Social Anxiety and The School Environment of Adolescents

Social Anxiety and the School
Environment of Adolescents 7
Anke W. Blöte, Anne C. Miers, David A. Heyne,
and P. Michiel Westenberg
During the school week, adolescents ordinarily spend somewhere between

one-third and one-half of their waking time at school, necessitating a considerable
degree of social interaction. As noted by McShane et al. (2004), the climate at
secondary school is one of “forced and broad social interaction” (p. 54). In adoles-
cence, peers also become a major influence in the life of the young person. As
Eckert (1989) put it: “In secondary school, where the social structure of the student
cohort dominates virtually all aspects of life in the institution, choices in all
domains are restricted, not so clearly by adult judgment as by peer social
boundaries” (p. 12). On the one hand, social interactions within school settings can
be very stimulating for the developing adolescent and promote efficient and
successful learning of the educational curriculum and life skills. On the other hand,
these social interactions bring with them a less positive aspect, namely, the
possibility that one will be negatively judged and evaluated.
Empirical findings show a normative increase in subjective and physiological
sensitivity to negative evaluation from age peers during adolescence (Van den Bos
et al. 2014; Westenberg et al. 2004). The inherently social nature of school com-
bined with a developmental increase in sensitivity to negative evaluation highlights
the potential influence of this setting on the adolescent. Being placed under the
scrutiny of others in social situations can cause concern and worry and may increase
or at least maintain social anxiety in some students.
Social anxiety occurs in degrees. Concern or apprehension about a social
situation is described as being at the lower end of a continuum of social anxiety,
with intense social anxiety at the upper end (Rapee and Spence 2004). A sizeable
A.W. Blöte, PhD (*) • A.C. Miers, PhD •

D.A. Heyne, BA, Dip Ed Psych, M Psych, PhD • P.M. Westenberg, PhD
Developmental & Educational Psychology Unit,
Institute of Psychology, Faculty of Social and Behavioural Sciences,
Leiden University, Leiden, The Netherlands
e-mail: [email protected]
© Springer International Publishing Switzerland 2015 151

