groups were each found to have significantly
lower perceived social acceptance (on the SPPC) than the
control group, and the mixed group had significantly lower
self-perceptions than the socially anxious group but not the
dysphoric group. On both mother and father reports of
social acceptance, the mixed group had significantly lower
social acceptance than the control group, and on mother
report, the mixed group also had significantly lower social
acceptance than each of the socially anxious and dysphoric
groups. These findings, collectively, highlight the impor-
tance of comorbid symptoms.
Using a different analytical approach, Starr and Davila
(2008) found that adolescent girls’ perceived social accep-
tance/close friendships (on adolescent version of the SPPC)
were related to their social anxiety after controlling for
depression but were not related to depression after con-
trolling for social anxiety. Similarly, preadolescent girls’
perceived and mother-reported peer acceptance (on the
SPPC) have been found to be related to their social anxiety
after controlling for depression but were not related to their
depression after controlling for social anxiety (Hutcherson
and Epkins 2009). Thus, at least for girls, perceived and
mother-rated girls’ social acceptance appears to be a unique
and specific correlate of social anxiety and not depressive
symptoms when comorbid symptoms are considered or
controlled for.
Clin Child Fam Psychol Rev (2011) 14:329–376 351
123
A few longitudinal studies have assessed depression
and social anxiety. Borelli and Prinstein (2006) reported
prospective (11 months) correlations in a sample of
6th–8th graders, indicating that time 1 peer-assessed peer
rejection (LM -LL) was related to time 2 self-reported
depression and social anxiety (rs=-.17 and -.18,
respectively), and time 1 depression and social anxiety
was related to time 2 social preference (rs=-.26 and
-.31). However, they examined depression and social
anxiety separately, so the role of comorbid symptoms and
depression versus social anxiety specificity could not be
addressed. Their findings suggest reciprocal relations
between peer rejection and social anxiety and depression,
yet they conflict with Cole et al. (1996) and Nolan et al.
(2003) discussed above that did not find depression to be
related to later acceptance or rejection after controlling for
time 1 acceptance/rejection.
Perceived social exclusion has been theorized to be tied
to both social anxiety and depression (see Leary 1990).
Studies by Gazelle and her colleagues find that anxious
solitude and teacher-reported peer exclusion sometimes
co-occur (as early as kindergarten). Their longitudinal
findings suggest the combination of anxious solitude and
peer exclusion maintains social avoidance and anxious
solitude over time, as well as predicts increasing depression
over the course of middle childhood (Gazelle and Ladd
2003) and during a 1-year period in early adolescence
(Gazelle and Rudolph 2004). Interestingly, a peer nomi-
nation item of rejection (‘‘someone I do not like to play
with’’) was a partial mediator of the relation between
anxious solitude and elevated peer exclusion trajectories
over middle childhood, and anxious solitude predicted peer
exclusion trajectories after controlling for rejection
(Gazelle and Ladd 2003). As Gazelle and Ladd note, ‘‘peer
rejection is distinguishable from overt peer exclusion’’
(p. 266).
Summary of Peer Acceptance and/or Rejection
and Evidence for a Cumulative Risk Model
As seen in Table 2, for elementary school-aged youth, peer
rejection (dislike) and not low acceptance (neglect) per se
has been found in most studies to be related to social
anxiety. In contrast, for adolescents, and consistent with the
notion of cumulative risk, low acceptance (i.e., neglected
status) as well as rejection (being disliked) is associated
with social anxiety. Consistent with the above, peer
acceptance and rejection (especially for girls) have been
found to be concurrently and prospectively related to
adolescents’ anxious/depressed and internalizing behavior,
as well as depression, yet studies on younger samples are
needed. Although not examining social anxiety per se,
lower acceptance (i.e., low LM) in anxiety-disordered
youth has been found to be a function of comorbid
depression (Strauss et al. 1988).
With regard to questionnaire methods, social anxiety is
concurrently related to perceived social acceptance, and
perceived peer exclusion is associated with increases in
social anxiety over time (and not vice verse). In anxiety-
disordered youth, social anxiety is related to children’s
expectations to be disliked/rejected, and social anxiety
symptoms and SAD are related to having unfamiliar peers
actually rate children as less likeable.
Depression has also been found to be associated with
low self- and other-informant reports of social acceptance,
receiving low unfamiliar peer ratings of popularity or
likeability, and expectations to not be accepted and to be
rejected from hypothetical unfamiliar peers. Reciprocal or
bidirectional relations have been found between children’s
self-perceptions of their social acceptance and their
depression. In contrast, when acceptance and rejection are
defined by multiple-informant-based constructs, only uni-
directional relations are present with acceptance and
rejection prospectively linked to later adolescents’
depression (and not vice verse).
Only a few studies have examined social anxiety and
depression and peer acceptance and/or rejection simulta-
neously in either concurrent correlational studies or in
prospective longitudinal designs. Consistent with a cumu-
lative risk model, the joint influence of anxious solitude
and peer exclusion has been found to contribute to elevated
depression symptoms over time (Gazelle and Ladd 2003;
Gazelle and Rudolph 2004).
It will be important for future research to examine peer
acceptance and rejection in the context of other peer-rela-
ted interpersonal risk factors. For example, a correlational
study found that peer victimization (assessed by teacher
and peer reports) partially mediated the relation between
peer-nominated peer rejection (LM – LL) and 4th- and
5th-grade children’s depressive symptoms (Morrow et al.
2008). Thus, peer victimization is important in under-
standing the link between peer rejection and depressive
symptoms.
Peer Victimization
In addition to peer rejection, aversive peer experiences
such as peer victimization have also been noted to be an
important component in theoretical models of social anx-
iety (Gazelle 2010; Kearney 2005, Rapee and Spence
2004). Peer victimization is also noted in interpersonal
models of depression (Rudolph et al. 2008).
Peer victimization is the experience in which children
are the target of peers’ aggressive behavior. Peer victim-
ization theorists and researchers acknowledge two forms of
aggressive behavior, supported in factor analytic work (see
352 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Card et al. 2008; Cole et al. 2010). One form of aggression
reflects more direct/overt physical and verbal aggression,
and the other form reflects more indirect/covert social and/
or relational aggression (see Card et al. 2008, for review).
A recent meta-analysis found reciprocal or bidirectional
relations, with internalizing problems functioning as both
causes of and consequences of peer victimization (Reijntjes
et al. 2010). Reijntjes et al. (2010) examined studies that
included a wide variety of narrow-band internalizing
behaviors (withdrawal, loneliness, depression, anxiety,
social anxiety, somatic symptoms) or emotional problems
or internalizing problems in general. Moreover, they did not
examine whether the different types of victimization are
differentially related to various types of internalizing
symptoms, such as social anxiety and depression.
Peer Victimization and Subclinical/Clinical Social Anxiety
In a meta-analysis, Hawker and Boulton (2000) found that
peer victimization is associated with social anxiety. In
more recent years, research has examined the relation
between the two types of victimization and social anxiety.
Research indicates that both direct/overt and indirect/cov-
ert relational victimization are associated with social anx-
iety in boys and girls (as reviewed by Kingery et al. 2010,
and Storch and Ledley 2005). However, as Kingery et al.
noted, there is little research on peer victimization and
clinical anxiety. We uncovered only one study on peer
victimization and SAD. Ranta et al. (2009b) found that
68% of adolescents with SAD (and 45% with subclinical
SAD) reported they had been bullied by peers in the past in
a way that caused harm or suffering (on a yes/no question),
which was more than 8% reported in their control group.
Importantly, studies have also examined the differential
relations between the different types of victimization.
Emerging research consistently indicates that after con-
trolling for direct/overt victimization, indirect/covert rela-
tional victimization has been found to be related to: (1)
both adolescent boys’ and girls’ social anxiety (La Greca
and Moore Harrison 2005; Siegel et al. 2009; Storch et al.
2003a) and (2) related to 5th- and 6th-grade girls’ and not
boys’ self-reported social anxiety in a mostly Hispanic and
African American sample (Storch et al. 2003c).
One prospective longitudinal study that Reijntjes et al.
(2010) included in their meta-analysis as well as one
recently published study focused on social anxiety. In their
study using all self-report measures in a sample of 9th-
grade adolescents in a parochial school, Storch et al. (2005)
found that relational victimization, and not overt victim-
ization, predicted SAD symptoms 1 year later for both
boys and girls. However, SAD symptoms did not predict
either type of victimization 1 year later. In another study
examining self-reported peer victimization and social
anxiety (not included in the meta-analysis), Siegel et al.
(2009) focused on adolescents in grades 10–12 in a public
school assessed at two time points, 2 months apart. In
addition to assessing overt and relational victimization,
they examined ‘‘reputational’’ victimization, which they
define as damaging others’ relationships or reputation in
the broader peer group via spreading rumors or gossiping.
They found relational victimization (controlling for overt
and reputational victimization) predicted increasing social
anxiety over time for girls, but not boys. Moreover, social
anxiety predicted increases in relational (and not overt or
reputational) victimization. Thus, reciprocal or bidirec-
tional relations were found, at least for girls. The difference
between Siegel et al.’s and Storch et al.’s findings may be
due to characteristics of their samples, time frame for
follow-up, or the fact that Storch et al. excluded from their
sample those that scored high on SAD symptoms and
subsequently were involved in a SAD treatment study (i.e.,
those with increased social anxiety were excluded from
their sample).
Peer Victimization and Subclinical/Clinical Depression
In a meta-analysis, Hawker and Boulton (2000) found that
peer victimization is associated with depression. Since
then, studies have found that both direct/overt and indirect/
covert peer victimization are associated with depression
(see Storch and Ledley 2005; Storch et al. 2003a). Also,
youth with MDD have been found, relative to a control
group, to have more mother-reported ‘‘being teased’’ by
peers (Birmaher et al. 2004). Recent research found that
youth (age 2–17) with a variety of lifetime disorders
(including MDD), in comparison with youth with no life-
time diagnoses, report higher rates ‘‘emotional bullying’’
by peers (Cuevas et al. 2009).
In adolescents, self-reported indirect/relational victim-
ization has been found to be related to girls’ and not boys’
depression, whereas direct/overt victimization was related
to depression in boys and not in girls (Prinstein et al. 2001).
After controlling for direct/overt victimization, self-repor-
ted indirect/covert relational victimization is related to
adolescent boys’ and girls’ depression (La Greca and
Moore Harrison 2005; Prinstein et al. 2001).
In younger samples, after controlling for direct/overt
victimization, self-reported indirect/covert relational vic-
timization has been found to be: (1) uniquely related to 4th-
and 5th-grade Japanese children’s depression (Kawabata
et al. 2010) and (2) related to 5th- and 6th-grade girls’ and
not boys’ depression in a mostly Hispanic and African
American sample (Storch et al. 2003c). However, Cole
et al. (2010) recently found no gender differences in rela-
tions between victimization and depression when they
assessed overt and covert peer victimization via self,
Clin Child Fam Psychol Rev (2011) 14:329–376 353
123
parent, and peer informants in a sample composed of lar-
gely Caucasian 3rd through 6th graders. They also found
that after controlling for direct/overt peer victimization,
indirect/covert victimization was related to children’s
depression and after controlling for indirect/covert, direct/
overt victimization was not related to depression.
One prospective study that Reijntjes et al. (2010)
included in their meta-analysis focused on depression.
Sweeting et al. (2006) assessed a large Scottish cohort of
youth when aged 11, 13, and 15 on self-report measures.
These authors found, at age 13, evidence for reciprocal
relations between victimization and depression for both
boys and girls, ‘‘with a stronger path from victimization to
depression than vice versa’’ (p. 577). These findings are
consistent with Reijntjes et al.’s (2010) meta-analysis
finding—the effects of victimization on internalizing
symptoms were stronger than the reverse, although not
significantly stronger in the meta-analysis. Thus, reciprocal
relations have been demonstrated (although two of the
three other studies in the meta-analysis that focused on
depression yielded nonsignificant effects).
Peer Victimization and Both Social Anxiety
and Depression
While two of the above-noted studies have assessed both
depression and social anxiety, they each examined social
anxiety and depression separately in relation to peer vic-
timization (e.g., La Greca and Moore Harrison 2005;
Storch et al. 2003c). This leaves unanswered questions
about whether peer victimization is uniquely or specifically
related to depression and/or social anxiety, and whether the
comorbidity between depression and social anxiety affects
this relation. We only uncovered one study that has con-
sidered these important issues. Ranta et al. (2009a) defined
four groups on cutoffs on self-report symptom measures:
socially anxious only (or phobic; SP); depressive only
(DEP); both SP and DEP; and a control group with neither
SP nor DEP. Ranta et al. obtained 15–16-year-old adoles-
cents’ self-reports of overt and covert victimization. They
found for boys, the comorbid group reported higher rates of
both types of victimization relative to the DEP and SP
groups. For girls, covert, but not overt, victimization was
more prevalent in the comorbid group relative to the DEP
and SP groups. For both boys and girls, there were no
differences between the DEP and SP groups. However, the
SP and comorbid boys and girls, but not the DEP boys and
girls, were at increased risk relative to controls of reporting
more victimization of both types. Ranta et al. concluded
that social anxiety and not depression is associated with
peer victimization. Yet, when depression is comorbid with
social anxiety, there is a stronger relation with victimiza-
tion than that of social anxiety alone.
Summary of Peer Victimization and Evidence
for a Cumulative Risk Model
As shown in Table 2, peer victimization is associated with
both social anxiety and depression. After controlling for
direct/overt victimization, indirect/covert relational vic-
timization is related to both children’s and adolescents’
depression and social anxiety. Some findings are consistent
with girls finding relational victimization to be more dis-
tressing than boys (i.e., Crick and Grotpeter 1996).
Only a few prospective studies have examined recipro-
cal or bidirectional relations between victimization and
either depression or social anxiety. Reciprocal relations
were found between depression and victimization in one
study, yet various types of victimization were not assessed
(Sweeting et al. 2006). The two prospective studies on
social anxiety focused on adolescents. Both found rela-
tional victimization was related to later social anxiety,
although this was only true for girls in one study. Con-
flicting results were found in the relation between social
anxiety and later victimization, with one finding significant
linkages over 2 months and no gender differences (Siegel
et al. 2009) and the other finding minimal support (Storch
et al. 2005). No prospective study has examined social
anxiety and depression in tandem. Recent work by Ranta
et al. (2009a) suggests SAD symptoms, and not depressive
symptoms alone, are more closely related to victimization
in adolescents, yet when depression is comorbid with social
anxiety, there is a stronger relation with victimization than
that of SAD symptoms alone.
Consistent with the notion of cumulative risk, findings
also indicate, at least in adolescents, that youth who self-
report both or co-occurring direct/overt and indirect/covert
victimization by peers have been found to self-report
higher levels of social anxiety and depression, in compar-
ison with adolescents who only report one type of peer
victimization (Klomek et al. 2008; Prinstein et al. 2001;
Storch et al. 2003a). Whether similar findings exist in
children has yet to be investigated.
Consistent with a cumulative risk model, genetic lia-
bility has been found to moderate the relation between
relational victimization and 10–14-year-old girls’ depres-
sion, with relational victimization only related to girls’
depression in girls with genetic liability (Benjet et al.
2010). Aspects of children’s friendships also are salient in
understanding the relation between peer victimization and
depression or social anxiety. In a sample of 3rd through 5th
graders, positive qualities of friendships moderated the
relation between victimization and depression, for girls
(and not boys), with positive qualities as protective factors
(Schmidt and Bagwell 2007). Erath and colleagues’ find-
ings in 6th and 7th graders revealed peer victimization
(composite of self- and peer-defined) and perceived
354 Clin Child Fam Psychol Rev (2011) 14:329–376
123
friendship quality explained unique and additive variance
in social anxiety (Flanagan et al. 2008). Moreover, the
number of close mutual friendships moderated the relation
between self-reported victimization and social anxiety for
boys but not girls (Erath et al. 2010). Here, peer victim-
ization was related to boys’ social anxiety only when
friendships were low in number. For girls, victimization
was related to social anxiety at both high and low number
of close friendships. Children’s friendships are also noted
in interpersonal models of depression and social anxiety.
Friendships
Children’s friendships (i.e., their mutual and dyadic rela-
tionships) represent another peer-related interpersonal con-
struct that has long been considered to be important in
children’s normal and abnormal development (see Kingery
et al. 2010; Rubin et al. 2008). Indeed, poor-quality friend-
ships are viewed as risk factors for depression (Rudolph
et al. 2008) while friendships are conceptualized as being
protective factors in etiological models of SAD (Kearney
2005) as well as relationship perspectives on social with-
drawal and social anxiety (Rubin et al. 2010). As stated
nicely by Rubin et al. (2010), friendship may protect with-
drawn children from peer rejection, victimization, and
exclusion and their associated ‘‘costs’’ (p. 87).
Parker and Asher’s (1993) seminal study documented
the important distinction of children’s peer group accep-
tance (how much children are liked/disliked by their gen-
eral peer group; i.e., peer acceptance/rejection), having a
mutual friend, and friendship quality, as these three con-
structs were independently and uniquely associated with
children’s adjustment.
Friendships and Subclinical/Clinical Social Anxiety
The independence of these constructs has been emphasized
with respect to social anxiety. Aspects of both close
friendships (including number of best friends; social sup-
port from, and intimacy in, close friendships; and positive
and negative friendship qualities) and general peer accep-
tance (including peer-assessed social acceptance, perceived
social acceptance, and support from classmates) have been
found to be associated with children’s and adolescents’
social anxiety, particularly girls’ (Greco and Morris 2005;
Hutcherson and Epkins 2009; La Greca and Lopez 1998).
Importantly, La Greca and Lopez (1998) found peer
acceptance variables were related to adolescent girls’ social
anxiety even after controlling for girls’ perceived close
friendships and friendship quality. In contrast, close
friendships and friendship quality were not related to girls’
social anxiety after controlling for peer acceptance vari-
ables. Thus, peer acceptance variables are more robustly
related to adolescent girls’ social anxiety. Moreover, Greco
and Morris (2005) found the relation between 8- and
12-year-old children’s SAD symptoms and their peer
nomination–based social preference scores (i.e., LM -LL,
rejection) were moderated by perceived negative (but not
positive) friendship quality, for girls. In line with the notion
of cumulative risk, peer rejection was only related to SAD
symptoms for girls who rated their best friendships high in
negative qualities. These findings highlight the distinction
between peer acceptance/rejection and friendships.