K. Ranta et al. (eds.), Social Anxiety and Phobia in Adolescents: Development,
Manifestation and Intervention Strategies, DOI 10.1007/978-3-319-16703-9_7
152 A.W. Blöte et al.
group of adolescents are very anxious about social situations and potential negative
evaluation from others (Gren-Landell et al. 2009). In these cases, a high level of
anxiety for social situations may interfere with their daily functioning. Giving an
oral presentation, answering questions in class, making friends, and participating in
cliques or gangs are all potentially stressful for them. In these situations, they may
be ridiculed, excluded, or even victimized. The socially anxious student may stop
socializing with classmates and friends, stop attending certain classes, or even
refuse to attend school altogether. This can have severe and detrimental conse-
quences for their cognitive and social development as well as their academic
achievements (Van Ameringen et al. 2003).
This chapter begins with a description of the way social anxiety manifests itself
in the school setting. More specifically, we review situations which are distressful
for and even avoided by socially anxious students. An extreme consequence of this
distress and avoidance, school refusal, is also discussed. In the second part of the
chapter, we describe the way in which socially anxious students’ behavior, and the
behavior of their peers or classmates, may contribute to the difficulty that socially
anxious youth experience during social interactions at school. In addition to these
behavioral and interpersonal factors, we pay attention to the negative social cogni-
tions of socially anxious students. We discuss whether, and to what extent, these
negative cognitions are biased or contain a kernel of truth (Norton and Hope 2001).
Finally, we present some considerations for intervention and future research.
The Manifestation of Social Anxiety in the School Setting
Distress and Avoidance in Specific School Situations
What do we know about how adolescents with high levels of social anxiety experi-
ence social situations in school settings? Two studies focused on how socially anx-
ious and non-anxious adolescents differed in their fear and avoidance of
school-related social situations (Gren-Landell et al. 2009; Ranta et al. 2012). Two
other studies investigated fear and avoidance of social situations in adolescents with
clinical social anxiety levels only (Beidel et al. 2007; Rao et al. 2007), and three
investigated adolescents from the general population (Essau et al. 1999; Ranta et al.
2007; Wittchen et al. 1999). The following overview begins with the two studies
conducted with clinical samples.
In a sample of 150 children and adolescents with clinical social anxiety levels,
Rao et al. (2007) used the Anxiety Disorders Interview Schedule for Children
(ADIS-C; Silverman and Albano 1996) to investigate distress and avoidance related
to 20 different social situations. More than 80 % of adolescents (13–17 years) diag-
nosed with Social Anxiety Disorder (SAD) reported moderate-to-severe distress in
the school situations focused on “giving oral reports/presentations” and “asking
teacher a question.” These two situations were also frequently avoided. Respectively,
71.1 and 73.7 % of adolescents reported at least moderate avoidance. Fewer adoles-
cents reported at least moderate distress or avoidance in other school situations
7 Social Anxiety and the School Environment of Adolescents 153
focused on “taking tests” and “participating in gym class.” Across all situations
adolescents reported significantly greater fear and more avoidance than did chil-
dren. Specifically, a significantly higher percentage of adolescents than children
reported moderate-to-severe distress and at least moderate avoidance in the school
situations “asking teacher a question” and “writing on chalkboard.” Children and
adolescents did not differ in distress or avoidance for the situations “giving oral
reports/presentations” or “taking tests” (Rao et al. 2007). In the Beidel et al. (2007)
study, which also used the ADIS-C in a study of 63 adolescents (aged 13–16 years)
with social anxiety disorder, very similar results were reported. The school situa-
tions “oral reports or reading aloud” and “asking the teacher a question or asking for
help” were again two of the most distressing social situations reported by adoles-
cents. The percentages of adolescents endorsing at least moderate distress in those
two school situations were 90.5 and 87.3 %, respectively. Furthermore, these situa-
tions were also frequently avoided. Respectively, 65.1 and 69.8 % reported at least
moderate avoidance (Beidel et al. 2007). In all, these two studies conducted with
clinical populations show a very high prevalence of fear and avoidance of school-
related social situations.
Other studies have investigated the frequency of social fears and/or avoidance in
community samples of adolescents. Essau et al. (1999) investigated the frequency
of social fears in a large community sample of German adolescents aged 12–17 years.
The most commonly feared social situations were performance/test situations and
public speaking, reportedly feared by 31.1 and 19.7 % of the sample, respectively.
In a second, large sample of 14–24-year-olds, Wittchen et al. (1999) reported a
slightly lower prevalence, with 18.2 and 13.2 % of the sample fearing performance/
test situations and public speaking, respectively. Ranta et al. (2007) administered
the Social Phobia Inventory (SPIN; Connor et al. 2000) in a large Finnish popula-
tion sample of adolescents aged between 12 and 16 years. Just over 12 % of the
sample reported extreme avoidance of speeches (Ranta et al. 2007). The situations
investigated in these three studies are not specific to the school setting, and the
findings are not related to adolescents’ general level of social anxiety. Hence, these
studies do not specifically inform about the impact of school-related social situa-
tions on socially anxious adolescents.
Gren-Landell et al. (2009) study of a large sample of Swedish adolescents
(12–14 years) attending secondary school investigated the fear of specific social
situations, including school situations, using a self-report measure. The school
situations included in the questionnaire were “speaking in front of the class,”
“raising your hand during a lesson,” “being together with others during breaks,”
and “eating together with others during lunch break.” In the total sample, “speaking
in front of the class” was the most feared situation, with 6.2 % endorsing marked
fear of this situation. Of the students who fulfilled DSM-IV criteria for SAD
(n = 93), 63.4 % reported marked fear in the situation “speaking in front of the
class”; this was the most common fear in this group. In contrast, only 3.6 % of the
students who did not fulfill SAD criteria (n = 2,035) reported marked fear in this
school situation. For the other three school situations, up to 15 % of adolescents in
the SAD group reported marked fear in contrast with 2.3 % of the non-SAD group
(Gren-Landell et al. 2009). In a second study, Ranta et al. (2012) compared a group
of adolescents (12–17 years) diagnosed with SAD (n = 22) with a group without
SAD (n = 299). Based on reports on the SPIN, 64 % of the SAD group reported
avoiding speeches at least “very much” versus 31 % of the non-SAD group.
Although the latter study did not focus on school situations specifically, the results
are consistent with those of Gren-Landell et al. (2009), inasmuch as more than
60 % of clinically socially anxious adolescents reported moderate fear or avoidance
of speech situations.
The impact of school-related social situations on adolescents with high levels of
social anxiety is well illustrated by findings from the Social Anxiety and Normal
Development (SAND) study (Westenberg et al. 2009). This study made use of a
sample of adolescents with a wide range of social anxiety levels. The adolescents
completed a questionnaire that asked how distressed they felt in 20 different social
situations and how frequently they tried to avoid these situations (Sumter et al.
2009). The questionnaire was based on the social phobia module from the ADIS-C
(Silverman and Albano 1996). The questionnaire includes situations that are spe-
cific to the school context such as answering questions in class, giving a speech in
class, and asking the teacher a question or asking for help. The distress and avoid-
ance questions are answered on a 9-point scale. For the present chapter, we com-
pared the socially anxious and non-anxious adolescents, as described below.
A group of high and low socially anxious adolescents was selected (12–18 years),
using scores on the Social Anxiety Scale for Adolescents (SAS-A; La Greca and
Lopez 1998). Forty high socially anxious adolescents were selected based on their
scoring in the top 20 % of their gender-specific distribution. The high socially anx-
ious group had a mean SAS-A score of 56.73, which is above the clinical cutoff
recommended by La Greca (1998). Subsequently, an equal number of adolescents
were selected with low (but not the lowest) social anxiety scores, SAS-A scores
between 10 and 32 % according to the gender-specific distribution. The percentage
of adolescents in each social anxiety group (high and low) endorsing a low, moder-
ate, and high degree of distress and avoidance is presented in Table 7.1. The table
presents distress and avoidance results for all 20 social situations included in the
questionnaire, but for the purposes of this chapter, we now focus our discussion on
the social situations that are relevant to the school context.
With regard to experienced distress, significant differences between high and low
socially anxious adolescents can be seen, particularly in the following school-
related social situations: “answering questions in class,” “giving a speech in class,”
“reading aloud in class,” “writing on the board,” and “taking tests.” For the majority
of these five school situations, none of those in the low socially anxious group
endorsed high distress, compared to between 6 and 25 % of those in the high socially
anxious group. As well as experiencing more distress in school-related social situa-
tions, high socially anxious adolescents were more likely to try to avoid these situ-
ations relative to low socially anxious adolescents. For the classroom situations
“answering questions,” “giving a speech,” “reading aloud,” and “writing on the
board,” between 20 and 27 % of high socially anxious adolescents indicated high
avoidance, compared to 7 % or fewer of low socially anxious adolescents.
7
Table 7.1 Distress and avoidance per ADIS situation in high (HSA) and low (LSA) socially anxious participants aged 12 years and older
Distress % Avoidance %
Mann- Mann-
ADIS situation Low (0–2) Moderate (3–5) High (6–8) Whitney U Low (0–2) Moderate (3–5) High (6–8) Whitney U
LSA HSA LSA HSA LSA HSA LSA HSA LSA HSA LSA HSA
1. Answering questions in 95.5 72.7 2.3 20.5 2.3 6.8 751.0* 81.8 52.3 15.9 27.3 2.3 20.5 656.5*
class
2. Giving a speech in class 79.5 47.7 20.5 27.3 0 25.0 610.5** 84.1 54.5 9.1 18.2 6.8 27.3 670.0*
3. Reading aloud in class 95.5 59.1 4.5 29.5 0 11.4 611.0** 86.4 63.6 11.4 11.4 2.3 25.0 723.0*
4. Asking the teacher a 95.5 77.3 4.5 18.2 0 4.5 790.0 86.4 70.5 11.4 13.6 2.3 15.9 799.5
question or for help
5. Taking tests 88.6 65.9 11.4 18.2 0 15.9 730.5* 90.9 84.1 6.8 4.5 2.3 11.4 895.5
6. Writing on the board 100 70.5 0 15.9 0 13.6 682.0** 90.9 63.6 6.8 13.6 2.3 22.7 692.0*
7. Working/playing with a 100 86.4 0 13.6 0 0 836.0 95.5 81.8 4.5 15.9 0 2.3 835.0
group of kids
8. Gym class 95.5 79.5 2.3 15.9 2.3 4.5 816.5 88.6 86.4 6.8 9.1 4.5 4.5 947.0
9. Walking in the hallways 97.7 77.3 2.3 20.5 0 2.3 769.5* 100 86.4 0 9.1 0 4.5 836.0
10. Starting or joining in on 97.7 86.4 2.3 9.1 0 4.5 857.0 97.7 77.3 2.3 13.6 0 9.1 768.0*
a conversation
Social Anxiety and the School Environment of Adolescents
11. Using school or public 90.9 79.5 9.1 13.6 0 6.8 852.0 75.0 61.4 11.4 20.5 13.6 18.2 843.0
bathrooms
12. Eating in front of others 95.5 70.5 4.5 22.7 0 6.8 723.0* 97.7 84.1 2.3 6.8 0 9.1 834.0
13. Meetings such as scouts 97.7 84.1 0 11.4 2.3 4.5 838.5 93.2 81.8 6.8 13.6 0 4.5 855.0
or team
14. Answering or talking on 93.2 77.3 6.8 15.9 0 6.8 809.5 86.4 63.6 13.6 25.0 0 11.4 733.0*
the telephone
155
Table 7.1 (continued)
156
Distress % Avoidance %
Mann- Mann-
ADIS situation Low (0–2) Moderate (3–5) High (6–8) Whitney U Low (0–2) Moderate (3–5) High (6–8) Whitney U
LSA HSA LSA HSA LSA HSA LSA HSA LSA HSA LSA HSA
15. Musical or athletic 90.9 59.1 9.1 20.5 0 20.5 642.0** 90.9 68.2 6.8 15.9 2.3 15.9 741.0*
performances
16. Inviting a friend to get 95.5 75.0 4.5 18.2 0 6.8 767.0* 93.2 77.3 6.8 15.9 0 6.8 809.5
together
17. Speaking to an adult 97.7 79.5 2.3 13.6 0 6.8 790.5* 97.7 72.7 2.3 20.5 0 6.8 724.5*
18. Talking to persons you 100 47.7 0 31.8 0 20.5 462.0** 97.7 54.5 2.3 18.2 0 27.3 544.0**
don’t know well
19. Attending parties 93.2 79.5 4.5 11.4 2.3 9.1 834.5 90.9 84.1 6.8 9.1 2.3 6.8 899.5
20. Having picture taken 97.7 75.0 2.3 20.5 0 4.5 747.0* 95.5 77.3 2.3 15.9 2.3 6.8 794.0
**p < .001; *p < .01; (1-tailed). P values in bold < .0025 (Bonferroni correction). HSA = 44 (23 boys, 21 girls), LSA = 44 (20 boys, 24 girls). HSA-LSA
differences tested with Mann-Whitney U
A.W. Blöte et al.
Remarkably, the school-related situations associated with “asking the teacher a

question/for help” and “working/playing with a group of kids” (both of which may
occur in the classroom but are not limited to the classroom) did not show social
anxiety group differences for distress and avoidance. The lack of group differences
for these situations may be because students can choose whether to ask a question
and when and where to ask it and can choose with whom they work or play. In con-
trast, the activities causing considerable distress and avoidance for high socially
anxious students – “answering questions,” “giving a speech,” “reading aloud” and
“writing on the board” – are all guided by the teacher and therefore offer the student
little to no choice.
A consistent finding in the studies reviewed here is that socially anxious
adolescents are particularly fearful of, and would like to avoid, public perfor-
mance situations in their own classroom: “giving a speech in class,” “reading
aloud in class,” “raising your hand during lessons,” “asking or answering ques-
tions in class,” and “writing on the board.” This is likely to have negative conse-
quences for the socially anxious adolescent and might lead to, for example,
decreased participation in school activities and thus lower academic results. In
contrast, socially anxious adolescents report less fear and avoidance of other
classroom situations (e.g., “asking teacher for help,” “working with group of
kids”). These situations do not directly expose the adolescent to public scrutiny
and might offer more choice with respect to interaction partners. The possibility
of choosing one’s interaction partner(s) is relevant to socially anxious adolescents
because this could provide the opportunity to minimize the likelihood of being
negatively treated or victimized (section “Factors explaining social anxiety in the
school setting”), thereby reducing fear for, and avoidance of, these types of school
situations.
School Refusal
Social Anxiety and School Absenteeism

Because of the inherently social nature of school, it is self-evident that social
anxiety would sometimes contribute to school absenteeism. Studies of adults’
retrospective reports provide tenuous support for this notion. For example, Davidson
et al. (1993) found that a marginally significantly higher proportion of adults with
SAD reported that they “played truant at least twice in a year” during schooling
relative to adults without SAD (p. 713). In Van Ameringen and colleagues’ (2003)
study of anxiety-disordered adults, there were 98 subjects who reported that they
“thought that they left school prematurely” (p. 565). Of these, the majority (61 %)
had a current diagnosis of generalized social phobia (GSP). One hundred and three
subjects did not think that they left school early. Only 45 % of this group had a cur-
rent diagnosis of GSP, and this percentage was significantly less compared with the
percentage (61 %) of those who left school prematurely. The problem with adult
studies such as these is that they do not establish a concurrent relationship between
social anxiety and school absenteeism.
Stronger evidence comes from a number of community-based cross-sectional

studies conducted with the youth. In a German study of over 3,000 adolescents and
young adults (14–24 years; Wittchen et al. 1999), it was found that 57 % of those
with GSP reported that “social fears or avoidance interfered a lot” with work,
school, or household management (p. 312). Further, 15 % of those with GSP
reported being unable to go to school or work on at least 3 days in the past month as
a result of GSP. Among 174 African-American youth (M age = 11.7 years), a posi-
tive association was found between actual/desired avoidance of situations involving
interaction with peers or evaluation in class, on the one hand, and unexcused
absences from school on the other hand (Lyon 2010). Presumably the youth’s actual
or desired avoidance of social or evaluative situations at school was fueled by some
degree of social anxiety. No associations were found between unexcused absences
and nonsocial factors such as the pursuit of attention from parents. In a survey con-
ducted in the continental United States with over 10,000 adolescents (13–18 years),
those diagnosed with SAD were found to report greater impairment in the area of
school/work (in the worst month of the past year) relative to shy adolescents and
adolescents with no shyness (Burstein et al. 2011). Unfortunately rates of school
absenteeism were not reported. Most recently, a study of 865 Norwegian adoles-
cents (16–21 years; M age = 17.2 years) involved a comparison between high-
anxious youth often absent from school and high-anxious youth attending school
regularly (Ingul and Nordahl 2013). Those who were often absent from school had
higher social anxiety and fewer close friends. Because absenteeism was analyzed
categorically rather than dimensionally, it is premature to conclude that progres-
sively higher levels of social anxiety will be associated with progressively higher
levels of absenteeism.
The aforementioned studies conducted with young people predominantly
focused on adolescence. This is a developmental period in which the prevalence of
SAD increases (Costello et al. 2003) and the prevalence of school attendance prob-
lems increases (Heyne 2006; Nakamura et al. 2010). A relationship between social
anxiety and school absenteeism may also exist earlier in development, as suggested
by the study of Weeks et al. (2009). In their predominantly Caucasian sample of 178
Canadian children (7–8 years; M age = 7.6 years), a positive association was found
between social anxiety and the desire to avoid school. Perhaps the desire to avoid
school during childhood does not translate into school absenteeism as quickly as it
does in adolescence. That is, the parents of a socially anxious child may be more
willing and able to get their child to attend school than are the parents of a socially
anxious adolescent.
Social Anxiety and School Refusal