There are very few studies on the friendships of clinically
anxious youth. However, in an anxiety-disordered sample,
children’s social anxiety was found to be associated with
their reports of more negative (but not less positive) inter-
actions with friends (Ginsburg et al. 1998). In addition, 75%
of children with SAD have been found to report that they
had no or few friends (Beidel et al. 1999). Moreover,
Shanahan et al. (2008) found having no friends was related
to SAD in preadolescent and adolescent boys and girls.
Only one longitudinal study has examined social anxiety
and friendships. Vernberg et al. (1992) found adolescents’
social anxiety at the beginning of the school year was
found to predict later lower levels of intimacy in close
friendships, especially for girls. They also found higher
intimacy and companionship in friendships in the fall
predicted lower social anxiety later in the school year.
Thus, aspects of friendships, and having no friends, appear
critical in youth with social anxiety and SAD, and several
studies suggest this may be more so for girls.
Friendships and Subclinical/Clinical Depression
In their review, Rudolph et al. (2008) cite a few studies
finding depression is concurrently associated with less
stable friendships and poorer-quality friendships. In addi-
tion, having no friends was found to be associated with
MDD in preadolescent boys and girls (but not adolescents;
Shanahan et al. 2008). Low social support from friends was
found to be more strongly associated with MDD versus
nonaffective disorders in adolescents (Lewinsohn et al.
1997). Moreover, youth with MDD (Mage 11.5, SD 2.0),
relative to both high- and low-risk control youth, have been
found to have more problems with duration of friendships
and spending time with friends (Birmaher et al. 2004).
Although only a few prospective studies have been con-
ducted, there is some support for bidirectional relationships,
yet there are more consistent findings for depression leading
to decreases in the quality and stability of friendships than
vice versa. Prinstein et al. (2005) sample of 6th- through 8th-
grade adolescents was followed over three annual time
points. They found low levels of perceived positive (and not
negative) friendship quality predicted increased depression
over time for boys and girls. Depression predicted both less
Clin Child Fam Psychol Rev (2011) 14:329–376 355
123
stability in reciprocal dyadic friendships (for both boys and
girls) and an increase in perceived negative qualities in
friendships (for girls), over time. Their findings dovetail
with those of Rudolph et al. (2007) who examined 3rd
graders through the 6th graders. Here, parent-reported youth
depression predicted decreases in the number of reciprocal
friendships and perceived poorer friendship quality (less
positive and more negative) over time in girls, but not in
boys. In 6th to 10th graders assessed three times spaced
5 weeks apart, Oppenheimer and Hankin (2011) found
depression predicted later increases in negative, and
decreases in positive, friendship qualities. In contrast to
findings by Prinstein et al., neither positive nor negative
perceived friendship qualities predicted increases in
depression. Differences in these findings may be due to
differences in age and/or time periods of assessment.
Friendships and Both Social Anxiety and Depression
After controlling for depression, Hutcherson and Epkins
(2009) found close friend support was not related to pre-
adolescent girls’ social anxiety. In contrast, after control-
ling for social anxiety, close friend support was related to
depression. Starr and Davila (2008) combined subscales of
social acceptance and close friendships and could not
examine the relations of close friendships to their adoles-
cent girls’ social anxiety and/or depression.
In a sample of 14–19-year-olds, La Greca and Moore
Harrison (2005) found that adolescents’ perceived negative
qualities in best friendships were related to social anxiety and
depression, whereas perceived positive qualities were inver-
sely related to social anxiety yet not related to depression.
Social anxiety and depression were examined separately so
the role of comorbid symptoms could not be assessed.
Borelli and Prinstein’s (2006) study of 6th- to 8th-grade
adolescents reported 11-month prospective correlations
showing time 1 depressive and social anxiety symptoms
were each related to time 2 perceived friendship criticism
(rs=.13 and .12, respectively). Also, time 1 perceived
friendship criticism was related to both time 2 depressive
and social anxiety symptoms (rs=.16 and .12, respec-
tively). Their findings suggest reciprocal relations. How-
ever, social anxiety and depression were examined
separately so the role of comorbid symptoms was not
addressed, and time 1 friendships or symptoms were not
controlled for in these correlations.
Summary of Friendships and Evidence for a Cumulative
Risk Model
As seen in Table 2, the quantity and quality of friendships
are related to social anxiety and depression. Having few or
no friends is associated with social anxiety in clinical and
nonclinical samples. Having few or no friends is associated
with MDD in children (and not adolescents) and has been
shown to be a consequence of depression in elementary
school-aged girls and not boys.
In terms of friendship quality, both low positive and
high negative qualities are associated with social anxiety,
especially in girls. Low positive qualities have been found
to be a consequence of social anxiety in girls and not boys
(Vernberg et al. 1992), whereas high negative friendship
qualities have been found to be a consequence of depres-
sion in girls and not boys (Prinstein et al. 2005). In pre-
adolescent girls, after controlling for depression, low
positive qualities were not found to be related to social
anxiety, but after controlling for social anxiety, low posi-
tive qualities were related to depression (Hutcherson and
Epkins 2009). Other studies find low positive qualities in
friendships are related to and a risk factor for depression in
adolescents. Both low positive and high negative qualities
have been found to be consequences of depression in
adolescents (Oppenheimer and Hankin 2011) and in pre-
adolescent girls and not boys (Rudolph et al. 2007). To
date, there are more findings showing aspects of friend-
ships are correlates and consequences of, and not risk
factors for, depression and social anxiety.
High positive qualities in friendships are protective
factors with respect to social anxiety (La Greca and Moore
Harrison 2005; Vernberg et al. 1992). As reviewed above,
friendship constructs (i.e., number of friends and positive
qualities in friendships) have been found to moderate the
relation between peer victimization and girls’ depression
(Schmidt and Bagwell 2007) and boys’ social anxiety
(Erath et al. 2010). In addition, peer rejection was found to
be only related to SAD symptoms for 8–12-year-old girls
who rated their best friendships high in negative qualities
(Greco and Morris 2005). These findings highlight the
importance of friendships as protective factors in the face
of adverse peer experiences such as peer victimization and
peer rejection in children’s social anxiety and depression.
In adolescent girls, peer acceptance variables are more
robustly related to social anxiety than are friendship vari-
ables (La Greca and Lopez 1998). In preadolescent girls,
after controlling for comorbid symptoms, peer acceptance
variables were only related to social anxiety (and not
depression) and friendship variables were only related to
depression (and not social anxiety; Hutcherson and Epkins
2009). Thus, peer acceptance variables are uniquely related
to social anxiety, whereas friendship variables are more
uniquely related to depression, at least in girls.
Many studies reviewed above highlight the importance
of separating out the constructs of peer acceptance/rejec-
tion and aspects of close friendships. As we noted earlier,
the SPPC social acceptance subscale that is used in much
research has four of the six items that focus on aspects of
356 Clin Child Fam Psychol Rev (2011) 14:329–376
123
friendships (e.g., number of friends, wanting or not wanting
more friends, ease or difficulty in making friends, and
doing things with other children versus alone). Not only do
some of these items assess aspects of friendships, but some
tap aspects of loneliness.
Loneliness
Loneliness involves quantitative and/or qualitative aspects
of social relationships (Dill and Anderson 1999). Not sur-
prising, children’s loneliness has been found to be related
to children’s peer relationships, including peer acceptance
and rejection, as well as the quantity and quality of
friendships (e.g., see Asher and Paquette 2003, for review).
Moreover, children’s peer group acceptance/rejection,
having a mutual friend, and friendship quality have been
found to be independently and uniquely associated with
children’s loneliness (Parker and Asher 1993). Many
studies have found children in the rejected peer social
status group self-report more loneliness than youth in each
of the other four social status groups, including the
neglected group, whereas neglected children have been
found to not differ from any other groups (see findings of,
and review in, Crick and Ladd 1993). Consistent with these
data, loneliness has been conceptualized as and found to be
a consequence of peer rejection (Pedersen et al. 2007).
Peer victimization is also associated with increased
loneliness (Hawker and Boulton 2000). Similar to social
anxiety and depression, studies also find that both direct/
overt and indirect/covert peer victimization in children and
adolescents are associated with increased loneliness (see
Storch and Ledley 2005; Storch et al. 2003a). Adolescents’
self-reported relational victimization, but not their direct
victimization, has been found to be related to their self-
reported loneliness (Woods et al. 2009). After controlling for
direct/overt victimization, indirect/covert relational victim-
ization has been found to be related to adolescent boys’ and
girls’ loneliness (Prinstein et al. 2001; Storch et al. 2003a).
Loneliness and Subclinical/Clinical Social Anxiety
Given the above literature, it is not surprising that lone-
liness is related to children’s and adolescents’ social
anxiety in both nonclinical samples and in youth with
SAD (Beidel et al. 1999; Prinstein and La Greca 2002;
Romero and Epkins 2008). Moreover, adolescents with
SAD have been found to report significantly higher levels
of loneliness relative to a control group (Beidel et al.
2007b), and relative to children with SAD (Rao et al.
2007). However, Erath et al. (2010) found in their sample
of 6th- and 7th-grade students that the number of close
mutual friendships moderated the relation between social
anxiety and loneliness, with loneliness more strongly
related to social anxiety at lower number of close friend-
ships. Finally, Crick and Ladd (1993) found loneliness was
related to 3rd- through 5th-grade girls’ but not boys’ social
anxiety.
Loneliness and Subclinical/Clinical Depression
Loneliness has also found to be associated with children’s
and adolescents’ depression symptoms (e.g., Prinstein and
La Greca 2002; Stednitz and Epkins 2006). Loneliness is
also related to the onset of depressive disorders and recovery
from MDD (Joiner et al. 2002). Stronger associations have
been found between loneliness and depressive symptoms in
10–13-year-old girls, than in boys (Storch et al. 2003b).
Loneliness and Both Social Anxiety and Depression
Preadolescent and adolescent girls’ loneliness has been
found to be related to depression after controlling for social
anxiety, and related to social anxiety after controlling for
depression (Hutcherson and Epkins 2009; Starr and Davila
2008; Stednitz and Epkins 2006). Thus, loneliness appears
to be an interpersonal construct that shows unique associ-
ations with both social anxiety and depression, at least in
girls. This is consistent with other studies that examined
social anxiety (Crick and Ladd 1993) and depression
(Storch et al. 2003b) separately and found stronger rela-
tions (or only significant relations) for girls versus boys.
Preadolescent girls’ depression and loneliness (and not
social anxiety) was found to be related to their decreased
expected acceptance and increased expected rejection from
unfamiliar hypothetical peers (Romero and Epkins 2008).
We located only one longitudinal study that examined
loneliness and depression and social anxiety. Prinstein and
La Greca (2002) assessed youth in grades 4–6 and then again
when they were in grades 10–12. They reported bivariate
correlations indicating time 1 depressive and social anxiety
symptoms were each significantly related to time 2 loneli-
ness (rs=.17 and .19, respectively). Also, time 1 loneliness
was significantly related to both time 2 depressive and social
anxiety symptoms (rs=.24 and .17, respectively). Their
findings suggest reciprocal relations. However, social anx-
iety and depression were examined separately, so the role of
comorbid symptoms was not addressed, and time 1 loneli-
ness or symptoms were not controlled for in these correla-
tions (as this was not the main focus of their study).
Summary of Loneliness and Evidence for a Mediating
Role in Cumulative Risk Model
Loneliness is related to social anxiety and depression in
both nonclinical and clinical samples. Stronger associations
appear to exist between girls’ versus boys’ loneliness and
Clin Child Fam Psychol Rev (2011) 14:329–376 357
123
social anxiety and depression. As with social anxiety and
depression, it is peer rejection and not low peer acceptance
per se that is related to loneliness in children. By definition,
and supported by data, loneliness is associated with low
quantity of friendships, as well as less positive and more
negative friendship quality (Asher and Paquette 2003;
Parker and Asher 1993).
Loneliness, like social anxiety and depression, is associated
with peer victimization, especially indirect/covert relational
peer victimization. Similar to as wasshown with social anxiety
and depression, and consistent with the notion of cumulative
risk, adolescents who self-report both or co-occurring direct/
overt and indirect/covert victimization by peers have been
found to self-report higher levels of loneliness in comparison
with adolescents who only report one type of peer victimiza-
tion (Prinstein et al. 2001; Storch et al. 2003a).
Loneliness therefore has been found to be associated
with, like social anxiety and depression, all the peer-related
interpersonal risk factors for depression and social anxiety
that we have reviewed as contained in interpersonal models
of depression or social anxiety. Importantly, loneliness is
the only interpersonal construct that we have reviewed that
has been found, at least to date, to show unique associa-
tions with both social anxiety and depression (after con-
trolling for comorbid symptoms), at least in girls.
Importantly, loneliness has also been conceptualized as,
and found to be, a mediator of the relations between peer-
related interpersonal risk factors (peer rejection and/or peer
victimization) and depressive symptoms in children, in
both correlational (Nangle et al. 2003) and several longi-
tudinal studies (Boivin et al. 1995; Pedersen et al. 2007).
Moreover, a recent study spanning 10 years by Fontaine
et al. (2009) found that loneliness partially mediated the
relation between early childhood peer preference
(LM -LL, rejection) and adolescents’ anxious/depressed
symptoms (as assessed by multiple informants). Impor-
tantly, these findings were present after controlling for time
1 anxious/depressed behavior as well as deleting overlap-
ping items from measures. Social anxiety was not exam-
ined in the above studies. Regarding social anxiety,
correlational studies also find preadolescent girls’ loneli-
ness partially mediates the relation between their perceived
social acceptance and social anxiety (after controlling for
depressive symptoms; Hutcherson and Epkins 2009).
Given all of the above, it is no wonder that loneliness has
been conceptualized as ‘‘an exemplar of social relationship
deficits’’ (Heinrich and Gullone 2006, p. 695).
Status of Models of Social Anxiety and Depression
and Implications for Comorbidity
As summarized in Table 3, our review uncovered a number
of risk factors, correlates, consequences, and protective
factors that have been demonstrated with respect to social
anxiety and depression. In addition, as summarized in
Table 4, a number of cumulative risks, and mediators of
risks, have also been identified throughout our review. The
notion of risk factors interacting to contribute to negative
outcomes, or combining in an additive manner, is certainly
not a new conceptualization (Rutter 1979; Sameroff 2000).
However, we have extended the literature by documenting
precisely what the specific cumulative risks are, and where
the interactions are, at least to date. Previous models of
social anxiety and depression, as reviewed earlier, identify
a number of constructs potentially involved in the etiology
of these symptoms and disorders. Our review has shed
some light on how these etiological influences combine
with and interact with each other, in social anxiety and
depression. However, as noted throughout our review,
despite the high comorbidity between social anxiety and
depression symptoms and disorders, very few studies have
simultaneously examined social anxiety and depression to
determine whether the risk factors, correlates, conse-
quences, and protective factors are specific or unique to
social anxiety and not depression, specific or unique to
depression and not social anxiety, related to both condi-
tions, or related to the comorbidity of social anxiety and
depression. This work remains an important mission for the
further development and refinement of etiological models
of social anxiety, depression, and the comorbidity of social
anxiety and depression.
As seen in Table 3, sixteen constructs we reviewed
have been shown to be correlates of both social anxiety
and depression. In contrast, while fewer consequences
and protective factors have been demonstrated for each
of social anxiety and depression, there are no conse-
quences or protective factors that have been documented
for both social anxiety and depression. Eight constructs
have been demonstrated to be risk factors for both social
anxiety and depression. Thus, these eight areas may
represent shared risk factors: they put youth at risk of
social anxiety and they put youth at risk of depression.
These eight risk factors largely reflect aspects of core
risk factors for psychopathology, particularly for social
anxiety and depression symptoms and disorders as
described in our review (i.e., temperament, namely BI;
genetic liability; parental psychopathology, specifically
parental depression or MDD and anxiety disorders).
Importantly, subthreshold anxious solitude and social
withdrawal/isolation are also shared risk factors, and both
social anxiety and depression have shared and nonshared
environmental influences or risk factors. These common
risk factors may also explain the comorbidity of social
anxiety and depression.
The notion that children who develop depression and
comorbid disorders is a consequence of high-risk children
358 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Table 3 Summary of demonstrated risk factors, correlates, consequences, and protective factors in social anxiety and depression
Social anxiety Depression
Risk factors
Anxious solitude
Social withdrawal/isolation
Shyness
BI
BI and controlling/overprotective/critical parenting together
BI and high maternal NE/A—depression together
Genetic liability
High nonshared environmental influences
Modest shared environmental influences
Parental depression or MDD
Parental anxiety disorder
Parental SAD
Ambivalent attachment
Adolescent-perceived parental overprotection, rejection and warmth
(retrospective reports)
Self-reported peer exclusion (especially girls)
Teacher-reported peer exclusion
Relational PV (adolescents, especially girls)
Risk factors
Social anxiety/SAD/anxious solitude
Social withdrawal/isolation
Low PE/A
High NE/A and low PE/A together
Low PE/A and low support relationships together (adolescents)
High NE/A and poor relationships with parents together
High NE/A and peer rejection together (girls only)
BI
Genetic liability (especially in adolescence)
Shared environmental influences (especially in children)
Nonshared environmental influences
High genetic liability and family conflict
Parental depression or MDD
Grandparent MDD
Parental and grandparent depression or MDD together
Parental anxiety disorder
Maternal and paternal anxiety disorders (or MDD) together
Paternal depression and low closeness in father–child relationship together (adolescent girls only)
Insecure attachment
Disorganized attachment
Anxious/avoidant attachment (adolescent self-report)
Less parental support
More family conflict
Low parental warmth and harsh punishment together (girls)
Social skill deficits (modest support, nonclinical samples)
Low perceived social acceptance
Low social acceptance (adolescents, not children)
Peer rejection (adolescents)
Peer exclusion and anxious solitude together
PV
Low perceived positive friendship qualities (adolescents)
Loneliness (adolescents)
Clin Child Fam Psychol Rev (2011) 14:329–376 359
123
Table 3 continued
Social anxiety Depression
Correlates
Social withdrawal/isolation
Anxious solitude
High NE/A
Low PE/A (only in clinical or SAD samples)
BI
Insecure attachment
Disorganized attachment
Maternal overprotection (youth self-reported)
Paternal control
Maternal negative commands/statements
Social skill deficits
High peer rejection (especially children)
High peer rejection and low peer acceptance (especially adolescents)
Peer rejection and perceived high negative qualities in friendships
together (girls and not boys)
Low perceived social acceptance
Direct/overt PV
Indirect/relational PV
Indirect/relational, controlling for direct/overt PV
Indirect/relational and overt/direct PV together (adolescents)
PV and perceived friendship quality together
PV and low number close friendships together (boys and not girls)
No friends or few friends
Low support and intimacy in close friendships
Low positive friendship qualities
High negative friendship qualities
Loneliness
Loneliness and low number close friendships together
Correlates
Social withdrawal/isolation
High NE/A
Low PE/A
Low EC
High NE/A and low EC together (adolescents)
Low PE/A and low EC together (adolescent girls only)
BI
Insecure attachment
Ambivalent attachment
Disorganized attachment
Insecure attachment and social withdrawal together
High parental rejection
Low parental warmth/acceptance/support
Parental aversive behavior/conflict
Low positive and high negative parenting together
Social skill deficits
High peer rejection
Low perceived social acceptance
Direct/overt PV
Indirect/relational PV
Indirect/relational, controlling for direct/overt PV
Indirect/relational and overt/direct PV together (adolescents)
Relational PV and high genetic liability together (girls)
PV and low positive qualities in friendships together (girls and not boys)
No friends or few friends (children, not adolescents)
Less stable friendships
Low support and intimacy in close friendships
Perceived negative qualities in friendships (adolescents)
Loneliness
360 Clin Child Fam Psychol Rev (2011) 14:329–376
123
being exposed to multiple risk factors is certainly not new
(see Compas and Hammen 1996). Given our findings,
children at high risk to develop social anxiety or depres-
sion symptoms or disorders, or comorbid social anxiety
and depression, are children with temperamental vulnera-
bilities (namely BI), genetic liability, parental psychopa-
thology (specifically depression or MDD and anxiety
disorders), and subthreshold conditions of anxious solitude
and social withdrawal. As we demonstrated, these risk
factors are neither necessary nor sufficient for the devel-
opment of social anxiety or depression, as they depend on
or interact with the presence or absence of other multiple
interpersonal risk factors or protective factors.
Although the commonalities across social anxiety and
depression may represent shared risk factors and explain
the comorbidity of social anxiety and depression, the
nonshared or different demonstrated risk factors, corre-
lates, consequences, and protective factors offer some
insight into empirically refined models of social anxiety
and depression. As noted previously, social anxiety often
precedes depression, yet social anxiety does not always
lead to later depression. Moreover, depression can develop
without prior social anxiety. The findings uncovered in our
review offer some empirically based speculations about
these pathways.
Differential Risks: Parents or Peers
Our review indicates that family-related variables are
more strongly linked to child and adolescent depression
than social anxiety, and peer-related variables are more
strongly linked to child and adolescent social anxiety than
depression. This was demonstrated in three correlational
studies that controlled for comorbid depressive and social
anxiety symptoms (i.e., Hutcherson and Epkins 2009;
Johnson et al. 2005; Starr and Davila 2008). In addition,
meta-analyses focusing on parenting per se find parenting
accounts for twice as much variance in concurrent child
depression than in child anxiety (i.e., McLeod et al.
2007a,b). Moreover, perceived low parental support and
not peer support predicted increases in depression and
onset of MDD over a 2-year period in adolescent girls
(Stice et al. 2004). Along these lines, adolescents’ per-
ceived negative interactions and conflict with parents and
not peers partially mediated the relation between their
perceived social acceptance (a risk factor for depression;
as assessed on the SPPC) and later depressive symptoms
(Lee et al. 2010). Furthermore, quantitative genetic studies
find that nonshared environmental influences (e.g., peer
relationships) differentiate social anxiety from other types
of anxiety and are especially substantial for social anxiety
and SAD (i.e., Eley et al. 2008; Hallett et al. 2009).
Importantly, a number of family-related factors (low
Table 3 continued
Social anxiety Depression
Consequences
Relational PV (adolescents)
Lower intimacy in close friendships (especially girls)
Consequences
Low perceived social acceptance
Less stability in dyadic friendships (adolescents)
Increase in perceived negative qualities in friendships (adolescents, especially girls)
Decrease in positive friendship qualities (adolescents)
Decreases in number of reciprocal friends and poorer perceived friendship quality
(both decrease in positive and increase in negative; preadolescent girls and not boys
Protective factors
High number of close mutual friendships (for PV and social anxiety;
for boys and not girls)
Perceived low negative qualities in friendships (for peer rejection
and social anxiety, for girls only)
High intimacy and companionship in close friendships
High positive qualities in friendships
Protective factors
Positive qualities in friendships (for PV and depression; for girls and not boys)
Bold text overlap in construct for depression and social anxiety, SAD social anxiety disorder, NE/A neuroticism/negative emotionality or affectivity, PE/A extraversion/positive emotionality or
affectivity, BI behavioral inhibition, MDD major depressive disorder, PV peer victimization
Clin Child Fam Psychol Rev (2011) 14:329–376 361
123
parental support, high family conflict, low parental
warmth, and harsh punishment) have been found to be
prospective risk factors for child and adolescent
depression, whereas no such family-related factors have
been demonstrated to be prospective risk factors for social
anxiety (see Table 3).
Table 4 Summary of demonstrated cumulative risks and mediators of risk of depression and/or social anxiety
Risk factor(s) Cumulative
risks of
Mediators for
DEP SANX DEP SANX
High NE/A and low PE/A X
Low PE/A and low supportive relationships X
High NE/A and poor relationships with parents X
High NE/A and peer rejection (girls only) X
NE/A EC EC
PE/A EC
BI (retrospective reports) SAD
BI and insecure attachment and parental control (child self-reported) X
Insecure attachment and social withdrawal X
BI and controlling/overprotective/critical parenting X
BI and high maternal NE/A—depression X
High genetic liability and family conflict X
Grandparent and parent depression X
Maternal depression or MDD Parenting and mother–child
relationship
Parental MDD Temperament (late adolescents’
self-reports)
Maternal and paternal anxiety disorders (or MDD) X
Paternal depression and low closeness in father–child relationship
(adolescent girls only)
X
Low parental warmth and harsh punishment (girls) X
Low positive and high negative parenting X
Parental SAD or MDD and youth perceived negative parenting
(retrospective reports)
X
Peer rejection Social skill
deficits
High peer rejection and low peer acceptance (especially adolescents) X
Perceived social acceptance (girls) Loneliness
Peer exclusion Peer rejection
Peer exclusion and anxious solitude X
Peer rejection PV
Peer rejection Loneliness
Peer rejection and perceived high negative qualities in friendships
(girls and not boys)
X
PV Loneliness
Direct/overt and indirect/relational PV X X
Relational PV and high genetic liability (girls) X
PV and low positive qualities in friendships (girls and not boys) X
PV and perceived friendship quality X
PV and low number close friendships (boys and not girls) X
Loneliness and low number of close mutual friends X
SANX social anxiety, DEP depression, NE/A neuroticism/negative emotionality or affectivity, PE/A extraversion/positive emotionality or
affectivity, BI behavioral inhibition, EC effortful control, SAD social anxiety disorder, PV peer victimization
362 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Differential Risks: General Peer Relations
or Friendships
Our review uncovered, at least in girls, that general peer
acceptance variables relative to friendship variables are
more strongly or uniquely related to social anxiety than to
depression, and friendship variables relative to peer
acceptance variables are more strongly or uniquely related
to depression than to social anxiety. Along these lines, peer
exclusion and relational peer victimization have been
shown to be prospective risk factors for social anxiety. In
contrast, low social acceptance (assessed primarily via the
SPPC self- and other-informant versions, which include
friendship and loneliness items), peer rejection, low per-
ceived positive friendship qualities and loneliness, and self-
reported victimization have been shown to be prospective
risk factors for adolescent depression (see Table 3).
The above is not intended to imply that friendships are
not important for social anxiety. Indeed, as seen in Table 3,
high positive qualities in friendships have been shown to be
protective factors in concurrent relations (La Greca and
Moore Harrison 2005) and prospective relations (Vernberg
et al. 1992) with respect to social anxiety. Moreover,
aspects of friendships are protective with respect to youth
social anxiety in the face of adverse peer experiences, such
as peer rejection for girls (Greco and Morris 2005) and peer
victimization for boys (Erath et al. 2010). Moreover, posi-
tive friendship qualities have been shown to be protective in
the relation between peer victimization and depression in
girls (Schmidt and Bagwell 2007). Although friendships are
important in both depression and social anxiety, there are
more findings showing aspects of friendships are correlates
and consequences of, and not risk factors for, social anxiety
and depression (see Tables 2and 3).
Cumulative Risk: Parents and Peers
Our review uncovered that a number of parent- and peer-
related constructs are indeed related to social anxiety and
depression. However, the literatures with respect to peer
and parent variables have largely been developed sepa-
rately. Few researchers have considered both parent- and
peer-related constructs simultaneously within a study on
either social anxiety or depression, or social anxiety and
depression. These issues are both important, as various
peer- and/or parent-related interpersonal risk factors may
have unique, combined, or interacting associations with, or
contributions to, depression and/or social anxiety. For
example, and consistent with the notion of cumulative risk,
adolescents’ problematic interaction patterns with parents
and with peers were found to uniquely, and additively,
predict increases in their depressive symptoms 1 year later
(Allen et al. 2006). Moreover, as discussed earlier,
Brendgen et al.’s (2005) findings showed aspects of tem-
perament interacted differently with parent-related and
peer-related interpersonal factors, as well as child sex, in
depression-related trajectories. Perceived parental support
and friendship quality has also been found to make both
independent and interactive contributions to 5th graders
internalizing problems, with high-quality friendships found
to buffer the effects of low parental support, especially for
girls (Rubin et al. 2004). Although this study was correla-
tional and did not examine social anxiety per se, it high-
lights what Rubin et al. (2010) note, ‘‘there is a need to
examine parent–child and friendship relationships in con-
cert’’ (p. 90). Furthermore, in a longitudinal study, peer
acceptance was found to protect against internalizing
problems resulting from parental rejection in early adoles-
cents, yet parental acceptance did not protect against the
effects of peer rejection (Sentse et al. 2010), highlighting
the importance of examining the peer and parent contexts
simultaneously. Examining both parent- and peer-related
variables is becoming, and will continue to become,
increasingly important in both correlational cross-sectional
research and prospective longitudinal studies. Future stud-
ies need to simultaneously examine peer- and parent-related
variables, so as to shed light on their interacting contribu-
tions to children’s depression and/or social anxiety in the
further development of etiological models of depression,
social anxiety, and their comorbidity. Until then, we offer
some empirically based speculations regarding the current
literature with respect to variables involved in the devel-
opment of depression, development of social anxiety, and
the development of social anxiety becoming comorbid with
depression. In doing so, given that our review uncovered
numerous conceptual and empirical similarities between
subthreshold and diagnostic levels of social anxiety and
depression, coupled with the general lack of research that
compares developmental pathways for subthreshold symp-
toms versus diagnostic levels, we refer to social anxiety and
depression more generally to reflect the symptom or diag-
nostic level.
Depression
As reflected in Table 3, children with temperamental vul-
nerabilities of high NE/A and low PE/A together, espe-
cially in combination with poor or low supportive
interpersonal relationships, are at risk of depression. Chil-
dren with genetic liability and parental depression and/or
anxiety disorders are also at risk. Children with a grand-
parent and parent with MDD have a cumulative risk, as do
children with a mother and father with MDD or anxiety
disorders. Disorganized parent–child attachment is the only
subtype of insecure attachment demonstrated to be a risk
factor for depression. These youngsters view their
Clin Child Fam Psychol Rev (2011) 14:329–376 363
123
caregiver as both a secure base and a source of apprehen-
sion. This form of attachment is likely coupled with the
low parental support and warmth, high family conflict, and
harsh punishment that have also been found to be pro-
spective risk factors for depression. The low support/
warmth, high conflict, and parental rejection in the family
results in the youngster’s continued apprehension in the
peer environment, including social withdrawal/isolation
and anxious solitude, which leads to concurrent social skill
deficits and then additional consequences follow: having
few or no friends, more negative and few positive qualities
in friendships, and low perceived social acceptance—all
cumulating in loneliness and continued depression. If the
youngster is rejected by peers and/or victimized by peers,
high positive qualities (support, validation) in a close
friendship is protective, especially for girls. Youth with a
genetic liability are more likely to develop depression in
response to family conflict (Rice et al. 2006) and peer
victimization (Benjet et al. 2010).
Social Anxiety and Social Anxiety Leading
to Depression
As reflected in Table 3, children with a temperamental
vulnerability of BI, especially in combination with par-
enting that is overprotective, controlling, and critical, are at
risk of social anxiety. Children with genetic liability and
parental depression and/or anxiety disorders are also at
risk. Ambivalent parent–child attachment is the only sub-
type of insecure attachment demonstrated to be a risk factor
for social anxiety. These youngsters show fearfulness and
negative emotions and display dependence as a means to
get attention from their caregiver. This form of attachment
is likely coupled with the controlling and overprotective
parenting associated with youth social anxiety, which may
be due to the parents own anxiety and/or the youngster’s BI
tendencies (i.e., Eley et al. 2010; van der Bruggen et al.
2010). The child’s anxiety and social fears may be learned
from their parents and/or be reinforced by their parents.
When they are immersed in the peer environment, they
continue to display fearfulness (and social withdrawal/
isolation and anxious solitude), which leads to concurrent
social skill deficits. These behaviors, coupled with their
lack of autonomy and independence, make them at risk of
being excluded by peers, a prospective risk factor for social
anxiety (i.e., Vernberg et al. 1992; Gazelle and Ladd 2003).
If anxious solitude and peer exclusion persist, that has been
demonstrated to be a risk factor for developing depression
(i.e., Gazelle and Ladd 2003; Gazelle and Rudolph 2004).
If the youngster is actively rejected or victimized by peers,
having close friendships and positive qualities in friend-
ships is protective against social anxiety. Moreover, if they
have a number of close friends, then social anxiety will not
likely be related to loneliness (i.e., Erath et al. 2010) and
then they will not develop subsequent depression. In con-
trast, if the youngster has no friendships or no positive
qualities in friendships (a risk factor for depression), then
loneliness (a risk factor for depression) and subsequent
depression will emerge.
Based on our findings and consistent with the notion of
cumulative risk, we contend that negative peer experiences
(exclusion, rejection, and/or victimization) coupled with a
lack of or poor-quality friendships, cumulating in loneli-
ness, explain the relation between social anxiety and later
depression. This notion is somewhat consistent with Rubin
et al.’s (2009) model of social withdrawal. Moreover, this
is also consistent with Erath et al.’s (2010) finding that the
number of close friends moderated the association between
social anxiety and loneliness, with social anxiety more
strongly related to loneliness when youth had a low number
of close friendships. Furthermore, Biggs et al. (2010) found
that adolescents’ low perceived peer social acceptance (on
the adolescent version of the SPPC) and high perceived
peer victimization each uniquely mediated the relation
between time 1 general anxiety symptoms and depressive
symptoms assessed 5 months later. Interestingly, qualities
of best friendships were not found to be mediators of the
anxiety–depression link. As Biggs et al. note, their
friendship findings may have been different if social anx-
iety versus general anxiety was examined. Indeed, more
research is needed on the pathways from social anxiety to
depression.
Treatment Implications
Our findings highlight several potential targets for pre-
vention and treatment, as well as delineate aspects of
children’s interpersonal relationships that may mediate or
moderate treatment outcome for youth with SAD and/or
MDD. In terms of targets for treatment, interpersonal
psychotherapy for depressed adolescents (IPT-A) is an
empirically supported treatment (see Mufson 2010, for a
review). IPT-A focuses on interpersonal interactions rela-
ted to depression, such as conflict with parents and social
problems with peers (see Mufson et al. 2004, for further
description). Given these targets, it is not surprising that
higher parent–child conflict and more social problems with
peers at baseline were related to better treatment outcome
for IPT-A compared to treatment as usual (Gunlicks-
Stoessel et al. 2010). Similarly, an adapted IPT-A skills
training was superior to school counseling in reducing
depression in adolescents who reported high (not low)
baseline conflict with mothers (Young et al. 2009). As
Mufson (2010) recently noted, ‘‘there are no identified
mediators of IPT-A outcome’’ (p. 68). Indeed, delineating
364 Clin Child Fam Psychol Rev (2011) 14:329–376
123
mediators will be important to do, as the mechanism of
change may be decreased parent–child conflict but it may
also be increased parent warmth/support, increased per-
ceived social acceptance, or decreased loneliness.
Social effectiveness therapy for children (SET-C) is an
empirically supported treatment for SAD, and it includes
social skills training, a peer generalization program (i.e.,
participating in social activities with nonanxious peers),
and exposure (see Beidel and Roberson-Nay 2005, for
further coverage). Adolescents displayed sustained benefits
on a variety of outcome measures (including social anxiety
and loneliness) 5 years after undergoing SET-C (Beidel
et al. 2006). Furthermore, significantly more youth treated
with SET-C no longer met DSM criteria for SAD (53%)
relative to those who were treated with fluoxetine (21%) or
placebo (3%) and were rated by independent observers as
more socially skilled when compared to the other two
groups (Beidel et al. 2007a). Importantly, a reduction in
loneliness, and not changes in observer-rated social skills,
mediated changes in SAD symptoms in youth who
underwent SET-C, and youth pretreatment depressive
symptoms did not moderate treatment outcome (Alfano
et al. 2009). Thus, loneliness, and not social skills, was the
critical mechanism of change. This is consistent with our
conclusion that loneliness is uniquely related to both
depression and social anxiety and is a mediator of peer-
related interpersonal risk factors and both depression and
social anxiety. VanderWeele et al. (2011) recently found
that reducing loneliness in treatment of adults would in turn
reduce symptoms of depression. Given these findings, as
well as our review and conclusions, interventions targeting
loneliness appear empirically justified in treatment of youth
social anxiety and/or depression.