School refusal is a type of school attendance problem that is often differentiated
from truancy (Heyne et al. in press). The term “school refusal” is used to describe a
young person’s reluctance or refusal to attend school when it is paired with emo-
tional distress (e.g., fearfulness, anxiety, somatic complaints, unhappiness); is not
concealed from parents and often involves the young person staying at home; and is
not associated with severe antisocial behavior (Berg 1997, 2002; Berg et al. 1969;
Bools et al. 1990). Truancy, on the other hand, is said to occur when a young person
is absent from school and the parents do not know about the child’s absence
(Kearney 2002) or whereabouts (Berg et al. 1985). Moreover, truancy is often asso-
ciated with severe antisocial behaviors (Vaughn et al. 2013), and it is not commonly
associated with anxiety (Heyne et al. in press). Following, we review literature indi-
cating the extent to which the serious problem of school refusal may be associated
with social factors, especially social anxiety. We also review the negative impact
that social factors seem to have on the short- and longer-term well-being of school-
refusing youth.
In an early study of 29 youth (M age = 14.9 years) diagnosed with DSM-III-R
social phobia, Strauss and Last (1993) found that the most common fear exhibited
was “a fear of school” (p. 146). Indeed, almost two-thirds (64 %) of the socially
phobic youth exhibited a fear of school. It is worth bearing in mind, however, that a
fear of school is not synonymous with the presence of school refusal as defined by
Berg and colleagues (Berg 1997, 2002; Berg et al. 1969; Bools et al. 1990). We turn
now to studies which were based on samples of school refusers selected according
to the comprehensive criteria of Berg and colleagues.
Place et al. (2002) interviewed the families of 17 school refusers (aged
12–15 years). These youth had difficulty with peer relationships, a sense of isolation
(most did not belong to a friendship group when they started secondary school), and
were bullied and teased at school. It is likely that social anxiety contributed to or
stemmed from the social difficulties experienced by these school-refusing youth.
Heyne et al. (1998) assessed self-efficacy among 135 children and adolescents
(5–15 years; M age = 11.4 years) referred for school refusal. Across the sample,
youth’s perception of their ability to cope was lowest for the social-related situation
of answering peers’ questions about absences from school and highest for the non-
social situation of doing schoolwork. The low level of self-efficacy for the social-
related situation may be associated with social anxiety, in line with Rudy et al.
(2014) finding that social self-efficacy uniquely contributed to levels of social anxi-
ety among youth. In Buitelaar et al. (1994) follow-up study of 25 school-refusing
adolescents (M age at referral = 14.8 years), the majority were found to have “unsat-
isfactory or insufficient social relationships” prior to referral (p. 251). Further, one
of the most common diagnoses at initial contact was avoidant disorder of childhood
or adolescence (AD), which overlaps extensively with SAD (APA 1994). In another
study of school-refusing adolescents (11–17 years; M = 14.6 years), SAD was a pri-
mary or secondary diagnosis among approximately two-thirds of the sample (65 %;
Heyne et al. 2011).
Two additional studies reportedly investigated school refusal even though Berg
and colleagues’ school refusal criteria were not used to recruit subjects. Bernstein
et al. (2001) studied 41 adolescents (M age = 15.8 years) who attended school less
than 80 % of the time and were diagnosed with both an anxiety disorder and a
depressive disorder. About two-thirds (67 %) of these adolescents had a diagnosis
of SAD. In the Beidas et al. (2010) study of children and adolescents (7–16 years;
M = 11.0 years) with “denial to attend school or difficulty remaining in school,” it
was found that more youth presented with a principal diagnosis of SAD (n = 11)
than with generalized anxiety disorder (n = 7) or separation anxiety disorder (n = 9)

(p. 255).
Results from the aforementioned studies of referred school refusers need to be
interpreted cautiously because of a bias that may occur due to referral and intake
procedures. In one setting, for example, school refusers may be referred to a school
refusal program, and in another setting, they may be referred to a general anxiety
team. If school refusers are referred to an anxiety team because of the co-occurrence
of anxiety symptoms, and a study is then based on a sample drawn from this popula-
tion, there may be an inflated association between school refusal and anxiety symp-
toms. Community-based studies provide a less biased picture of the relationship
between social anxiety and school refusal. Recently, Nair et al. (2013) reported on
a community sample of 500 adolescents (11–19 years) from rural India. Based on
logistic regression, a significant association was found between meeting SAD diag-
nostic criteria and meeting the criteria for school refusal,1 even when controlling for
comorbid major depressive disorder and dysthymia. The odds ratio statistic indi-
cated an eightfold increase of school refusal among adolescents meeting criteria for
SAD. A decade earlier, the largest comprehensive community-based study of school
attendance problems was conducted by Egger et al. (2003). These researchers stud-
ied school attendance problems according to type, drawing on data from more than
1,400 youth aged 9–16 years from North Carolina in the United States. They found
that being shy with peers, having difficulty making friends, and being bullied or
teased were significantly associated with anxious school refusal. The same social
factors were not associated with truancy. In an uncorrected model, the diagnosis of
SAD was significantly associated with school refusal and not with truancy. In a cor-
rected model (i.e., controlling for the effects of comorbid disorders), SAD was not
associated with school refusal, probably because SAD was highly predictive of
simple phobia and depression, both of which were associated with school refusal in
uncorrected models. It may be that many socially anxious youth find it difficult to
attend school because of the depressive affect they experience when confronted
with school, and the school setting may have become a phobic stimulus because of
the socially challenging aspects of school.
There is currently no research on the direction of influence between social fac-
tors and school refusal. Anecdotally, Buitelaar et al. (1994) referred to “the impor-
tance of social relationship factors in the development of school refusal” (p. 252). It
is feasible that social anxiety is one of the factors that contributes to the develop-
ment of school refusal, but also to its maintenance. It is equally feasible that school
refusal perpetuates social anxiety. As noted by Albano (1995), continued absence
from school severely reduces the quality and number of opportunities for socially
anxious school refusers to increase social interactions. Consequently, there are
fewer opportunities for interventions such as socially-related exposure tasks and
practicing social skills. Longitudinal studies are needed in order to determine the
1
The authors used the term “school phobia,” and adolescents were deemed to have school phobia
if their score on the school phobia subscale of the self-report Screen for Child Anxiety Related
Emotional Disorders (SCARED) was ≥3.
(bi)directionality of the relationship between social anxiety and school refusal and
to determine which factors moderate and mediate the relationship.
The relationship between social anxiety and school refusal appears to be age
related. Kearney and Albano (2004) examined the function of youths’ school
refusal, drawing on questionnaire responses from 143 youth (5–17 years; M = 11.6)
and their parents. Youth who refused school to escape from aversive social and/or
evaluative situations were typically older, whereas younger school refusers were
more likely to endorse other reasons for refusing to attend. More specifically, the
mean age of youth seeking to escape aversive social and/or evaluative situations was
14.4 years (SD = 1.8), whereas youth seeking to avoid stimuli that provoke negative
affectivity were 11.8 years on average (SD = 2.7), youth refusing school for atten-
tion were 9.2 years on average (SD = 2.8), and youth pursuing tangible reinforce-
ment outside of school were 12.9 years on average (SD = 2.8). Although this study
did not measure social anxiety per se, the older youth’s motivation to escape aver-
sive social and/or evaluative situations is clearly related to social anxiety. Last and
Strauss (1990) reported that, at intake, school refusers with SAD were older than
school refusers with separation anxiety disorder.
The higher prevalence of social anxiety among older school refusers, as reported
by Last and Strauss (1990), may simply be a reflection of the higher prevalence of
SAD among older youth relative to younger youth (e.g., Costello et al. 2003). It
might also be explained by the increasingly complex and demanding nature of the
secondary school environment relative to the primary school environment. Galloway
(1985) argued that, as the child grows older, school attendance problems are increas-
ingly under the influence of school-based factors. At secondary school the student
is confronted with a larger and more complex social environment involving multiple
teachers, moving between classes, and needing to function more autonomously
(Steinberg 2005, cited in Holmbeck et al. 2012). These aspects of secondary school-
ing, combined with the increasing importance of the peer context during adoles-
cence, may lead some vulnerable youth to become overwhelmed and to escape to
the security of the home environment.
There is accumulating evidence that social anxiety is associated with poor
response to treatment for school refusal. In Bernstein and colleagues’ (2001) 1-year
follow-up of school-refusing adolescents treated with cognitive-behavioral therapy
(CBT) plus imipramine or CBT plus placebo, the retention rate of disorders was
higher for SAD (50 % retention) and AD (50 % retention) relative to other disorders.
In further analysis of data from the original cohort, Layne et al. (2003) found that the
presence of AD was a significant predictor of poorer school attendance at posttreat-
ment.2 There was no treatment group by diagnosis (AD/no AD) interaction effect,
suggesting that the additional use of pharmacotherapy does not change the impact of
social avoidance on the outcome of CBT for school refusal. Heyne et al. (2011)
reported that school attendance 2 months following treatment was lower for school-
refusing adolescents who still met criteria for SAD (18 % of school-time attended)
relative to those who had no disorder or a disorder other than SAD following
2
Social anxiety disorder was not analyzed as a predictor of treatment outcome.
treatment (68 % of school-time attended). Interestingly, adolescent school refusers