Our review uncovered findings that dovetail with the
treatment literature and suggest it would likely be beneficial
to involve parents in the treatment of youth social anxiety
and depression. This would be useful to either target key
interpersonal parental and family factors or address parents’
possible own anxiety and/or depression. Family-focused
cognitive-behavioral therapy (FCBT) combines individual
child-focused cognitive-behavioral therapy (ICBT) and
increased parent training to treat child anxiety disorders.
When both parents had an anxiety disorder, FCBT was
better in reducing self-reported childhood anxiety symp-
toms compared to ICBT (Kendall et al. 2008). Creswell and
Cartwright-Hatton’s (2007) review suggested that children
are likely to have poorer treatment outcomes if parental
anxiety goes unaddressed. However, they also noted,
‘‘Whether it is parental anxiety per se or associated cogni-
tive or behavioral features of the parent–child relationship
that need to be addressed within treatment requires sys-
tematic evaluation’’ (p. 248). In support of the parent–child
relationship potentially being the active mechanism of
change, recent research found children who had ICBT plus
parent anxiety management (PAM) had better treatment
outcome (i.e., more likely to have no anxiety disorder)
3 years later than those who had only ICBT, regardless of
whether parents had high or low initial anxiety levels
(Cobham et al. 2010). As these authors and others have
noted, aspects of parenting such as parental overinvolve-
ment or parental support may mediate child outcomes (see
Cobham et al. 2010).
Indeed, aspects of parenting have been found to mediate
treatment outcome. Wood et al. (2009) found that a
decrease in parental intrusiveness mediated the relation
between FCBT and the reduction in anxiety symptoms in
early adolescents. Further, child-reported maternal emo-
tional warmth and fathers’ self-reported symptoms of
anxiety and depression predicted less favorable treatment
outcomes for children undergoing a brief CBT program for
anxiety (Liber et al. 2008). Mother-reported frequency of
parent–adolescent conflict was found to be a predictor of
poorer treatment outcomes of depressed adolescents,
regardless of whether they received CBT, medication, a
combination of the two, or placebo (Feeny et al. 2009).
Prevention efforts for both depression and social anxiety
should target those at high risk as indicated in our review
(i.e., parents with depression and/or anxiety disorders,
youngsters with BI, social withdrawal or anxious solitude).
Early intervention for those at high risk is important. For
instance, children (between the ages of 4–7) with BI at
baseline were less likely to lose their anxiety diagnoses
following a developmentally appropriate parent–child CBT
(Hirshfeld-Becker et al. 2010). Thus, children with BI may
require unique or more intensive interventions (Liber et al.
2008), particularly since they are at risk of both depression
and social anxiety. In terms of prevention, a recent ran-
domized clinical trial involving parents with current or past
MDD and their 9–15-year-old children found that changes
in behaviorally observed positive parenting mediated the
effects of a 12-session family group cognitive-behavioral
intervention and changes in youngsters’ depression 1 year
later (Compas et al. 2010). Interestingly, changes in youth
depressive symptoms at 2 months predicted changes in
behaviorally observed negative parenting over a 6-month
period, indicating reciprocal relations between negative
parenting and youth behavior. Similar reciprocal relations
between maternal parenting behaviors and youth anxiety
were found by Silverman et al. (2009) in a study focusing
on the treatment of child anxiety disorders (18% with
SAD). Importantly, child and maternal anxiety, parenting,
and the mother–child relationship showed similarly sig-
nificant improvement after both an intervention that only
targeted youth anxiety (CBT) and a CBT treatment that
also actively involved parents (targeting parenting and the
parent–child relationship). Thus, parenting and aspects of
Clin Child Fam Psychol Rev (2011) 14:329–376 365
123
the parent–child relationship may be a mechanism of
change, regardless of whether these aspects are targeted
directly in prevention or intervention in youth depression
and anxiety.
As Kaslow et al. (2009) concluded, ‘‘To date, there is a
dearth of well-conducted research examining family
interventions for depressed youth, despite the well docu-
mented links between depression and family factors’’
(p. 554). This statement also holds true for social anxiety.
Importantly, the Family Assessment Clinician-Rated
Interview (FACI) was recently developed to assess parent
and family factors that contribute to youth anxiety (Eh-
renreich et al. 2009b). Similar assessment tools that include
aspects of parent and peer relationships would be useful in
treating SAD and MDD. Importantly, assessing peer
rejection and peer victimization experiences, as well as
quantity and quality of friendships, including loneliness,
would be critical areas to assess as pretreatment assessment
for depression and/or social anxiety.
Unfortunately, as with the other areas we have reviewed
in this paper, very few prevention or treatment studies have
examined social anxiety and depression. Moreover,
research examining the effectiveness of evidence-based
treatments of comorbid disorders is still in its infancy
(Ollendick et al. 2008). Developing such a protocol is
critical given that youth with comorbid SAD and depres-
sive disorders are significantly more impaired and appear
to achieve poorer treatment outcomes relative to youth with
only one of these disorders (Crawley et al. 2008; Ollendick
et al. 2008; Young et al. 2006). However, a promising
unified treatment protocol for emotional disorders was
found to decrease clinician severity ratings of generalized
anxiety disorder, MDD, and SAD in an adolescent
(Ehrenreich et al. 2009a). This unified protocol focuses
largely on emotion regulation strategies, and behavioral
and cognitive-behavioral strategies, for youngsters with
comorbid depression and anxiety. As we have demon-
strated in this paper, developing a unified protocol for
comorbid depression and social anxiety per se would likely
need to target, in large part, children’s relationships with
parents and peers.
References
Abela, J. R. Z., & Hankin, B. L. (2008). Depression in children and
adolescents: Causes, treatment, and prevention. In J. R. Abela &
B. L. Hankin (Eds.), Handbook of depression in children and
adolescents (pp. 3–5). New York, NY: Guilford Press.
Alfano, C. A., Beidel, D. C., & Turner, S. M. (2006). Cognitive
correlates of social phobia among children and adolescents.
Journal of Abnormal Child Psychology, 34, 189–201. doi:
10.1007/s10802-005-9012-9.
Alfano, C. A., Pina, A. A., Villalta, I. K., Beidel, D. C., Ammerman,
R. T., & Crosby, L. E. (2009). Mediators and moderators of
outcome in the behavioral treatment of childhood social phobia.
Journal of the American Academy of Child and Adolescent
Psychiatry, 48, 945–953. doi:10.1097/CHI.0b013e3181af8216.
Allen, J. P., Insabella, G., Porter, M. R., Smith, F. D., Land, D., &
Phillips, N. (2006). A social interactional model of the devel-
opment of depressive symptoms in adolescence. Journal of
Consulting and Clinical Psychology, 74, 55–65. doi:10.1037/
0022-006X.74.1.55.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
Anderson, E. R., & Hope, D. A. (2008). A review of the tripartite
model for understanding the link between anxiety and depression
in youth. Clinical Psychology Review, 28, 275–287. doi:10.1016/
j.cpr.2007.05.004.
Anderson, E. R., Veed, G. J., Inderbitzen-Nolan, H. M., & Hansen, D. J.
(2010). An evaluation of the applicability of the tripartite
constructs to social anxiety in adolescents. Journal of Clinical
Child and Adolescent Psychology, 39, 195–207. doi:10.1080/
15374410903532643.
Angold, A., Costello, E. J., & Erkanli, A. (1999a). Comorbidity.
Journal of Child Psychology and Psychiatry, 40, 57–87. doi:
10.1111/1469-7610.00424.
Angold, A., Costello, E. J., Farmer, E. M. Z., Burns, B. J., & Erkanli,
A. (1999b). Impaired but undiagnosed. Journal of the American
Academy of Child and Adolescent Psychiatry, 38, 129–137. doi:
10.1097/00004583-199902000-00011.
Asher, S. R., & Paquette, J. A. (2003). Loneliness and peer relations
in childhood. Current Directions in Psychological Science, 12,
75–78. doi:10.1111/1467-8721.01233.
Aune, T., & Stiles, T. C. (2009). The effects of depression and
stressful life events on the development and maintenance of
syndromal social anxiety: Sex and age differences. Journal of
Clinical Child and Adolescent Psychology, 38, 501–512. doi:
10.1080/15374410902976304.
Avenevoli, S., Knight, E., Kessler, R. C., & Merikangas, K. R. (2008).
Epidemiology of depression in children and adolescents. In
J. R. Abela & B. L. Hankin (Eds.), Handbook of depression in
children and adolescents (pp. 6–32). New York, NY: Guilford
Press.
Barber, B. K. (1996). Parental psychological control: Revisiting a
neglected construct. Child Development, 67, 3296–3319. doi:
10.2307/1131780.
Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007).
Predicting children’s anxiety from early attachment relation-
ships. Journal of Anxiety Disorders, 21, 1061–1068. doi:
10.1016/j.janxdis.2006.10.013.
Beesdo, K., Bittner, A., Pine, D. S., Stein, M. B., Hofler, M., Lieb, R.,
et al. (2007). Incidence of social anxiety disorder and the
consistent risk for secondary depression in the first three decades
of life. Archives of General Psychiatry, 64, 903–912. doi:
10.1001/archpsyc.64.8.903.
Beidel, D. C., & Roberson-Nay, R. (2005). Treating childhood social
phobia: Social effectiveness therapy for children. In E. D. Hibbs,
P. S. Jensen, E. D. Hibbs, & P. S. Jensen (Eds.), Psychosocial
treatments for child and adolescent disorders: Empirically based
strategies for clinical practice (2nd ed., pp. 75–96). Washington,
DC: American Psychological Association.
Beidel, D. C., & Turner, S. M. (2007). Shy children, phobic adults:
Nature and treatment of social anxiety disorder (2nd ed.).
Washington, DC: American Psychological Association.
Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology
of childhood social phobia. Journal of the American Academy of
Child and Adolescent Psychiatry, 38, 643–650. doi:10.1097/
00004583-199906000-00010.
366 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Beidel, D. C., Turner, S. M., Sallee, F. R., Ammerman, R. T., Crosby,
L. A., & Pathak, S. (2007a). SET-C versus fluoxetine in the
treatment of childhood social phobia. Journal of the American
Academy of Child and Adolescent Psychiatry, 46, 1622–1632.
doi:10.1097/chi.0b013e318154bb57.
Beidel, D. C., Turner, S. M., & Young, B. J. (2006). Social
effectiveness therapy for children: Five years later. Behavior
Therapy, 37, 416–425. doi:10.1016/j.beth.2006.06.002.
Beidel, D. C., Turner, S. M., Young, B. J., Ammerman, R. T., Sallee,
F. R., & Crosby, L. (2007b). Psychopathology of adolescent
social phobia. Journal of Psychopathology and Behavioral
Assessment, 29, 47–54. doi:10.1007/s10862-006-9021-1.
Bell-Dolan, D. J., Foster, S. L., & Christopher, J. S. (1995). Girls’
peer relations and internalizing problems: Are socially neglected,
rejected, and withdrawn girls at risk? Journal of Clinical Child
Psychology, 24, 463–473. doi:10.1207/s15374424jccp2404_10.
Bell-Dolan, D. J., Reaven, N. M., & Peterson, L. (1993). Depression
and social functioning: A multidimensional study of linkages.
Journal of Clinical Child Psychology, 22, 306–315. doi:10.1207/
s15374424jccp2203_1.
Benjet, C., Thompson, R. J., & Gotlib, I. H. (2010). 5-HTTLPR
moderates the effect of relational peer victimization on depres-
sive symptoms in adolescent girls. Journal of Child Psychology
and Psychiatry, 51, 173–179. doi:10.1111/j.1469-7610.2009.
02149.x.
Biederman, J., Hirshfeld-Becker, D. R., Rosenbaum, J. F., He
´rot, C.,
Friedman, D., Snidman, N., et al. (2001). Further evidence of
association between behavioral inhibition and social anxiety in
children. The American Journal of Psychiatry, 158, 1673–1679.
doi:10.1176/appi.ajp.158.10.1673.
Biggs, B. K., Nelson, J. M., & Sampilo, M. L. (2010). Peer relations
in the anxiety-depression link: Test of a mediation model.
Anxiety, Stress & Coping: An International Journal, 23,
431–447. doi:10.1080/10615800903406543.
Birmaher, B., Bridge, J. A., Williamson, D. E., Brent, D. A., Dahl,
R. E., Axelson, D. A., et al. (2004). Psychosocial functioning in
youths at high risk to develop major depressive disorder. Journal
of the American Academy of Child and Adolescent Psychiatry,
43, 839–846. doi:10.1097/01.chi.0000128787.88201.1b.
Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman,
J., Dahl, R. E., et al. (1996). Childhood and adolescent
depression: A review of the past 10 years, part I. Journal of
the American Academy of Child and Adolescent Psychiatry, 35,
1427–1439. doi:10.1097/00004583-199611000-00011.
Blount, T. H., & Epkins, C. C. (2009). Exploring modeling-based
hypotheses in preadolescent girls’ and boys’ cognitive vulner-
ability to depression. Cognitive Therapy and Research, 33,
110–125. doi:10.1007/s10608-008-9195-9.
Bogels, S. M., Alden, L., Beidel, D. C., Clark, L. A., Pine, D. S.,
Stein, M. B., et al. (2010). Social anxiety disorder: Questions and
answers for the DSM-V. Depression and Anxiety, 27, 168–189.
doi:10.1002/da.20670.
Bogels, S. M., van Oosten, A., Muris, P., & Smulders, D. (2001).
Familial correlates of social anxiety in children and adolescents.
Behaviour Research and Therapy, 39, 273–287. doi:10.1016/
S0005-7967(00)00005-X.
Boivin, M., Hymel, S., & Burkowski, W. M. (1995). The roles of
social withdrawal, peer rejection, and victimization by peers in
predicting loneliness and depressed mood in childhood. Devel-
opment and Psychopathology, 7, 765–785. doi:10.1017/S095
4579400006830.
Borelli, J. L., & Prinstein, M. J. (2006). Reciprocal, longitudinal
associations among adolescents’ negative feedback-seeking,
depressive symptoms, and peer relations. Journal of Abnormal
Child Psychology, 34, 159–169. doi:10.1007/s10802-005-
9010-y.
Brady, E., & Kendall, P. C. (1992). Comorbidity of anxiety and
depression in children and adolescents. Psychological Bulletin,
111, 244–255. doi:10.1037/0033-2909.111.2.244.
Branje, S. T., Hale, W., Frijns, T., & Meeus, W. J. (2010). Longitudinal
associations between perceived parent–child relationship quality
and depressive symptoms in adolescence. Journal of Abnormal
Child Psychology, 38, 751–763. doi:10.1007/s10802-010-9401-6.
Brendgen, M., Wanner, B., Morin, A. J. S., & Vitaro, F. (2005).
Relations with parents and with peers, temperament, and
trajectories of depressed mood during early adolescence. Journal
of Abnormal Child Psychology, 33, 579–594. doi:10.1007/
s10802-005-6739-2.
Bruder-Costello, B., Warner, V., Talati, A., Nomura, Y., Bruder, G.,
& Weissman, M. (2007). Temperament among offspring at high
and low risk for depression. Psychiatry Research, 153, 145–151.
doi:10.1016/j.psychres.2007.02.013.
Brumariu, L. E., & Kerns, K. A. (2008). Mother-child attachment and
social anxiety symptoms in middle childhood. Journal of
Applied Developmental Psychology, 29, 393–402. doi:10.1016/j.
appdev.2008.06.002.
Brumariu, L. E., & Kerns, K. A. (2010a). Mother–child attachment
patterns and different types of anxiety symptoms: Is there
specificity of relations? Child Psychiatry and Human Develop-
ment, 41, 663–674. doi:10.1007/s10578-010-0195-0.
Brumariu, L. E., & Kerns, K. A. (2010b). Parent–child attachment and
internalizing symptoms in childhood and adolescence: A review of
empirical findings and future directions. Development and Psy-
chopathology, 22, 177–203. doi:10.1017/S0954579409990344.
Bureau, J., Easterbrooks, M. A., & Lyons-Ruth, K. (2009). Maternal
depressive symptoms in infancy: Unique contribution to chil-
dren’s depressive symptoms in childhood and adolescence?
Development and Psychopathology, 21, 519–537. doi:10.1017/
S0954579409000285.
Burstein, M., Ginsburg, G. S., & Tein, J. (2010). Parental anxiety and
child symptomatology: An examination of additive and interac-
tive effects of parent psychopathology. Journal of Abnormal
Child Psychology, 38, 897–909. doi:10.1007/s10802-010-9415-0.
Card, N. A., Stucky, B. D., Sawalani, G. M., & Little, T. D. (2008).
Direct and indirect aggression during childhood and adoles-
cence: A meta-analytic review of gender differences, intercor-
relations, and relations to maladjustment. Child Development,
79, 1185–1229. doi:10.1111/j.1467-8624.2008.01184.x.
Caron, A., Weiss, B., Harris, V., & Catron, T. (2006). Parenting
behavior dimensions and child psychopathology: Specificity,
task dependency, and interactive relations. Journal of Clinical
Child and Adolescent Psychology, 35, 34–45. doi:10.1207/
s15374424jccp3501.
Cartwright-Hatton, S. (2006). Editorial: Anxiety of childhood and
adolescence: Challenges and opportunities. Clinical Psychology
Review, 26, 813–816. doi:10.1016/j.cpr.2005.12.001.
Cartwright-Hatton, S., Hodges, L., & Porter, J. (2003). Social anxiety
in childhood: The relationship with self and observer rated social
skills. Journal of Child Psychology and Psychiatry, 44, 737–742.
doi:10.1111/1469-7610.00159.
Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety
in a neglected population: Prevalence of anxiety disorders in pre-
adolescent children. Clinical Psychology Review, 26, 817–833.
doi:10.1016/j.cpr.2005.12.002.
Cartwright-Hatton, S., Tschernitz, N., & Gomersall, H. (2005). Social
anxiety in children: Social skills deficit, or cognitive distortion?
Behaviour Research and Therapy, 43, 131–141. doi:10.1016/
j.brat.2003.12.003.
Caspi, A., Moffitt, T. E., Newman, D. L., & Silva, P. A. (1996).
Behavioral observations at age 3 predict adult psychiatric
disorders: Longitudinal evidence from a birth cohort. Archives
of General Psychiatry, 53, 1033–1039.
Clin Child Fam Psychol Rev (2011) 14:329–376 367
123
Chansky, T. E., & Kendall, P. C. (1997). Social expectancies and self-
perceptions in anxiety-disordered children. Journal of Anxiety
Disorders, 11, 347–363. doi:10.1016/S0887-6185(97)00015-7.
Chavira, D. A., Stein, M. B., Bailey, K., & Stein, M. T. (2004).
Comorbidity of generalized social anxiety disorder and
depression in a pediatric primary care sample. Journal of
Affective Disorders, 80, 163–171. doi:10.1016/S0165-0327(03)
00103-4.
Chavira, D. A., Stein, M. B., & Malcarne, V. L. (2002). Scrutinizing
the relationship between shyness and social phobia. Journal of
Anxiety Disorders, 16, 585–598. doi:10.1016/S0887-6185(02)00
124-X.
Chorpita, B. F., Plummer, C. M., & Moffitt, C. E. (2000). Relations of
tripartite dimensions of emotion to childhood anxiety and mood
disorders. Journal of Abnormal Child Psychology, 28, 299–310.
doi:10.1023/A:1005152505888.
Chronis-Tuscano, A., Degnan, K. A., Pine, D. S., Perez-Edgar, K.,
Henderson, H. A., Diaz, Y., et al. (2009). Stable early maternal
report of behavioral inhibition predicts lifetime social anxiety
disorder in adolescence. Journal of the American Academy of
Child and Adolescent Psychiatry, 48, 928–935. doi:10.1097/
CHI.0b013e3181ae09df.
Cicchetti, D., & Rogosch, F. A. (1996). Equifinality and multifinality
in developmental psychopathology. Development and Psycho-
pathology, 8, 597–600. doi:10.1017/S0954579400007318.
Cicchetti, D., & Toth, S. L. (2009). The past achievements and future
promises of developmental psychopathology: The coming of age
of a discipline. Journal of Child Psychology and Psychiatry, 50,
16–25. doi:10.1111/j.1469-7610.2008.01979.x.
Clark, L. A. (2005). Temperament as a unifying basis for personality
and psychopathology. Journal of Abnormal Psychology, 114,
505–521. doi:10.1037/0021-843X.114.4.505.
Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive
theory and therapy of depression. New York, NY: Wiley.
Clark, L. A., & Watson, D. (1999). Temperament: A new paradigm
for trait psychology. In L. A. Pervin & O. P. John (Eds.),
Handbook of personality: Theory and research (2nd ed.,
pp. 399–423). New York, NY: Guilford Press.
Clark, L. A., & Watson, D. (2008). Temperament: An organizing
paradigm for trait psychology. In O. P. John, R. W. Robins, &
L. A. Pervin (Eds.), Handbook of personality psychology:
Theory and research (3rd ed., pp. 265–286). New York, NY:
Guilford Press.
Cobham, V. E., Dadds, M. R., Spence, S. H., & McDermott, B.
(2010). Parental anxiety in the treatment of childhood anxiety: A
different story three years later. Journal of Clinical Child and
Adolescent Psychology, 39, 410–420. doi:10.1080/15374411
003691719.
Coie, J. D., Dodge, K. A., & Coppotelli, H. (1982). Dimensions and
types of social status: A cross-age perspective. Developmental
Psychology, 18, 557–570. doi:10.1037/0012-1649.18.4.557.
Cole, D. A. (1991). Preliminary support for a competency-based
model of depression in children. Journal of Abnormal Psychol-
ogy, 100, 181–190. doi:10.1037/0021-843X.100.2.181.
Cole, D. A., Martin, J., & Powers, B. (1997). A competency-based model
of child depression: A longitudinal study of peer, parent, teacher,
and self-evaluations. Journal of Child Psychology and Psychiatry,
38, 505–514. doi:10.1111/j.1469-7610.1997.tb01537.x.
Cole, D. A., Martin, J., Powers, B., & Truglio, R. (1996). Modeling
causal relations between academic and social competence and
depression: A multitrait-multimethod longitudinal study of
children. Journal of Abnormal Psychology, 105, 258–270. doi:
10.1037/0021-843X.105.2.258.
Cole, D. A., Maxwell, M. A., Dukewich, T. L., & Yosick, R. (2010).
Targeted peer victimization and the construction of positive and
negative self-cognitions: Connections to depressive symptoms in
children. Journal of Clinical Child and Adolescent Psychology,
39, 421–435. doi:10.1080/15374411003691776.
Cole, D. A., Peeke, L. G., Martin, J. M., Truglio, R., & Seroczynski,
A. D. (1998). A longitudinal look at the relation between
depression and anxiety in children and adolescents. Journal of
Consulting and Clinical Psychology, 66, 451–460. doi:10.1037/
0022-006X.66.3.451.
Compas, B. E., Champion, J. E., Forehand, R., Cole, D. A., Reeslund,
K. L., Fear, J., et al. (2010). Coping and parenting: Mediators of
12-month outcomes of a family group cognitive-behavioral
preventive intervention with families of depressed parents.
Journal of Consulting and Clinical Psychology, 78, 623–634.
doi:10.1037/a0020459.
Compas, B. E., & Hammen, C. L. (1996). Child and adolescent
depression: Covariation and comorbidity in development. In
R. J. Haggerty, L. R. Sherrod, N. Garmezy, & M. Rutter (Eds.),
Stress, risk, and resilience in children and adolescents:
Processes, mechanisms, and interventions (pp. 225–267). New
York, NY: Cambridge University Press.
Connolly, J., Geller, S., Marton, P., & Kutcher, S. (1992). Peer
responses to social interaction with depressed adolescents.
Journal of Clinical Child Psychology, 21, 365–370. doi:
10.1207/s15374424jccp2104_6.
Cooper, P. J., Fearn, V., Willetts, L., Seabrook, H., & Parkinson, M.
(2006). Affective disorder in the parents of a clinic sample of
children with anxiety disorders. Journal of Affective Disorders,
93, 205–212. doi:10.1016/j.jad.2006.03.017.
Copeland, W. E., Shanahan, L., Costello, E. J., & Angold, A. (2009).
Configurations of common childhood psychosocial risk factors.
Journal of Child Psychology and Psychiatry, 50, 451–459. doi:
10.1111/j.1469-7610.2008.02005.x.
Costello, E. J., Egger, H. L., & Angold, A. (2005). The developmental
epidemiology of anxiety disorders: Phenomenology, prevalence,
and comorbidity. Child and Adolescent Psychiatric Clinics of
North America, 14, 631–648. doi:10.1016/j.chc.205.06.003.
Craske, M. G. (2003). Origins of phobias and anxiety disorders: Why
more women than men?. Oxford, UK: Elsevier.
Crawley, S. A., Beidas, R. S., Benjamin, C. L., Martin, E., & Kendall,
P. C. (2008). Treating socially phobic youth with CBT:
Differential outcomes and treatment considerations. Behavioural
and Cognitive Psychotherapy, 36, 379–389. doi:10.1017/S13524
65808004542.
Creswell, C., & Cartwright-Hatton, S. (2007). Family treatment of
child anxiety: Outcomes, limitations and future directions.
Clinical Child and Family Psychology Review, 10, 232–252. doi:
10.1007/s10567-007-0019-3.
Crick, N. R., & Grotpeter, J. K. (1996). Children’s treatment by peers:
Victims of relational and overt aggression. Development and
Psychopathology, 8, 367–380. doi:10.1017/S0954579400007148.
Crick, N. R., & Ladd, G. W. (1993). Children’s perceptions of their
peer experiences: Attributions, loneliness, social anxiety, and
social avoidance. Developmental Psychology, 29, 244–254. doi:
10.1037/0012-1649.29.2.244.
Cuevas, C. A., Finkelhor, D., Ormrod, R., & Turner, H. (2009).
Psychiatric diagnosis as a risk marker for victimization in a
national sample of children. Journal of Interpersonal Violence,
24, 636–652. doi:10.1177/088626058317197.
Cummings, C., & Fristad, M. (2008). Mood disorders in childhood. In
R. G. Steele, T. D. Elkin, & M. C. Roberts (Eds.), Handbook of
evidence-based therapies for children and adolescents: Bridging
science and practice (pp. 145–160). New York, NY: Springer.
Dallaire, D. H., Pineda, A. Q., Cole, D. A., Ciesla, J. A., Jacquez, F.,
LaGrange, B., et al. (2006). Relation of positive and negative
parenting to children’s depressive symptoms. Journal of Clinical
Child and Adolescent Psychology, 35, 313–322. doi:10.1207/
s15374424jccp3502_15.
368 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Degnan, K. A., Almas, A., & Fox, N. A. (2010). Temperament and
the environment in the etiology of childhood anxiety. Journal of
Child Psychology and Psychiatry, 51, 497–517. doi:10.1111/
j.1469-7610.2010.02228.x.
Degnan, K. A., Henderson, H. A., Fox, N. A., & Rubin, K. H. (2008).
Predicting social wariness in middle childhood: The moderating
roles of childcare history, maternal personality and maternal
behavior. Social Development, 17, 471–487. doi:10.1111/
j.1467-9507.2007.00437.x.
Diener, M. L., Isabella, R. A., Behunin, M. G., & Wong, M. S. (2008).
Attachment to mothers and fathers during middle childhood:
Associations with child gender, grade, and competence. Social
Development, 17, 84–101. doi:10.1111/j.1467-9507.2007.00416.
Dill, J. C., & Anderson, C. A. (1999). Loneliness, shyness, and
depression: The etiology and interrelationships of everyday
problems in living. In T. Joiner & J. C. Coyne (Eds.), The
interactional nature of depression (pp. 93–125). Washington,
DC: American Psychological Association.
Dougherty, L.R., Bufferd, S. J., Carlson, G. A., Dyson, M., Olino, T. M.,
Durbin, C. E., et al. (2011). Preschoolers’ observed temperament
and psychiatric disorders assessed with a parent diagnostic inter-
view. Journal of Clinical Child and Adolescent Psychology, 40,
295–306. doi:10.1080/15374416.2011.546046.
Dougherty, L. R., Klein, D. N., Durbin, C. E., Hayden, E. P., & Olino,
T. M. (2010). Temperamental positive and negative emotionality
and children’s depressive symptoms: A longitudinal prospective
study from age three to age ten. Journal of Social and Clinical
Psychology, 29, 462–488. doi:10.1521/jscp.2010.29.4.462.
Ehrenreich, J. T., Goldstein, C. R., Wright, L. R., & Barlow, D. H.
(2009a). Development of a unified protocol for the treatment of
emotional disorders in youth. Child & Family Behavior Therapy,
31, 20–37. doi:10.1080/07317100802701228.
Ehrenreich, J. T., Micco, J. A., Fisher, P. H., & Warner, C. (2009b).
Assessment of relevant parenting factors in families of clinically
anxious children: The Family Assessment Clinician-Rated
Interview (FACI). Child Psychiatry and Human Development,
40, 331–342. doi:10.1007/s10578-009-0128-y.
Eisen, A. R., Spasaro, S. A., Brien, L. K., Kearney, C. A., & Albano,
A. M. (2004). Parental expectancies and childhood anxiety
disorders: Psychometric properties of the Parental Expectancies
Scale. Journal of Anxiety Disorders, 18, 89–109. doi:10.1016/
j.janxdis.2001.10.001.
Eley, T. C., Napolitano, M., Lau, J. Y. F., & Gregory, A. M. (2010).
Does childhood anxiety evoke maternal control? A genetically
informed study. Journal of Child Psychology and Psychiatry,
51(7), 772–779. doi:10.1111/j.1469-7610.2010.02227.x.
Eley, T. C., Rijsdijk, F. V., Perrin, S., O’Connor, T. G., & Bolton, D.
(2008). A multivariate genetic analysis of specific phobia,
separation anxiety and social phobia in early childhood. Journal
of Abnormal Child Psychology, 36, 839–848. doi:10.1007/
s10802-008-9216-x.
Epkins, C. C. (1996). Affective confounding in social anxiety and
dysphoria in children: Child, mother, and father reports of
internalizing behaviors, social problems, and competence
domains. Journal of Social & Clinical Psychology, 15, 449–470.
Epkins, C. C. (1998). Mother- and father-rated competence, child
perceived competence, and cognitive distortions: Unique rela-
tions with children’s depressive symptoms. Journal of Clinical
Child Psychology, 27, 442–451. doi:10.1207/s15374424jccp
2704_8.
Erath, S. A., Flanagan, K. S., Bierman, K. L., & Tu, K. M. (2010).
Friendships moderate psychosocial maladjustment in socially
anxious early adolescents. Journal of Applied Developmental
Psychology, 31, 15–26. doi:10.1016/j.appdev.2009.05.005.
Essau, C., Conradt, J., & Petermann, F. (1999). Frequency and
comorbidity of social phobia and social fears in adolescents.
Behaviour Research and Therapy, 37, 831–843. doi:10.1016/
S0005-7967(98)00179-X.
Feeny, N. C., Silva, S. G., Reinecke, M. A., McNulty, S., Findling, R.
L., Rohde, P., et al. (2009). An exploratory analysis of the impact
of family functioning on treatment for depression in adolescents.
Journal of Clinical Child and Adolescent Psychology, 38,
814–825. doi:10.1080/15374410903297148.
Festa, C. C., & Ginsburg, G. S. (2011). Parental and peer predictors of
social anxiety in youth. Child Psychiatry and Human Develop-
ment, 42, 291–306. doi:10.1007/s10578-011-0215-8.
Field, A. P., Hamilton, S. J., Knowles, K. A., & Plews, E. L. (2003).
Fear information and social phobic beliefs in children: A
prospective paradigm and preliminary results. Behaviour
Research and Therapy, 41, 113–123. doi:10.1016/S0005-7967
(02)00050-5.
Fisak, B., & Grills-Taquechel, A. E. (2007). Parental modeling,
reinforcement, and information transfer: Risk factors in the
development of child anxiety? Clinical Child and Family Psychol-
ogy Review, 10, 213–231. doi:10.1007/s10567-007-0020-x.
Flanagan, K. S., Erath, S. A., & Bierman, K. L. (2008). Unique
associations between peer relations and social anxiety in early
adolescence. Journal of Clinical Child & Adolescent Psychol-
ogy, 37, 759–769. doi:10.1080/15374410802359700.
Flory, V., Vance, A. L. A., Birleson, P., & Luk, E. S. L. (2002). Early
onset dysthymic disorder in children and adolescents: Clinical
implications and future directions. Child and Adolescent Mental
Health, 7, 79–84. doi:10.1111/1475-3588.00015.
Fontaine, R. G., Yang, C., Burks, V. S., Dodge, K. A., Price, J. M.,
Pettit, G. S., et al. (2009). Loneliness as a partial mediator of the
relation between low social preference in childhood and anxious/
depressed symptoms in adolescence. Development and Psycho-
pathology, 21, 479–491. doi:10.1017/S0954579409000261.
Fox, N. A. (2010). Factors contributing to the emergence of anxiety
among behaviorally inhibited children: The role of attention. In
H. Gazelle & K. H. Rubin (Eds.), Social anxiety in childhood:
Bridging developmental and clinical perspectives. New Direc-
tions for Child and Adolescent Development (Vol. 127,
pp. 33–49). San Francisco: Jossey-Bass.
Fox, N. A., Henderson, H. A., Marshall, P. J., Nichols, K. E., &
Ghera, M. M. (2005). Behavioral inhibition: Linking biology and
behavior within a developmental framework. Annual Review of
Psychology, 56, 235–262. doi:10.1146/annurev.psych.55.090
902.141532.
Gazelle, H. (2010). Anxious solitude/withdrawal and anxiety disor-
ders: Conceptualization, co-occurrence, and peer processes
leading toward and away from disorder in childhood. In H.
Gazelle & K. H. Rubin (Eds.), Social anxiety in childhood:
Bridging developmental and clinical perspectives. New Direc-
tions for Child and Adolescent Development (Vol. 127,
pp. 67–78). San Francisco: Jossey-Bass.
Gazelle, H., & Ladd, G. W. (2003). Anxious solitude and peer
exclusion: A diathesis-stress model of internalizing trajectories
in childhood. Child Development, 74, 257–278. doi:10.1111/
1467-8624.00534.
Gazelle, H., & Rubin, K. H. (2010). Social anxiety in childhood:
Bridging developmental and clinical perspectives. In H. Gazelle
& K. H. Rubin (Eds.), Social anxiety in childhood: Bridging
developmental and clinical perspectives. New directions for
child and adolescent development (Vol. 127, pp. 1–16). San
Francisco: Jossey-Bass.
Gazelle, H., & Rudolph, K. D. (2004). Moving toward and away from
the world: Social approach and avoidance trajectories in anxious
solitary youth. Child Development, 75, 829–849. doi:10.1111/
j.1467-8624.2004.00709.x.
Gazelle, H., Workman, J. O., & Allan, W. (2010). Anxious solitude
and clinical disorder in middle childhood: Bridging
Clin Child Fam Psychol Rev (2011) 14:329–376 369
123
developmental and clinical approaches to childhood social
anxiety. Journal of Abnormal Child Psychology, 38, 1–17. doi:
10.1007/s10802-009-9343-z.