who still met criteria for SAD at 2-month follow-up less commonly had friends in
the same class at pretreatment, relative to adolescents who did not meet criteria for
SAD at follow-up (50 % versus 80 %, respectively). McShane et al. (2004) investi-
gated longer-term outcomes for 192 youth who were aged between 12 and 18 years
when treated for school refusal. A pretreatment diagnosis of SAD was found to
predict poorer functional outcomes (i.e., unemployment or home schooling) 3 years
after treatment. More specifically, only 40 % of those with SAD at pretreatment
were doing well 3 years after treatment, compared with 79 % of those without SAD.
In all, social anxiety and related social factors (e.g., difficulty with peer relation-
ships) are linked to the difficulty that some young people have with attending school
regularly. Among school refusers with SAD, the refusal to attend school may be
regarded as the avoidance component of the youths’ social anxiety. Studies suggest
that SAD among school-refusing adolescents is often treatment resistant and that
SAD is associated with poor outcomes well after the end of treatment for school
refusal. Suggestions to improve outcomes for school refusers with SAD have
included the following: adjunctive interventions such as social skills training and
pharmacotherapy (Layne et al. 2003); starting with individual treatment and pro-
gressing to group-based treatment (Albano 1995); greater flexibility at school, such
as reduced academic demands for adolescents already burdened with the challenge
of social anxiety (Heyne et al. 2011); longer and more intensive treatment (Heyne
et al. 2011; McShane et al. 2004); and targeting social isolation and promoting par-
ticipation in prosocial activities (Ingul and Nordahl 2013). According to Place et al.
(2000); there is little likelihood of school refusers ever returning to mainstream
schooling if peer functioning cannot be improved.
Factors Explaining Social Anxiety in the School Setting
Social Interactions with Classmates
Socially anxious adolescents may encounter all sorts of negative outcomes from
their interactions with classmates. The range of negative behaviors that can be expe-
rienced in the classroom varies from neglect, and lack of acceptance and support at
one end to rejection and direct teasing and physical aggression at the other (see
Kingery et al. 2010 for a review). The relation between social anxiety and these
forms of victimization appears to be bidirectional (for a review, please see Garcia-
Lopez et al. 2011). A meta-analysis of longitudinal studies showed that internaliz-
ing problems, including withdrawal and anxiety, predicted an increase in peer
victimization and peer victimization, in turn, predicted an increase in internalizing
problems (Reijntjes et al. 2010). Socially anxious students seem to be trapped in a
vicious cycle of social anxiety and victimization (Ollendick and Hirshfeld-Becker
2002; Siegel et al. 2009). This conclusion is based on studies using self-report
measures (e.g., La Greca and Harrison 2005; Ranta et al. 2009; Storch and
Masia-Warner 2004) as well as ratings from classmates in sociometric studies
(e.g., Erath et al. 2007; Inderbitzen et al. 1997). Furthermore, observations in the
school and classroom have substantiated the negative treatment of socially anxious
students (Blöte et al. 2007, 2010; Spence et al. 1999).
Some features of the social environment may to some extent protect socially
anxious youth against the harmful effects of negative peer treatment. For example,
the number and quality of friendships, being a member of a “crowd” (be it a high-
status or low-status crowd), and being liked by at least some peers have all been
found to predict lower levels of social anxiety (La Greca and Harrison 2005; London
et al. 2007) over time. However, there is no evidence that friendship and crowd
membership variables play a mediating or moderating role in the link between vic-
timization and social anxiety (La Greca and Harrison 2005). These variables pre-
dicted lower levels of social anxiety independent of the degree of victimization.
In the following section, we explore why socially anxious adolescents are treated
in a negative way by classmates. We firstly address factors in socially anxious stu-
dents themselves and then factors in the peer group.
Factors in the Socially Anxious Student