Ginsburg, G. S., La Greca, A. M., & Silverman, W. K. (1998). Social
anxiety in children with anxiety disorders: Relation with social
and emotional functioning. Journal of Abnormal Child Psychol-
ogy, 26, 175–185. doi:10.1023/A:1022668101048.
Gladstone, G., & Parker, G. (2006). Is behavioral inhibition a risk
factor for depression? Journal of Affective Disorders, 95, 85–94.
doi:10.1016/j.jad.2006.04.015.
Goodman, S. H. (2007). Depression in mothers. Annual Review of
Clinical Psychology, 3, 107–135. doi:10.1146/annurev.clinpsy.
3.022806.091401.
Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in
the children of depressed mothers: A developmental model for
understanding mechanisms of transmission. Psychological
Review, 106, 458–490. doi:10.1037/0033-295X.106.3.458.
Goodman, S. H., & Gotlib, I. H. (2002). Children of depressed
parents: Mechanisms of risk and implications for treatment.
Washington, DC: American Psychological Association.
Goodman, S. H., Schwab-Stone, M., Lahey, B. B., Shaffer, D., &
Jensen, P. S. (2000). Major depression and dysthymia in children
and adolescents: Discriminant validity and differential conse-
quences in a community sample. Journal of the American
Academy of Child and Adolescent Psychiatry, 39, 761–770. doi:
10.1097/00004583-200006000-00015.
Goodman, S. H., & Tully, E. (2008). Children of depressed mothers:
Implications for the etiology, treatment, and prevention of
depression in children and adolescents. In J. R. Z. Abela &
B. L. Hankin (Eds.), Handbook of depression in children and
adolescents (pp. 415–440). New York, NY: Guilford Press.
Goodrich, M. M., Epkins, C. C., Hoskinson, C. H., Alfar, N., Heckler,
D. R., & Dolph, M. (2008, November). Relations between
components of the tripartite model and children’s depression,
general anxiety, and social anxiety: Do age and gender
moderate? Poster session presented at the 42nd annual conven-
tion of the association of behavioral and cognitive therapies,
Orlando, FL.
Greco, L. A., & Morris, T. L. (2002). Paternal child-rearing style and
child social anxiety: Investigation of child perceptions and actual
father behavior. Journal of Psychopathology and Behavioral
Assessment, 24, 259–267. doi:10.1023/A:1020779000183.
Greco, L. A., & Morris, T. L. (2005). Factors influencing the link
between social anxiety and peer acceptance: Contributions of
social skills and close friendships during middle childhood.
Behavior Therapy, 36, 197–205. doi:10.1016/S0005-7894
(05)80068-1.
Gregory, A. M., & Eley, T. C. (2007). Genetic influences on anxiety
in children: What we’ve learned and where we’re heading.
Clinical Child and Family Psychology Review, 10, 199–212. doi:
10.1007/s10567-007-0022-8.
Gullone, E., Ollendick, T. H., & King, N. J. (2006). The role of
attachment representation in the relationship between depressive
symptomatology and social withdrawal in middle childhood.
Journal of Child and Family Studies, 15, 271–285. doi:10.1007/
s10826-006-9034-0.
Gunlicks-Stoessel, M., Mufson, L., Jekal, A., & Turner, J. B. (2010).
The impact of perceived interpersonal functioning on treatment
for adolescent depression: IPT-A versus treatment as usual in
school-based health clinics. Journal of Consulting and Clinical
Psychology, 78, 260–267. doi:10.1037/a0018935.
Hallett, V., Ronald, A., Rijsdijk, F., & Eley, T. C. (2009). Phenotypic and
genetic differentiation of anxiety-related behaviors in middle child-
hood. Depression and Anxiety, 26, 316–324. doi:10.1002/da.20538.
Hankin, B. L. (2009). Development of sex differences in depressive
and co-occurring anxious symptoms during adolescence:
Descriptive trajectories and potential explanations in a multiwave
prospective study. Journal of Clinical Child and Adolescent
Psychology, 38, 460–472. doi:10.1080/15374410902976288.
Hankin, B. L., Wetter, E., & Cheely, C. (2008). Sex differences in
child and adolescent depression: A developmental psychopath-
ological approach. In J. R. Z. Abela & B. L. Hankin (Eds.),
Handbook of depression in children and adolescents (pp.
377–414). New York, NY: Guilford Press.
Harter, S. (1985). Manual for the self-perception profile for children.
Denver, CO: University of Denver.
Hawker, D. S. J., & Boulton, M. J. (2000). Twenty years’ research on
peer victimization and psychosocial maladjustment: A meta-
analytic review of cross-sectional studies. Journal of Child
Psychology and Psychiatry, 41, 441–455.
Hayward, C., Wilson, K. A., Lagle, K., Kraemer, H. C., Killen, J. D.,
& Taylor, C. B. (2008). The developmental psychopathology of
social anxiety in adolescents. Depression and Anxiety, 25,
200–206. doi:10.1002/da.20289.
Heinrich, L. M., & Gullone, E. (2006). The clinical significance of
loneliness: A literature review. Clinical Psychology Review, 26,
695–718. doi:10.1016/j.cpr.2006.04.002.
Heinrichs, N., Rapee, R. M., Alden, L. A., Bogels, S., Hofmann, S.
G., Ja Oh, K., et al. (2006). Cultural differences in perceived
social norms and social anxiety. Behaviour Research and
Therapy, 44, 1187–1197. doi:10.1016/j.brat.2005.09.006.
Heiser, N. A., Turner, S. M., & Beidel, D. C. (2003). Shyness:
Relationship to social phobia and other psychiatric disorders.
Behaviour Research and Therapy, 41, 209–221.
Heiser, N. A., Turner, S. M., Beidel, D. C., & Roberson-Nay, R. (2009).
Differentiating social phobia from shyness. Journal of Anxiety
Disorders, 23, 469–476. doi:10.1016/j.janxdis.2008.10.002.
Hill, N. E., Bromell, L., Tyson, D. F., & Flint, R. (2007).
Developmental commentary: Ecological perspectives on parental
influences during adolescence. Journal of Clinical Child and
Adolescent Psychology, 36, 367–377.
Hilt, L. M., & Nolen-Hoeksema, S. (2009). The emergence of gender
differences in depression in adolescence. In S. Nolen-Hoeksema
& L. M. Hilt (Eds.), Handbook of depression in adolescents
(pp. 111–135). New York, NY: Routledge.
Hipwell, A., Keenan, K., Kasza, K., Loeber, R., Stouthamer-Loeber,
M., & Bean, T. (2008). Reciprocal influences between girls’
conduct problems and depression, and parental punishment and
warmth: A six year prospective analysis. Journal of Abnormal
Child Psychology, 36, 663–677. doi:10.1007/s10802-007-9206-4.
Hirshfeld-Becker, D. R. (2010). Familial and temperamental risk
factors for social anxiety disorder. In H. Gazelle & K. H. Rubin
(Eds.), Social anxiety in childhood: Bridging developmental and
clinical perspectives. New directions for child and adolescent
development (Vol. 127, pp. 51–65). San Francisco: Jossey-Bass.
Hirshfeld-Becker, D., Biederman, J., Henin, A., Faraone, S., Davis,
S., Harrington, K., et al. (2007). Behavioral inhibition in
preschool children at risk is a specific predictor of middle
childhood social anxiety: A five-year follow-up. Journal of
Developmental and Behavioral Pediatrics, 28, 225–233. doi:
10.1097/01.DBP.0000268559.34463.d0.
Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely, L. R.,
Pollock-Wurman, R. A., & Biederman, J. (2010). Cognitive
behavioral therapy for 4- to 7-year-old children with anxiety
disorders: A randomized clinical trial. Journal of Consulting and
Clinical Psychology, 78, 498–510. doi:10.1037/a0019055.
Hirshfeld-Becker, D., Micco, J., Henin, A., Bloomfield, A., Biederman,
J., & Rosenbaum, J. (2008). Behavioral inhibition. Depression and
Anxiety, 25, 357–367. doi:10.1002/da.20490.
Hoskinson, C. H., Epkins, C. C., Goodrich, M. M., Alfar, N., Heckler,
D. R., & Dolph, M. (2008, November). Does effortful control
mediate the relations between children’s negative and positive
370 Clin Child Fam Psychol Rev (2011) 14:329–376
123
affect and their internalizing symptoms? Poster session presented
at the 42nd annual convention of the association of behavioral
and cognitive therapies, Orlando, FL.
Hudson, J. L., Doyle, A. M., & Gar, N. (2009). Child and maternal
influence on parenting behavior in clinically anxious children.
Journal of Clinical Child and Adolescent Psychology, 38,
256–262. doi:10.1080/15374410802698438.
Hudson, J. L., & Rapee, R. M. (2009). Familial and social
environments in the etiology and maintenance of anxiety
disorders. In M. M. Antony & M. B. Stein (Eds.), Oxford
handbook of anxiety and related disorders (pp. 173–189). New
York, NY: Oxford University Press.
Hughes, A. A., Furr, J. M., Sood, E. D., Barmish, A. J., & Kendall, P. C.
(2009). Anxiety, mood, and substance use disorders in parents of
children with anxiety disorders. Child Psychiatry and Human
Development, 40, 405–419. doi:10.1007/s10578-009-0133-1.
Hughes, A. A., & Kendall, P. C. (2009). Psychometric properties of
the Positive and Negative Affect Scale for Children (PANAS-C)
in children with anxiety disorders. Child Psychiatry and Human
Development, 40, 343–352. doi:10.1007/s10578-009-0130-4.
Hummel, R. M., & Gross, A. M. (2001). Socially anxious children:
An observational study of parent–child interaction. Child &
Family Behavior Therapy, 23, 19–41. doi:10.1300/J019v23n03.
Hutcherson, S. T., & Epkins, C. C. (2009). Differentiating parent- and
peer-related interpersonal correlates of depressive symptoms and
social anxiety in preadolescent girls. Journal of Social and
Personal Relationships, 26, 875–897. doi:10.1177/026540750
9345654.
Inderbitzen, H. M., Walters, K. S., & Bukowski, A. L. (1997). The
role of social anxiety in adolescent peer relations: Differences
among sociometric status groups and rejected subgroups.
Journal of Clinical Child Psychology, 26, 338–348. doi:10.1207/
s15374424jccp2604_2.
Inderbitzen-Nolan, H. M., Anderson, E. R., & Johnson, H. S. (2007).
Subjective versus objective behavioral ratings following two
analogue tasks: A comparison of socially phobic and non-
anxious adolescents. Journal of Anxiety Disorders, 21, 76–90.
doi:10.1016/j.janxdis.2006.03.013.
Johnson, H. S., Inderbitzen-Nolan, H. M., & Schapman, A. M. (2005).
A comparison between socially anxious and depressive symp-
tomatology in youth: A focus on perceived family environment.
Journal of Anxiety Disorders, 19, 423–442. doi:10.1016/j.
janxdis.2004.04.004.
Joiner, T. E., Jr., Lewinsohn, P. M., & Seeley, J. R. (2002). The core
of loneliness: Lack of pleasurable engagement—more so than
painful disconnection—predicts social impairment, depression
onset, and recovery from depressive disorders among adoles-
cents. Journal of Personality Assessment, 79, 472–491. doi:
10.1207/S15327752JPA7903_05.
Joiner, T. E., & Lonigan, C. J. (2000). Tripartite model of depression
and anxiety in youth psychiatric inpatients: Relations with
diagnostic status and future symptoms. Journal of Clinical Child
Psychology, 29, 372–382. doi:10.1207/S15374424JCCP2903_8.
Joormann, J., Eugene, F., & Gotlib, I. H. (2009). Parental depression:
Impact on offspring and mechanisms underlying transmission of
risk. In S. Nolen-Hoeksema & L. M. Hilt (Eds.), Handbook of
depression in adolescents(p p. 441–472). Ne wY ork, NY: Routle dge.
Kagan, J. (2008). Behavioral inhibition as a risk factor for psychopa-
thology. In T. P. Beauchaine & S. P. Hinshaw (Eds.), Child and
adolescent psychopathology (pp. 157–179). Hoboken, NJ: Wiley.
Kane, P., & Garber, J. (2004). The relations among depression in
fathers, children’s psychopathology, and father-child conflict: A
meta-analysis. Clinical Psychology Review, 24, 339–360. doi:
10.1016/j.cpr.2004.03.004.
Kaslow, N. J., Broth, M. R., Arnette, N. C., & Collins, M. H. (2009).
Family based treatment for adolescent depression. In S. Nolen-
Hoeksema & L. M. Hilt (Eds.), Handbook of depression in
adolescents (pp. 531–570). New York, NY: Routledge.
Kawabata, Y., Crick, N. R., & Hamaguchi, Y. (2010). Forms of
aggression, social-psychological adjustment, and peer victim-
ization in a Japanese sample: The moderating role of positive
and negative friendship quality. Journal of Abnormal Child
Psychology, 38, 471–484. doi:10.1007/s10802-010-9386-1.
Kearney, C. A. (2005). Social anxiety and social phobia in youth:
Characteristics, assessment, and psychological treatment. New
York, NY: Springer.
Kendall, P. C., Hudson, J. L., Gosch, E., Flannery-Schroeder, E., &
Suveg, C. (2008). Cognitive behavioral therapy for anxiety
disordered youth: A randomized clinical trial evaluating child
and family modalities. Journal of Consulting and Clinical
Psychology, 76, 282–297. doi:10.1037/0022-006X.76.2.282.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Marikangas, K. R., &
Walters, E. E. (2005). Lifetime prevalence and age-of-onset
distributions of DSM-IV disorders in the National Comorbidity
Survey replication. Archives of General Psychiatry, 62, 593–602.
Kessler, R. C., Ruscio, A. M., Shear, K., & Wittchen, H.-U. (2009).
Epidemiology of anxiety disorders. In M. M. Antony & M.
B. Stein (Eds.), Oxford handbook of anxiety and related
disorders (pp. 19–33). New York, NY: Oxford University Press.
Kessler, R. C., Stang, P., Wittchen, H.-U., Stein, M., & Walters, E. E.
(1999). Lifetime co-morbidities between social phobia and mood
disorders in the US National Comorbidity Survey. Psychological
Medicine, 29, 555–567. doi:10.1017/S0033291799008375.
Kessler, R. C., & Wang, P. S. (2008). The descriptive epidemiology
of commonly occurring mental disorders in the United States.
Annual Review of Public Health, 29, 115–129. doi:10.1146/
annurev.publhealth.29.020907.090847.
Kingery, J. N., Erdley, C. A., Marshall, K. C., Whitaker, K. G., &
Reuter, T. R. (2010). Peer experiences of anxious and socially
withdrawn youth: An integrative review of the developmental
and clinical literature. Clinical Child and Family Psychology
Review, 13, 91–128. doi:10.1007/s10567-009-0063-2.
Kistner, J. (2006). Children’s peer acceptance, perceived acceptance,
and risk for depression. In T. E. Joiner, J. S. Brown, & J. Kistner
(Eds.), The interpersonal, cognitive, and social nature of
depression (pp. 1–21). Mahwah, NJ: Lawrence Erlbaum.
Kistner, J., Balthazor, M., Risi, S., & Burton, C. (1999). Predicting
dysphoria in adolescence from actual and perceived peer
acceptance in childhood. Journal of Clinical Child Psychology,
28, 94–104.
Kistner, J. A., David-Ferdon, C. F., Repper, K. K., & Joiner, T. E.
(2006). Bias and accuracy of children’s perceptions of peer
acceptance: Prospective associations with depressive symptoms.
Journal of Abnormal Child Psychology, 34, 349–361. doi:
10.1007/s10802-006-9028-9.
Klomek, A. B., Marrocco, F., Kleinman, M., Schonfeld, I. S., &
Gould, M. S. (2008). Peer victimization, depression, and
suicidality in adolescents. Suicide and Life-Threatening Behav-
ior, 38, 166–180. doi:10.1521/suli.2008.38.2.166.
Knappe, S., Beesdo, K., Fehm, L., Lieb, R., & Wittchen, H.-U.
(2009a). Associations of familial risk factors with social fears
and social phobia: Evidence for the continuum hypothesis in
social anxiety disorder? Journal of Neural Transmission, 116,
639–648. doi:10.1007/s00702-008-0118-4.
Knappe, S., Lieb, R., Beesdo, K., Fehm, L., Ping Low, N. C., Gloster, A.
T., et al. (2009b). The role of parental psychopathology and family
environment for social phobia in the first three decades of life.
Depression and Anxiety, 26, 363–370. doi:10.1002/DA.20527.
Kovacs, M., Akiskal, H. S., Gatsonis, C., & Parrone, P. L. (1994).
Childhood-onset dysthymic disorder: Clinical features and pro-
spective naturalistic outcome. Archives of General Psychiatry,
51, 365–374.
Clin Child Fam Psychol Rev (2011) 14:329–376 371
123
Kovacs, M., Goldston, D., & Gatsonis, C. (1993). Suicidal behaviors and
childhood-onsetdepressive disorders: A longitudinal investigation.
Journal of the American Academy of Child and Adolescent
Psychiatry, 32, 8–20. doi:10.1097/00004583-199301000-00003.
Kovacs, M., Obrosky, S., Gatsonis, C., & Richards, C. (1997). First-
episode major depressive and dysthymic disorder in childhood:
Clinical and sociodemographic factors in recovery. Journal of
the American Academy of Child and Adolescent Psychiatry, 36,
777–784. doi:10.1097/00004583-199706000-00014.
Krackow, E., & Rudolph, K. D. (2008). Life stress and the accuracy
of cognitive appraisals in depressed youth. Journal of Clinical
Child and Adolescent Psychology, 37, 376–385. doi:10.1080/
15374410801955797.
Krueger, R. F., Hicks, B. M., Patrick, C. J., Carlson, S. R., Iacono, W.
G., & McGue, M. (2002). Etiologic connections among
substance dependence, antisocial behavior, and personality:
Modeling the externalizing spectrum. Journal of Abnormal
Psychology, 111, 411–424. doi:10.1037/0021-843X.111.3.411.
Krueger, R. F., Markon, K. E., Patrick, C. J., Benning, S. D., &
Kramer, M. D. (2007). Linking antisocial behavior, substance
use, and personality: An integrative quantitative model of the
adult externalizing spectrum. Journal of Abnormal Psychology,
116, 645–666. doi:10.1037/0021-843X.116.4.645.
La Greca, A. M. (1999). Social anxiety scales for children and
adolescents: Manual and instructions for the SASC, SASC-R,
SAS-A (adolescents), and parent versions of the scales. Miami,
FL: University of Miami, Department of Psychology.
La Greca, A. M., Dandes, S. K., Wick, P., & Shaw, K. (1988).
Development of the Social Anxiety Scale for children: Reliability
and concurrent validity. Journal of Clinical Child Psychology,
17, 84–91.
La Greca, A. M., & Lopez, N. (1998). Social anxiety among
adolescents: Linkages with peer relations and friendships.
Journal of Abnormal Child Psychology, 26, 83–94. doi:10.1023/
A:1022684520514.
La Greca,A. M., & Moore Harrison, H. (2005). Adolescent peerrelations,
friendships, and romantic relationships: Do they predict social
anxiety and depression? Journal of Clinical Child and Adolescent
Psychology, 34, 49–61. doi:10.1207/s15374424jccp3401.
La Greca, A. M., & Stone, W. L. (1993). Social Anxiety Scale for
Children–Revised: Factor structure and concurrent validity.
Journal of Clinical Child Psychology, 22, 17–27.
Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1992). DSM-III-
R anxiety disorders in children: Sociodemographic and clinical
characteristics. Journal of the American Academy of Child and
Adolescent Psychiatry, 31, 1070–1076. doi:10.1097/00004583-
199211000-00012.
Last, C. G., Strauss, C. C., & Francis, G. (1987). Comorbidity among
childhood anxiety disorders. Journal of Nervous and Mental
Disease, 175, 726–730. doi:10.1097/00005053-198712000-
00004.
Lau, J. Y. F., & Eley, T. C. (2008). New behavioral genetic
approaches to depression in childhood and adolescence. In
J. R. Abela & B. L. Hankin (Eds.), Handbook of depression in
children and adolescents (pp. 124–148). New York, NY:
Guilford Press.
Lau, J. Y. F., & Eley, T. C. (2009). The genetics of adolescent
depression. In S. Nolen-Hoeksema & L. M. Hilt (Eds.),
Handbook of depression in adolescents (pp. 259–277). New
York, NY: Routledge.
Lau, J. Y. F., & Eley, T. C. (2010). The genetics of mood disorders.
Annual Review of Clinical Psychology, 6, 313–337. doi:
10.1146/annurev.clinpsy.121208.131308.
Leary, M. R. (1990). Responses to social exclusion: Social anxiety,
jealousy, loneliness, depression, and low self-esteem. Journal of
Social and Clinical Psychology, 9, 221–229.
Lee, A., & Hankin, B. L. (2009). Insecure attachment, dysfunctional
attitudes, and low self-esteem predicting prospective symptoms
of depression and anxiety during adolescence. Journal of
Clinical Child and Adolescent Psychology, 38, 219–231. doi:
10.1080/15374410802698396.
Lee, A., Hankin, B. L., & Mermelstein, R. J. (2010). Perceived social
competence, negative social interactions, and negative cognitive
style predict depressive symptoms during adolescence. Journal
of Clinical Child and Adolescent Psychology, 39, 603–615. doi:
10.1080/15374416.2010.501284.
Lester, K. J., Field, A. P., Oliver, S., & Cartwright-Hatton, S. (2009).
Do anxious parents interpretive biases towards threat extend into
their child’s environment? Behaviour Research and Therapy, 47,
170–174. doi:10.1016/j.brat.2008.11.005.
Lewinsohn, P. M. (1974). A behavioral approach to depression. In R.
M. Friedman & M. M. Katz (Eds.), The psychology of
depression: Contemporary theory and research (pp. 157–185).
New York, NY: Wiley.
Lewinsohn, P. M., Gotlib, I. H., & Seeley, J. R. (1997). Depression-
related psychosocial variables: Are they specific to depression in
adolescents? Journal of Abnormal Psychology, 106, 365–375.
doi:10.1037/0021-843X.106.3.365.
Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1998). Major
depressive disorder in older adolescents: Prevalence, risk factors,
and clinical implications. Clinical Psychology Review, 18,
765–794. doi:10.1016/S0272-7358(98)00010-5.
Liber, J. M., van Widenfelt, B. M., Goedhart, A. W., Utens, E. M.,
van der Leeden, A. J. M., Markus, M. T., et al. (2008). Parenting
and parental anxiety and depression as predictors of treatment
outcome for childhood anxiety disorders: Has the role of fathers
been underestimated? Journal of Clinical Child and Adolescent
Psychology, 37, 747–758. doi:10.1080/15374410802359692.
Lieb, R., Wittchen, H., Ho
¨fler, M., Fuetsch, M., Stein, M. B., &
Merikangas, K. R. (2000). Parental psychopathology, parenting
styles, and the risk of social phobia in offspring: A prospective-
longitudinal community study. Archives of General Psychiatry,
57, 859–866. doi:10.1001/archpsyc.57.9.859.
Liu, Y. (2008). An examination of three models of the relationships
between parental attachments and adolescents’ social function-
ing and depressive symptoms. Journal of Youth and Adoles-
cence, 37, 941–952. doi:10.1007/s10964-006-9147-1.
Lonigan, C. J., Phillips, B. M., & Hooe, E. S. (2003). Relations of
positive and negative affectivity to anxiety and depression in
children: Evidence from a latent variable longitudinal study.
Journal of Consulting and Clinical Psychology, 71, 465–481.
doi:10.1037/0022-006X.71.3.465.
Lonigan, C. J., Vasey, M. W., Phillips, B. M., & Hazen, R. A. (2004).
Temperament, anxiety, and the processing of threat—relevant
stimuli. Journal of Clinical Child and Adolescent Psychology,
33, 8–20. doi:10.1207/S15374424JCCP3301_2.
McLeod, B., Weisz, J., & Wood, J. (2007a). Examining the
association between parenting and childhood depression: A
meta-analysis. Clinical Psychology Review, 27, 986–1003. doi:
10.1016/j.cpr.2007.03.001.
McLeod, B., Wood, J., & Weisz, J. (2007b). Examining the
association between parenting and childhood anxiety: A meta-
analysis. Clinical Psychology Review, 27, 155–172. doi:
10.1016/j.cpr.2006.09.002.
Merikangas, K. R., Prusoff, B. A., & Weissman, M. M. (1988).
Parental concordance for affective disorders: Psychopathology in
offspring. Journal of Affective Disorders, 15, 279–290. doi:
10.1016/0165-0327(88)90025-0.
Micco, J. A., Henin, A., Mick, E., Kim, S., Hopkins, C. A., Biederman,
J., et al. (2009). Anxiety and depressive disorders in offspring at
high risk for anxiety: A meta-analysis. Journal of Anxiety
Disorders, 23, 1158–1164. doi:10.1016/j.janxdis.2009.07.021.
372 Clin Child Fam Psychol Rev (2011) 14:329–376
123
Mineka, S., Watson, D., & Clark, L. A. (1998). Comorbidity of
anxiety and unipolar mood disorders. Annual Review of
Psychology, 49, 377–412. doi:10.1146/annurev.psych.49.1.377.
Morgan, J., & Banerjee, R. (2006). Social anxiety and self-evaluation
of social performance in a nonclinical sample of children.
Journal of Clinical Child and Adolescent Psychology, 35,
292–301. doi:10.1207/s15374424jccp3502_13.
Morrow, M. T., Hubbard, J. A., Rubin, R. M., & McAuliffe, M. D.
(2008). The relation between childhood aggression and depres-
sive symptoms: The unique and joint mediating roles of peer
rejection and peer victimization. Merrill-Palmer Quarterly, 54,
316–340. doi:10.1353/mpq.0.0000.
Mufson, L. (2010). Interpersonal psychotherapy for depressed
adolescents (IPT-A): Extending the reach from academic to
community settings. Child and Adolescent Mental Health, 15,
66–72. doi:10.1111/j.1475-3588.2009.00556.x.
Mufson, L., Dorta, K. P., Moreau, D., & Weissman, M. M. (2004).
Interpersonal psychotherapy for depressed adolescents (2nd
ed.). New York, NY: The Guilford Press.
Muris, P., Bos, A. E. R., Mayer, B., Verkade, R., Thewissen, V., &
Dell’Avvento, V. (2009). Relations among behavioral inhibition,
big five personality factors, and anxiety disorder symptoms in
non-clinical children. Personality and Individual Differences,
46, 525–529. doi:10.1016/j.paid.2008.12.003.
Muris, P., de Jong, P. J., & Engelen, S. (2004). Relationships between
neuroticism, attentional control, and anxiety disorders symptoms
in non–clinical children. Personality and Individual Differences,
37, 789–797. doi:10.1016/j.paid.2003.10.007.
Muris, P., Meesters, C., & Rompelberg, L. (2007). Attention control
in middle childhood: Relations to psychopathological symptoms
and threat perception distortions. Behaviour Research and
Therapy, 45, 997–1010. doi:10.1016/j.brat.2006.07.010.
Muris, P., Merckelbach, H., Schmidt, H., Gadet, B., & Bogie, N. (2001).
Anxiety and depression as correlates of self-reported behavioural
inhibition in normal adolescents. Behaviour Research and Ther-
apy, 39, 1051–1061. doi:10.1016/S0005-7967(00)00081-4.
Muris, P., & Ollendick, T. H. (2005). The role of temperament in the
etiology of child psychopathology. Clinical Child and Family
Psychology Review, 8, 271–289. doi:10.1007/s10567-005-8809-y.
Muris, P., van Zwol, L., Huijding, J., & Mayer, B. (2010). Mom told me
scary things about this animal: Parents installingfear beliefs in their
children via the verbal information pathway. Behaviour Research
and Therapy, 48, 341–346. doi:10.1016/j.brat.2009.12.001.
Nangle, D. W., Erdley, C. A., Newman, J. E., Mason, C. A., &
Carpenter, E. M. (2003). Popularity, friendship quantity, and
friendship quality: Interactive influences on children’s loneliness
and depression. Journal of Clinical Child and Adolescent
Psychology, 32, 546–555. doi:10.1207/S15374424JCCP3204_7.
Naragon-Gainey, K., Watson, D., & Markon, K. E. (2009). Differ-
ential relations of depression and social anxiety symptoms to the
facets of extraversion/positive emotionality. Journal of Abnor-
mal Psychology, 118, 299–310. doi:10.1037/a0015637.
Newcomb, A. F., Bukowski, W. M., & Pattee, L. (1993). Children’s
peer relations: A meta-analytic review of popular, rejected,
neglected, controversial, and average sociometric status. Psycho-
logical Bulletin, 113, 99–128. doi:10.1037/0033-2909.113.1.99.
Nigg, J. (2006). Temperament and developmental psychopathology.
Journal of Child Psychology and Psychiatry, 47, 395–422. doi:
10.1111/j.1469-7610.2006.01612.x.
Nolan, S., Flynn, C., & Garber, J. (2003). Prospective relations
between rejection and depression in young adolescents. Journal
of Personality and Social Psychology, 85, 745–755. doi:
10.1037/0022-3514.85.4.745.
Olino, T. M., Klein, D. N., Dyson, M. W., Rose, S. A., & Durbin, C.
E. (2010). Temperamental emotionality in preschool-aged chil-
dren and depressive disorders in parents: Associations in a large
community sample. Journal of Abnormal Psychology, 119,
468–478. doi:10.1037/a0020112.
Ollendick, T. H., Costa, N. M., & Benoit, K. E. (2010). Interpersonal
processes and the anxiety disorders of childhood. In J. G. Beck
(Ed.), Interpersonal processes in the anxiety disorders: Impli-
cations for understanding psychopathology and treatment
(pp. 71–95). Washington, DC: American Psychological Associ-
ation. doi:10.1037/12084-003.
Ollendick, T. H., Jarrett, M. A., Grills-Taquechel, A. E., Hovey, L. D.,
& Wolff, J. C. (2008). Comorbidity as a predictor and moderator
of treatment outcome in youth with anxiety, affective, attention
deficit/hyperactivity disorder, and oppositional/conduct disor-
ders. Clinical Psychology Review, 28, 1447–1471. doi:10.1016/
j.cpr.2008.09.003.
Oppenheimer, C. W., & Hankin, B. L. (2011). Relationship quality
and depressive symptoms among adolescents: A short-term
multiwave investigation of longitudinal, reciprocal relations.
Journal of Clinical Child and Adolescent Psychology, 40,
486–493. doi:10.1080/15374416.2011.563462.
Parker, J. G., & Asher, S. R. (1993). Friendship and friendship quality
in middle childhood: Links with peer group acceptance and
feelings of loneliness and social dissatisfaction. Developmental
Psychology, 29, 611–621. doi:10.1037/0012-1649.29.4.611.
Pedersen, S., Vitaro, F., Barker, E. D., & Borge, A. I. H. (2007). The
timing of middle-childhood peer rejection and friendship: Linking
early behavior to early-adolescent adjustment. Child Develop-
ment, 78, 1037–1051. doi:10.1111/j.1467-8624.2007.01051.x.
Perren, S., & Alsaker, F. D. (2009). Depressive symptoms from
kindergarten to early school age: Longitudinal associations with
social skills deficits and peer victimization. Child and Adolescent
Psychiatry and Mental Health, 3, 28–38. doi:10.1186/1753-
2000-3-28.
Pettit, J. W., Olino, T. M., Roberts, R. E., Seeley, J. R., & Lewinsohn, P. M.
(2008). Intergenerational transmission of internalizing prob-
lems: Effects of parental and grandparental major depressive
disorder on child behavior. Journal of Clinical Child and
Adolescent Psychology, 37, 640–650. doi:10.1080/153744108021
48129.
Prinstein, M. J., & Aikins, J. W. (2004). Cognitive moderators of the
longitudinal association between peer rejection and adolescent
depressive symptoms. Journal of Abnormal Child Psychology,
32, 147–158. doi:10.1023/B:JACP.0000019767.55592.63.
Prinstein, M. J., Boergers, J., & Vernberg, E. M. (2001). Overt and
relational aggression in adolescents: Social-psychological adjust-
ment of aggressors and victims. Journal of Clinical Child
Psychology, 30, 479–491. doi:10.1207/S15374424JCCP3004_05.
Prinstein, M. J., Borelli, J. L., Cheah, C. S. L., Simon, V. A., &
Aikins, J. W. (2005). Adolescent girls’ interpersonal vulnerabil-
ity to depressive symptoms: A longitudinal examination of
reassurance-seeking and peer relationships. Journal of Abnormal
Psychology, 114, 676–688. doi:10.1037/0021-843X.114.4.676.
Prinstein, M. J., & Dodge, K. A. (Eds.). (2008). Understanding peer
influence in children and adolescents. New York, NY: The
Guilford Press.
Prinstein, M. J., & La Greca, A. M. (2002). Peer crowd affiliation and
internalizing distress in childhood and adolescence: A longitu-
dinal follow-back study. Journal of Research on Adolescence,
12, 325–351. doi:10.1111/1532-7795.00036.
Ranta, K., Kaltiala-Heino, R., Pelkonen, M., & Marttunen, M.
(2009a). Associations between peer victimization, self-reported
depression and social phobia among adolescents: The role of
comorbidity. Journal of Adolescence, 32, 77–93. doi:
10.1016/j.adolescence.2007.11.005.
Ranta, K., Kaltiala-Heino, R., Rantanen, P., & Marttunen, M.
(2009b). Social phobia in Finnish general adolescent population:
Prevalence, comorbidity, individual and family correlates, and
Clin Child Fam Psychol Rev (2011) 14:329–376 373
123
service use. Depression and Anxiety, 26, 528–536. doi:10.1002/
da.20422.
Rao, P. A., Beidel, D. C., Turner, S. M., Ammerman, R. T., Crosby,
L., & Sallee, F. R. (2007). Social anxiety disorder in childhood
and adolescence: Descriptive psychopathology. Behaviour
Research and Therapy, 45, 1181–1191. doi:10.1016/j.brat.2006.
07.015.
Rapee, R. M. (1997). Potential role of childrearing practices in the
development of anxiety and depression. Clinical Psychology
Review, 17, 47–67. doi:10.1016/S0272-7358(96)00040-2.
Rapee, R. M. (2002). The development and modification of temper-
amental risk for anxiety disorders: Prevention of a lifetime of
anxiety? Biological Psychiatry, 52, 947–957. doi:10.1016/
S0006-3223(02)01572-X.
Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral
model of anxiety in social phobia. Behaviour Research and
Therapy, 35, 741–756. doi:10.1016/S0005-967(97)00022-3.
Rapee, R. M., Schniering, C. A., & Hudson, J. L. (2009). Anxiety
disorders during childhood and adolescence: Origins and treat-
ment. Annual Review of Clinical Psychology, 5, 311–341. doi:
10.1146/annurev.clinpsy.032408.153628.
Rapee, R. M., & Spence, S. (2004). The etiology of social phobia:
Empirical evidence and an initial model. Clinical Psychology
Review, 24, 737–767. doi:10.1016/j.cpr.2004.06.004.
Reeb, B. T., & Conger, K. J. (2009). The unique effect of paternal
depressive symptoms on adolescent functioning: Associations
with gender and father-adolescent relationship closeness. Jour-
nal of Family Psychology, 23, 758–761. doi:10.1037/a0016354.
Reijntjes, A., Kamphuis, J. H., Prinzie, P., & Telch, M. J. (2010). Peer
victimization and internalizing problems in children: A meta-
analysis of longitudinal studies. Child Abuse and Neglect, 34,
244–252. doi:10.1016/j.chiabu.2009.07.009.