Most socially anxious youth are withdrawn, inhibited, or shy in the social situations
they fear. They lack social skills or, if they have those skills, do not employ them in
feared situations (Kingery et al. 2010). They may show safety behaviors (Clark
2001; Garcia-Lopez 2013; Hodson et al. 2008; Ranta et al. 2014) to keep the social
interaction at a minimum (e.g., by avoiding eye contact and keeping quiet, using
“shadow friend”) and to prevent making a negative impression on others (e.g., by
firmly holding an object to keep their trembling under control or keeping their arms
close to their body to hide sweat stains). A number of studies have been conducted
on the relation between these behavioral features and peer responses, some of the
studies in the domain of social anxiety and some in the domain of social withdrawal
and inhibition.
At the behavioral level, there is a clear overlap between social anxiety and social
withdrawal and inhibition, although not all socially anxious adolescents are inhib-
ited and withdrawn, with some even being risk-seeking and aggressive (Erath et al.
2012; Hanby et al. 2012). At the same time, not all socially withdrawn, inhibited
youth will be socially anxious, although in childhood as well as adolescence, social
withdrawal is associated with (social) anxiety (Rubin and Coplan 2004). The reason
we do not know the extent to which social withdrawal overlaps with social anxiety
is that social anxiety studies and social withdrawal studies are conducted in differ-
ent domains of psychological/psychiatric research, the clinical psychology and
developmental psychology domain, respectively (Kingery et al. 2010). Nevertheless,
studies on social withdrawal and its consequences for young people’s development
might be useful in understanding the peer relations of socially anxious youth. For
this reason, we review these studies in this chapter.
In the following sections, we address the question of what actually determines
whether socially anxious adolescents will be neglected, disliked, rejected, or victim-
ized in their school environment. Is it because of socially anxious students’ social
withdrawal, their safety behaviors, lack of confidence, and nervousness? Is it
perhaps because their anxiety is expressed in their body posture, facial expression,
voice, way of verbally communicating, and physical appearance? We also consider
how much time it takes before these students are perceived as socially anxious and
are treated in a negative way. We therefore discuss studies related to (a) the first
impression that socially anxious adolescents make on peers who are not acquainted
with them; (b) research on emerging social relations in new peer groups; and (c)
socially anxious adolescents’ ongoing relations in groups with familiar peers.
First Impressions
Recently, a few studies investigated the impression that socially anxious adolescents
make on unfamiliar peers. A study by Miers et al. (2010) addressed peer perceptions
of the social performance of socially anxious youth. Participants in this study were
adolescents aged between 13 and 17 years, divided into a high and a low socially
anxious group based on their anxiety scores on the SAS-A (La Greca and Lopez
1998). These participants gave a speech in front of a prerecorded audience. Video-
recorded 2-min fragments of the speeches were observed by whole school classes of
unfamiliar peers who individually rated the fragments. Peer observers rated speaker
behavior on speech content, facial expressions, posture/body movement, and way of
speaking (voice, language). Results showed that high socially anxious speakers
were judged as performing more poorly on all four behavioral aspects. After con-
trolling for self-reported depressive symptoms, the differences between the high-
and low-anxiety groups were still significant, except for facial expression. So, peer
responses to the speakers’ behavior could mainly be ascribed to speakers’ social
anxiety and not their depressed mood. Furthermore, the four aspects of perceived
speaker behavior were strongly related, and the authors concluded that because no
particular behavior made a unique contribution to predicting which group speakers
belonged to (i.e., high or low anxious), there may be a general lack of social skills
in socially anxious speakers. An alternative conclusion reached by the authors was
that socially anxious speakers exhibit certain behavior that elicits a negative halo
effect (a general impression determining the judgment of individual qualities of a
person, Thorndike 1920) in other people’s judgments.
Another study further supports the proposition that socially anxious adolescents
make a general negative impression on unfamiliar peers, and it also presents evi-
dence regarding mediators in the social anxiety – rejection link. Blöte et al. (2015)
divided adolescents (13–17 years) into a high socially anxious group and a low
socially anxious group. The video-recorded speeches of these adolescents were
observed by whole classes of unfamiliar same-aged peers. The peers rated the
speeches with respect to the social performance of the speaker and the speaker’s
likeability (rejection). Each peer rated the speakers on only one of the four behav-
ioral aspects in order to prevent carryover effects that might have caused the high
intercorrelations in the Miers et al. (2010) study. Trained adult observers also rated
the social performance using the Performance Questionnaire (PQ; Cartwright-
Hatton et al. 2005; Miers et al. 2009). The physical attractiveness of the speakers
was rated by different peers (i.e., different to those rating social performance and
likeability) using photographs (screenshots) of the speakers taken before they
started their speech. Results showed that the ratings of the four different aspects of
social performance were once again strongly related. That is, the result replicated
that of the Miers et al. (2010) study, even when different peers rated different aspects
of social performance. The main findings of the study were that socially anxious
adolescents were relatively less liked compared to their non-anxious counterparts
and that physical attractiveness and social performance equally mediated the link
between social anxiety and peer liking. However, the mediation effect was partial,
as the direct link between social anxiety and peer liking was still significant after
including the mediators in the model. The authors argued that there may be one or
more characteristics other than physical appearance and social performance that
lead peers to reject socially anxious adolescents who are unfamiliar to them.
A study by Verduin and Kendall (2008) suggests that overt nervousness may be
one of these other mediators in the link between social anxiety and likeability. The
study investigated the effect of anxiety on peer liking in children and young adoles-
cents (9–13 years). Same-aged unfamiliar peers rated video-recorded speeches of
youth with different anxiety disorders, among them a group with social phobia and
a control group without any anxiety disorder. Peers rated the state anxiety and like-
ability of the speakers. Results suggested that peer-rated state anxiety partially
mediated the link between social phobia and peer liking. The authors argued that
there must be other characteristics in addition to overt nervousness, such as depres-
sion or poor social skill, that make socially phobic youth less attractive to unfamiliar
others. This conclusion and the conclusion from the Blöte et al. (2015) study sug-
gest that at least three variables mediate the link between social anxiety and peer
liking in first impressions, namely, overt nervousness, social performance, and
physical appearance.
There is also evidence that high socially anxious adolescents are perceived as
“different” by same-aged unfamiliar peers. Blöte et al. (2012) asked the entire class-
rooms to rate the video-recorded speeches of high and low socially anxious adoles-
cents from the Miers et al. (2010) study. Results showed that high socially anxious
speakers were perceived as less similar to the peer raters themselves compared to
low socially anxious speakers and that similarity perceptions mediated the link
between social anxiety and peer rejection. Notably, not only low, but also high,
socially anxious peer raters perceived high socially anxious speakers as different.
As suggested by the authors, the similarity rating may have been influenced by
wishful thinking, with peers not wishing to be like the high anxious speakers. The
perception of dissimilarity may be part of the general negative halo in the judgments
of both high and low socially anxious peers.
A recent study helps to shed further light on the question of why high socially
anxious adolescents are less effective in social situations relative to nonsocially
anxious adolescents. Blöte et al. (in press) aimed to identify explicit differences in
behavior between high and low socially anxious youth. The study used naive observ-
ers to describe conspicuous features in the video-recorded speech behavior of
socially anxious speakers (9–16 years). Based on these descriptions, the Speech
Performance Observation Scale for Youth (SPOSY) was developed, including sub-
scales related to expressiveness, confidence, and agitation. Expressiveness as
measured with the SPOSY comprises behavioral features such as looking friendly,
having a good intonation, using adequate gestures, and showing facial expressions.
It also comprises directing attention to the public. It was found that expressiveness
and confidence are important features distinguishing between high and low socially
anxious youth. Low expressiveness in combination with a lack of confidence may
explain the negative peer responses towards socially anxious youth (Blöte et al. in
press; Van Beek et al. 2006).
Emerging Relationships
Very few studies have addressed the relation between social anxiety and peer rejec-
tion/victimization in the first weeks or months of newly formed groups. One study
by Vernberg et al. (1992) investigated peer relations of relocated adolescents (12–
14 years) followed over a period of 8 months. Victimization measures were exclu-
sion and direct aggression. It was found that the level of adolescents’ social anxiety
did not predict self-reported exclusion or direct aggression experiences in the new
social group, but it did negatively affect the development of friendships.
A study by Gazelle et al. (2005) examined the effect of anxious solitude on social
interactions with familiar and unfamiliar same-aged peers in young preadolescent
girls (9-year-olds). Anxious solitary girls and a control group participated in two
playgroups, one made up of familiar female classmates and the other made up of
unfamiliar girls. In general, anxious solitary girls were perceived by playmates as
less socially competent and were less liked and more victimized by playmates com-
pared to the controls. Notably, these effects were larger in the playgroup of familiar
classmates relative to the so-called unfamiliar playgroup. Anxious solitary girls
showed more whining, complaining, and repetitive behavior in the familiar play-
group than in the unfamiliar playgroup, and the familiar playgroup reacted more
negatively towards them than the unfamiliar playgroup. So, the girls were better off
in the new group of unfamiliar peers than in the group of familiar classmates. This
does not mean that it is generally better for socially anxious youth to be placed in a
new social environment. Gazelle et al. (2005) argue that relatively positive peer
behavior in unfamiliar groups may become more negative with time. Once a social
group starts to agree on the low social status of the anxious solitary youth, exclusion
and victimization may start.
Established Relationships
A number of studies have focused on the social interactions of socially anxious
students in their school environment. Spence et al. (1999) conducted school-based
observations of socially phobic children and adolescents (7–14 years) and found
that youth with social phobia were less socially skilled compared to a control group.
They were also treated less positively by school peers. Relative to the control group,
the socially phobic youth initiated fewer social interactions and had less interactions
with their schoolmates. The socially phobic youth were less socially competent,
according to parents’ perceptions and the perceptions of the youth themselves. The
authors argued that the poor social skills of socially phobic youth may result in
negative peer responses.
Erath et al. (2007) ascertained whether social skills and withdrawal-disengagement