Rice, F., Harold, G., Shelton, K., & Thapar, A. (2006). Family conflict
interacts with genetic liability in predicting childhood and
adolescent depression. Journal of the American Academy of
Child and Adolescent Psychiatry, 45, 841–848. doi:10.1097/01.
chi.0000219834.08602.44.
Romero, L. E., & Epkins, C. C. (2008). Girls’ cognitions of
hypothetical friends: Are they related to depression, loneliness,
social anxiety and perceived similarity? Journal of Social and
Personal Relationships, 25, 311–332. doi:10.1177/02654075
07087961.
Rork, K. E., & Morris, T. L. (2009). Influence of parenting factors on
childhood social anxiety: Direct observation of parental warmth
and control. Child & Family Behavior Therapy, 31, 220–235.
doi:10.1080/07317100903099274.
Rose, A. J., & Rudolph, K. D. (2006). A review of sex differences in
peer relationship processes: Potential trade-offs for the emotional
and behavioral development of girls and boys. Psychological
Bulletin, 132, 98–131. doi:10.1037/0033-2909.132.1.98.
Rothbart, M. K., & Bates, J. E. (2006). Temperament. In N.
Eisenberg, W. Damon, & R. M. Lerner (Eds.), Handbook of
child psychology: Social, emotional, and personality develop-
ment (6th ed., Vol. 3, pp. 99–166). Hoboken, NJ: Wiley.
Rubin, K. H., Burgess, K., & Hastings, P. (2002). Stability and social-
behavioral consequences of toddlers’ inhibited temperament and
parenting behaviors. Child Development, 73, 483–495. doi:
10.1111/1467-8624.00419.
Rubin, K. H., & Coplan, R. J. (2004). Paying attention to and not
neglecting social withdrawal and social isolation. Merrill-
Palmer Quarterly, 50, 506–534. doi:10.1353/mpq.2004.0036.
Rubin, K. H., Coplan, R. J., & Bowker, J. C. (2009). Social
withdrawal in childhood. Annual Review of Psychology, 60,
141–171. doi:10.1146/annurev.psych.60.110707.163642.
Rubin, K. H., Dwyer, K. M., Booth-LaForce, C., Kim, A. H., Burgess,
K. B., & Rose-Krasnor, L. (2004). Attachment, friendship, and
psychosocial functioning in early adolescence. Journal of Early
Adolescence, 24, 326–356. doi:10.1177.0272431604268530.
Rubin, K., Fredstrom, B., & Bowker, J. (2008). Future directions in
friendship in childhood and early adolescence. Social Develop-
ment, 17, 1085–1096. doi:10.1111/j.1467-9507.2007.00445.x.
Rubin, K. H., Nelson, L. J., Hastings, P., & Asendorpf, J. (1999). The
transaction between parents’ perceptions of their children’s
shyness and their parenting styles. International Journal of
Behavioral Development, 23, 937–958. doi:10.1080/0165025
99383612.
Rubin, K. H., Root, A. K., & Bowker, J. (2010). Parents, peers, and
social withdrawal in childhood: A relationship perspective. In H.
Gazelle & K. H. Rubin (Eds.), Social anxiety in childhood:
Bridging developmental and clinical perspectives. New direc-
tions for child and adolescent development (Vol. 127,
pp. 79–94). San Francisco: Jossey-Bass.
Rudolph, K. D., & Clark, A. G. (2001). Conceptions of relationships
in children with depressive and aggressive symptoms: Social-
cognitive distortion or reality? Journal of Abnormal Child
Psychology, 29, 41–56. doi:10.1023/A.1005299429060.
Rudolph, K. D., Flynn, M., & Abaied, J. L. (2008). A developmental
perspective on interpersonal theories of youth depression. In
J. R. Z. Abela & B. L. Hankin (Eds.), Handbook of depression in
children and adolescents (pp. 79–102). New York, NY: Guilford
Press.
Rudolph, K. D., Ladd, G., & Dinella, L. (2007). Gender differences in
the interpersonal consequences of early-onset depressive symp-
toms. Merrill-Palmer Quarterly, 53, 461–488. doi:10.1353/mpq.
2007.0020.
Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., &
Kessler, R. C. (2008). Social fears and social phobia in the USA:
Results from the National Comorbidity Survey Replication.
Psychological Medicine, 38, 15–28. doi:10.1017/S0033291
707001699.
Rutter, M. (1979). Protective factors in children’s responses to stress
and disadvantage. Annals of the Academy of Medicine, Singa-
pore, 8, 324–338.
Rutter, M., Kim-Cohen, J., & Maughan, B. (2006a). Continuities and
discontinuities in psychopathology between childhood and adult
life. Journal of Child Psychology and Psychiatry, 47, 276–295.
doi:10.1111/j.1469-7610.2006.01614.x.
Rutter, M., Moffitt, T. E., & Capsi, A. (2006b). Gene-environment
interplay and psychopathology: Multiple varieties but real
effects. Journal of Child Psychology and Psychiatry, 47,
226–261. doi:10.1111/j.1469-7610.2005.01557.x.
Sameroff, A. J. (2000). Dialectical processes in developmental
psychopathology. In A. J. Sameroff, M. Lewis, & S. M. Miller
(Eds.), Handbook of developmental psychopathology (2nd ed.,
pp. 23–40). New York, NY: Kluwer/Plenum.
Schmidt, M. E., & Bagwell, C. L. (2007). The protective role of
friendships in overtly and relationally victimized boys and girls.
Merrill-Palmer Quarterly, 53, 439–460. doi:10.1353/mpq.2007.
0021.
Segrin, C. (2000). Social skills deficits associated with depression.
Clinical Psychology Review, 20, 379–403. doi:10.1016/S0272-
7358(98)00104-4.
Seligman, L. D., & Ollendick, T. H. (1998). Comorbidity of anxiety and
depression in children and adolescents: An integrative review.
Clinical Child and Family Psychology Review, 1, 125–144.
Sentse, M., Lindenberg, S., Omvlee, A., Ormel, J., & Veenstra, R.
(2010). Rejection and acceptance across contexts: Parents and
peers as risks and buffers for early adolescent psychopathology.
The TRAILS study. Journal of Abnormal Child Psychology, 38,
119–130. doi:10.1007/s10802-009-9351-z.
Shanahan, L., Copeland, W., Costello, E. J., & Angold, A. (2008).
Specificity of putative psychosocial risk factors for psychiatric
374 Clin Child Fam Psychol Rev (2011) 14:329–376
123
disorders in children and adolescents. Journal of Child Psychol-
ogy and Psychiatry, 49, 34–42. doi:10.1111/j.1469-7610.2007.
01822.x.
Sheeber, L. B., Davis, B., Leve, C., Hops, H., & Tildesley, E. (2007).
Adolescents’ relationships with their mothers and fathers:
Associations with depressive disorder and subdiagnostic symp-
tomatology. Journal of Abnormal Psychology, 116, 144–154.
doi:10.1037/0021-843X.116.1.144.
Sheeber, L., Hops, H., Alpert, A., Davis, B., & Andrews, J. (1997).
Family support and conflict: Prospective relations to adolescent
depression. Journal of Abnormal Child Psychology, 25,
333–344. doi:10.1023/A:1025768504415.
Siegel, R. S., La Greca, A. M., & Harrison, H. M. (2009). Peer
victimization and social anxiety in adolescents: Prospective and
reciprocal relationships. Journal of Youth and Adolescence, 38,
1096–1109. doi:10.1007/s10964-009-9392-1.
Silverman, W. K., Kurtines, W. M., Jaccard, J., & Pina, A. A. (2009).
Directionality of change in youth anxiety treatment involving
parents: An initial examination. Journal of Consulting and
Clinical Psychology, 77, 474–485. doi:10.1037/a0015761.
Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (1999).
Social skills, social outcomes, and cognitive features of child-
hood social phobia. Journal of Abnormal Psychology, 108,
211–221. doi:10.1037/0021-843X.108.2.211.
Starr, L. R., & Davila, J. (2008). Differentiating interpersonal
correlates of depressive symptoms and social anxiety in adoles-
cence: Implications for models of comorbidity. Journal of
Clinical Child and Adolescent Psychology, 37, 337–349. doi:
10.1080/15374410801955854.
Stednitz, J. N., & Epkins, C. C. (2006). Girls’ and mothers’ social
anxiety, social skills, and loneliness: Associations after accounting
for depressive symptoms. Journal of Clinical Child and Adoles-
cent Psychology, 35, 148–154. doi:10.1207/s15374424jccp3501.
Stein, M. B., Chavira, D. A., & Jang, K. L. (2001). Bringing up
bashful baby: Developmental pathways to social phobia.
Psychiatric Clinics of North America, 24, 661–675.
Stice, E., Ragan, J., & Randall, P. (2004). Prospective relations
between social support and depression: Differential direction of
effects for parent and peer support? Journal of Abnormal
Psychology, 113, 155–159. doi:10.1037/0021-843X.113.1.155.
Storch, E. A., Brassard, M. R., & Masia-Warner, C. L. (2003a). The
relationship of peer victimization to social anxiety and loneliness
in adolescence. Child Study Journal, 33, 1–18.
Storch, E. A., Eisenberg, P. S., Roberti, J. W., & Barlas, M. E. (2003b).
Reliability and validity of the Social Anxiety Scale for children-
revised for Hispanic children. Hispanic Journal of Behavioral
Sciences, 25, 410–422. doi:10.1177/0739986303256915.
Storch, E. A., & Ledley, D. (2005). Peer victimization and
psychosocial adjustment in children: Current knowledge and
future directions. Clinical Pediatrics, 44, 29–38. doi:10.1177/
000992280504400103.
Storch, E. A., Masia-Warner, C., Crisp, H., & Klein, R. G. (2005).
Peer victimization and social anxiety in adolescence: A
prospective study. Aggressive Behavior, 31, 437–452. doi:
10.1002/ab.20093.
Storch, E. A., Phil, M., Nock, M. K., Masia-Warner, C., & Barlas, M. E.
(2003c). Peer victimization and social-psychological adjustment
in Hispanic and African American children. Journal of Child and
Family Studies, 12, 439–452. doi:10.1023/A:1026016124091.
Strauss, C. C., Lahey, B. B., Frick, P., Frame, C. L., & Hynd, G. W.
(1988). Peer social status of children with anxiety disorders.
Journal of Consulting and Clinical Psychology, 56, 137–141.
doi:10.1037/0022-006X.56.1.137.
Sweeting, H., Young, R., West, P., & Der, G. (2006). Peer
victimization and depression in early-mid adolescence: A
longitudinal study. British Journal of Educational Psychology,
76, 577–594. doi:10.1348/000709905X49890.
Tackett, J. L. (2006). Evaluating models of the personality-psycho-
pathology relationship in children and adolescents. Clinical
Psychology Review, 26, 584–599. doi:10.1016/j.cpr.2006.04.003.
Thapar, A., Harold, G., Rice, F., Langley, K., & O’Donovan, M.
(2007). The contribution of gene-environment interaction to
psychopathology. Development and Psychopathology, 19,
989–1004. doi:10.1017/S0954579407000491.
Turner, S. M., Beidel, D. C., Roberson-Nay, R., & Tervo, K. (2003).
Parenting behaviors in parents with anxiety disorders. Behaviour
Research and Therapy, 41, 541–554. doi:10.1016/S0005-7967
(02)00028-1.
Turner, S. M., Beidel, D. C., & Townsley, R. M. (1990). Social
phobia: Relationship to shyness. Behaviour Research and
Therapy, 28, 497–505. doi:10.1016/0005-7967(90)90136-7.
van Brakel, A. M. L., Muris, P., Bogels, S. M., & Thomassen, C.
(2006). A multifactorial model for the etiology of anxiety in non-
clinical adolescents: Main and interactive effects of behavioral
inhibition, attachment and parental rearing. Journal of Child and
Family Studies, 15, 569–579. doi:10.1007/s10826-006-9061-x.
van der Bruggen, C. O., Bo
¨gels, S. M., & van Zeilst, N. (2010). What
influences parental controlling behaviour? The role of parent and
child trait anxiety. Cognition and Emotion, 24, 141–149. doi:
10.1080/02699930802618843.
VanderWeele, T. J., Hawkley, L. C., Thisted, R. A., & Cacioppo, J. T.
(2011). A marginal structural model analysis for loneliness:
Implications for intervention trials and clinical practice. Journal
of Consulting and Clinical Psychology, 79, 225–235. doi:
10.1037/a0022610.
Verduin, T. L., & Kendall, P. C. (2008). Peer perceptions and liking
of children with anxiety disorders. Journal of Abnormal Child
Psychology, 36, 459–469. doi:10.1007/s10802-007-9192-6.
Vernberg, E. M., Abwender, D. A., Ewell, K. K., & Beery, S. H.
(1992). Social anxiety and peer relationships in early adoles-
cence: A prospective analysis. Journal of Clinical Child
Psychology, 21, 189–196. doi:10.1207/s15374424jccp2102_11.
Verstraeten, K., Vasey, M. W., Raes, F., & Bijttebier, P. (2009).
Temperament and risk of depressive symptoms in adolescence:
Mediation by rumination and moderation by effortful control.
Journal of Abnormal Child Psychology, 37, 349–361. doi:
10.1017/s10802-008-9293-x.
Viana, A. G., Rabian, B., & Beidel, D. C. (2008). Self-report measures
in the study of comorbidity in children and adolescents with social
phobia: Research and clinical utility. Journal of Anxiety Disor-
ders, 22, 781–792. doi:10.1016/j.janxdis.2007.08.005.
Warren, S. L., Huston, L., Egeland, B., & Sroufe, L. A. (1997). Child
and adolescent anxiety disorders and early attachment. Journal
of the American Academy of Child and Adolescent Psychiatry,
36, 637–644. doi:10.1097/00004583-199705000-00014.
Watson, D., Gamez, W., & Simms, L. J. (2005). Basic dimensions of
temperament and their relation to anxiety and depression: A
symptom-based perspective. Journal of Research in Personality,
39, 46–66. doi:10.1016/j.jrp.2004.09.006.
Watson, D., & Naragon-Gainey, K. (2010). On the specificity of
positive emotional dysfunction in psychopathology: Evidence
from the mood and anxiety disorders and schizophrenia/schizo-
typy. Clinical Psychology Review, 30, 839–848. doi:10.1016/
j.cpr.2009.11.002.
Weissman, M. M., Warner, V., Wickramaratne, P., Nomura, Y.,
Merikangas, K. R., Bruder, G. E., et al. (2004). Offspring at high
risk for anxiety and depression: Preliminary findings from a
three-generation study. In J. M. Gorman (Ed.), Fear and anxiety:
The benefits of translational research (pp. 65–83). Arlington,
VA: American Psychiatric Publishing, Inc.
Clin Child Fam Psychol Rev (2011) 14:329–376 375
123
Weissman, M. M., Wickramaratne, P., Nomura, Y., Warner, V.,
Pilowsky, D., & Verdeli, H. (2006). Offspring of depressed
parents: 20 years later. American Journal of Psychiatry,163,
1001–1008. http://ajp.psychiatryonline.org.
Wetter, E. K., & Hankin, B. L. (2009). Mediational pathways through
which positive and negative emotionality contribute to anhe-
donic symptoms of depression: A prospective study of adoles-
cents. Journal of Abnormal Child Psychology, 37, 507–520. doi:
10.1007/s10802-009-9299-z.
Wierzbicki, M., & McCabe, M. (1988). Social skills and subsequent
depressive symptomatology in children. Journal of Clinical
Child Psychology, 17, 203–208.
Wilson, S., & Durbin, C. E. (2010). Effects of paternal depression on
fathers’ parenting behaviors: A meta-analytic review. Clinical
Psychology Review, 30, 167–180. doi:10.1016/j.cpr.2009.10.007.
Wittchen, H.-U., Stein, M. B., & Kessler, R. C. (1999). Social fears
and social phobia in a community sample of adolescents and
young adults: Prevalence, risk factors, and co-morbidity.
Psychological Medicine, 29, 309–323. doi:10.1017/S003329
1798008174.
Wood, J. J., McLeod, B. D., Piacentini, J. C., & Sigman, M. (2009).
One-year follow-up of family versus child CBT for anxiety
disorders: Exploring the roles of child age and parental
intrusiveness. Child Psychiatry and Human Development, 40,
301–316. doi:10.1007/s10578-009-0127-z.
Wood, J. J., McLeod, B. D., Sigman, M., Hwang, W., & Chu, B. C.
(2003). Parenting and childhood anxiety: Theory, empirical,
findings, and future directions. Journal of Child Psychology and
Psychiatry, 44, 134–151. doi:10.1111/1469-7610.00106.
Woods, S., Done, J., & Kalsi, H. (2009). Peer victimization and
internalizing difficulties: The moderating role of friendship
quality. Journal of Adolescence, 32, 293–308. doi:10.1016/j.
adolescence.2008.03.005.
Young, J. F., Gallop, R., & Mufson, L. (2009). Mother-child conflict
and its moderating effects on depression outcomes in a
preventive intervention for adolescent depression. Journal of
Clinical Child and Adolescent Psychology, 38, 696–704. doi:
10.1080/15374410903103577.
Young, J. F., Mufson, L., & Davies, M. (2006). Impact of comorbid
anxiety in an effectiveness study of interpersonal psychotherapy
for depressed adolescents. Journal of the American Academy of
Child and Adolescent Psychiatry, 45, 904–912. doi:10.1097/01.
chi.0000222791.23927.5f.
Zahn-Waxler, C., Shirtcliff, E. A., & Marceau, K. (2008). Disorders
of childhood and adolescence: Gender and psychopathology.
Annual Review of Clinical Psychology, 4, 275–303. doi:
10.1146/annurev.clinpsy.3.022806.091358.
Zimmer-Gembeck, M., Hunter, T., & Pronk, R. (2007). A model of
behaviors, peer relations and depression: Perceived social
acceptance as a mediator and the divergence of perceptions.
Journal of Social & Clinical Psychology, 26, 273–302. doi:
10.1521/jscp.2007.26.3.273.
376 Clin Child Fam Psychol Rev (2011) 14:329–376
123