mediated the link between social anxiety and peer acceptance and victimization.
Subjects were 6th and 7th graders (11–12 years) divided into a socially anxious
group and a control group. The study used a social interaction task with a research
assistant to investigate target students’ social skills. A peer nomination procedure
(on grade level and school level) was used for measuring peer acceptance and vic-
timization. Teachers rated students’ withdrawal-disengagement. Social skills during
the interaction task were rated by independent observers. The study found relations
between social anxiety on the one hand and peer acceptance and victimization on
the other. The link between social anxiety and peer acceptance was mediated by
target students’ expectations about the quality of their performance and their
withdrawal-disengagement. However, no significant mediators were found for the
link between social anxiety and victimization. The authors suggested that this is
probably due to gender differences in the relations between various variables and
victimization. For example, the relation between victimization and social anxiety
was stronger in boys than in girls. It is argued that gender differences in adolescent
peer interactions and in particular the role of withdrawal and aggression in gender
groups are important factors in explaining gender-related victimization.
Unexpectedly, students’ social skills during the conversation were not related to
their social anxiety level. The authors argued that using adults as interaction part-
ners instead of same-aged peers might explain why socially anxious adolescents did
not perform more poorly in the interaction task.
Two studies from our own research group on the link between social anxiety and
victimization investigated the behavior of classmates towards socially anxious stu-
dents (13–16 years) giving an oral presentation in their own classroom (Blöte et al.
2007, 2010). An important question posed in the first study was how class behavior
is related to speakers’ trait social anxiety and state anxiety as indicated by observa-
tions of nervous and communicative behavior (Blöte et al. 2007). An independent
observer rated the behavior of the speakers as well as class behavior. Class behavior
was also rated by the speakers themselves. Both the independent observer and
speakers used the Class Behavior List (CBL) which consists of a selection of items
from the Perception of Treatment Lists (PTLs) (Blöte and Westenberg 2007).
Furthermore, the independent observer rated the speaker’s nervousness and level of
interaction with the class. It was found that class behavior as rated by the indepen-
dent observer was related to speakers’ trait social anxiety. Speakers with higher
levels of social anxiety were treated more negatively. Class behavior was not related
to speakers’ overt nervousness during the speech. This is remarkable because
socially anxious individuals assume that their nervousness is apparent and nega-
tively influences others’ behavior towards them (e.g., Cartwright-Hatton et al. 2005;
Rapee and Lim 1992). Given that the level of the speaker’s interaction with the class
was not related to class behavior either, the question of how trait social anxiety may
affect peer behavior could not be answered.
The second study looked more closely at the characteristics of socially anxious
adolescent speakers (13–18 years) in order to explain negative responses from class-
mates (Blöte et al. 2010). For example, what is the importance of social skills, such
as looking friendly and speaking in a clear voice, and of overt nervousness, as

indicated by blushing or stuttering? And what role does the quality of the speech
play? Social skills and nervousness were observed and recorded by an independent
observer using an adapted Dutch version of the PQ (Cartwright-Hatton et al. 2005;
Miers et al. 2009). To evaluate the speeches, the Speech Content Evaluation Scale
was developed. Using the CBL, class behavior was rated by an independent observer,
the teacher, and the speakers themselves (Blöte et al. 2007). Results showed that,
according to the independent observer, the teacher, and the speakers themselves,
socially anxious speakers were treated more negatively by their classmates.
Furthermore, class behavior was better predicted by the social skills of the speakers
than by their overt nervousness. Surprisingly, with all other variables controlled for,
higher-quality speeches elicited more negative class responses (i.e., speeches with
the speaker’s point of view made clearly, presented systematically, with a logical
line of thought). The authors argued that classmates might respond more positively
to socially attractive behavior, such as making personal remarks and jokes, than to
a well-prepared speech (Blöte et al. 2010).
Peer Group Factors

Studies on specific peer and peer group factors that influence the rejection/
victimization of high socially anxious adolescents are few. As far as “first impres-
sion” studies are concerned, one would expect that peers who are socially anxious
themselves may not immediately reject unfamiliar adolescents who appear
anxious. However, the study by Verduin and Kendall (2008) did not support this
proposition. Although peer observers with higher levels of social anxiety did rate
speakers as more likable, their social anxiety was not a moderator in the link
between perceived anxiety and liking of the speakers. That is to say, peers who
themselves were socially anxious still liked non-anxious speakers more than
anxious speakers. This finding was corroborated by the Blöte et al. (2012) study,
which showed that the actual similarity in social anxiety level between speakers
and peers was neither related to perceived similarity with the speakers nor to lik-
ing of the speakers.
As far as the influence of peer group characteristics on victimization of socially
anxious youth in emerging and established relationships is concerned, research has
focused on socially withdrawn children. The results of these studies are ambiguous.
One study showed that in first-grade classrooms with predominantly withdrawn
children, withdrawn boys had a higher social status relative to withdrawn boys in
classrooms that had less withdrawn children (Stormshak et al. 1999). Another study,
which was longitudinal, found no specific effect of classroom climate on exclusion
(Avant et al. 2011). Although solitary anxious students (followed from third through
fifth grade) were excluded less during the course of the school year, this was not
related to classroom climate. This effect occurred in classrooms with emotionally
supportive climates and in classrooms with emotionally unsupportive climates. So,
this positive finding is difficult to interpret.
In sum, available research does not clearly identify peer group factors related to
social anxiety and peer victimization.
Role of Gender in the Relation Between Social Anxiety

and Peer Victimization
Girls and boys differ in their relationships with peers. For example, girls experience
more stress in peer relationships and tend to talk more with friends about their prob-
lems, possibly making the problems bigger, whereas boys tend to ruminate less,
taking problems more lightly (Rose and Rudolph 2006). Therefore, the relation
between social anxiety and peer victimization might be different for boys and girls.
However, studies on gender as a moderating variable in the relation between social
anxiety and peer victimization have yielded mixed results. For example, in a pro-
spective study, Siegel et al. (2009) found that social anxiety predicted an increase in
relational victimization (exclusion, friendship withdrawal) in both sexes. In con-
trast, other prospective studies showed that social anxiety predicted an increase in
victimization only for girls (Tillfors et al. 2012) or only for boys (Ranta et al. 2013).
As far as the influence of victimization on social anxiety is concerned, relational
victimization predicts an increase in social anxiety in girls (Ranta et al. 2013; Siegel
et al. 2009; Vernberg et al. 1992) whereas direct victimization predicts social anxiety
in boys (Ranta et al. 2013). In addition, the effect of victimization on social anxiety
appears to depend on adolescent males’ self-worth. A cross-sectional study on 6th
graders (11–13 years) found that boys’ self-worth was a moderator in the link between
victimization and general anxiety (that included social anxiety; Grills and Ollendick
2002). That is to say, boys with higher self-worth were affected less by victimization.
Their self-worth may protect them from becoming anxious. However, girls’ self-
worth seems to play a different role as it was found to be a mediator between victim-
ization and anxiety. This suggests that victimization negatively affects girls’ self-worth
and low self-worth then makes them more anxious (Grills and Ollendick 2002).
Conclusion and Discussion of Social Interactions

In sum, for socially anxious adolescents, interactions with classmates are rather dif-
ficult. Socially anxious students are more likely than nonsocially anxious students
to be victimized, not accepted, and not supported, and these negative outcomes from
social interactions in turn increase their social anxiety (Reijntjes et al. 2010).
Figure 7.1 presents a schematic overview of the course of peer relationships over
time. The figure is partly based on the results of the reviewed studies and partly,
where studies were lacking, on extrapolations. Importantly, Fig. 7.1 shows that neg-
ative judgments and rejection by peers start in the very first minutes of social con-
tacts. Probably, negative outcomes from social interactions then worsen when
students get to know each other more and their low social status in the group has
been determined, up to the point where, in their ongoing relationships, a certain
negative interaction pattern is firmly established.
The first impression socially anxious students make (relative to their non-anxious
counterparts) on unfamiliar age-mates is generally a negative one. They are per-
ceived as anxious (Verduin and Kendall 2008) and socially ineffective (Miers et al.
2010). Socially anxious students are also seen as “different” (Blöte et al. 2012) and
as physically less attractive (Blöte et al. 2015). These perceptions seem to play a
role in the immediate dislike/rejection by peers towards them. However, we cannot
Overt anxiety
First impressions
Social anxiety Social performance Rejection
Physical attractiveness
Emerging relationships
Social anxiety Social performance Victimization
Social performance
Established relationships
Social anxiety Victimization
Self-worth
Crowd boys
Friendships
membership
Self-worth girls
Fig. 7.1 Overview of results of studies reviewed in this chapter regarding the association between
social anxiety and rejection/victimization. Solid lines tested pathways; Dotted lines hypothesized
pathways
conclude from the reviewed studies that some aspects in the behavior of socially
anxious students are more important than others in eliciting negative peer judg-
ments. The studies seem to suggest that a general negative halo effect (Alden and
Taylor 2004; Miers et al. 2010) is at work in peer judgments of high socially anxious
adolescents. Future studies are needed to ascertain whether this immediate negative
impression is triggered by one or more specific characteristics, which is then carried
over to other aspects of the person judged. High socially anxious adolescents may
show their anxiety in their behavior and facial/body expression (possibly lacking
expressiveness), and peers may not like this, consequently extending their negative
opinion to the whole person (Blöte et al. 2015). The finding that socially anxious
students are negatively judged and disliked very quickly, in the first minutes of their
social performance, is quite disconcerting in view of the possible consequences of
this response. Negative self-perceptions of socially anxious students about their
social performance seem to be immediately confirmed by peers. This in turn will
have consequences for their behavior in subsequent peer interactions.
In light of the negative first impression socially anxious students make on peers, it
is not surprising that they encounter negative social outcomes when entering unfa-
miliar social groups. It is not yet clear which behaviors specifically elicit the negative
peer responses in emerging social relationships (just as it was not clear in first impres-
sions), although the Gazelle et al. (2005) study suggests that in girls, “annoying”
behaviors like whining and complaining might (partly) mediate the link between
anxious solitude and victimization. Furthermore, this study suggested that placing a
victimized socially anxious student in a new social group will have some positive
effect at first, when the social status of this student is not yet determined by the group.
However, this effect is only temporary and victimization may increase over time.
In established relationships, socially anxious students’ poor social skills may
(partly) explain why they are treated in a negative way by schoolmates (Blöte et al.
2010). Nervous behavior that appears to be a trigger for dislike/rejection at first
sight (Verduin and Kendall 2008) does not seem to have this effect among class-
mates who have known each other for some time (Blöte et al. 2007, 2010). In that
situation the social status of individual students has been agreed on and unpopular
students are disliked by classmates regardless of whether or not they are nervous
during a social performance. However, this explanation needs the necessary caution
because of method differences between studies, in particular differences in age and
diagnostic status of the participants and in the age of the observers. Verduin and
Kendall (2008) studied preadolescents and young adolescents with social phobia
and used peer-rated nervousness, whereas Blöte et al. (2007) and (2010) studied a
normative sample of older adolescents whose nervousness was judged by an adult
observer. Future studies will be needed in order to better understand the role of overt
nervousness in peer rejection/victimization.
In view of differences in peer interactions between boys and girls (Rose and
Rudolph 2006); it seems likely that the relation between social anxiety and victim-
ization is different between the sexes. Some studies indeed found evidence for the
moderating effect of gender (Ranta et al. 2013; Siegel et al. 2009; Tillfors et al.
2012). At the same time, it is difficult to draw conclusions from these studies
because of the dissimilar findings. They present an ambiguous picture of the effect
of social anxiety on victimization and, in turn, also of victimization on social anxiety

for boys and girls. A complicating factor is that different forms of victimization are
used in studies, for example, overt/direct victimization (physical or verbal),
relational victimization (social exclusion, friendship withdrawal), and reputational
victimization (negative interference in other person’s relationships). Focusing on
these specific kinds of victimization, however, further complicates drawing conclu-
sions as results on the specific kinds of victimization have also been equivocal.
More research is needed that pays attention to the different forms that victimization
takes for boys and girls. Moreover, the moderators in the relation between victim-
ization and social anxiety might be different for boys and girls. Self-worth has been
shown to play a different moderating role between the sexes (Grills and Ollendick
2002), and depression may also play such a role (Ranta et al. 2013).
Very little is known about which peer group factors influence the victimization
of socially anxious students in classrooms. This is unfortunate because it means that
schools cannot yet be informed about evidence-supported ways to prevent or stop
victimization of socially anxious students. Having (good) friends and belonging to
a social group may protect socially anxious students (as well as non-anxious stu-
dents) to some extent from becoming (more) socially anxious (La Greca and
Harrison 2005). Furthermore, common sense would say that the presence of more
socially anxious students in a group would have a positive effect because these stu-
dents would be less negative towards each other. However, studies on first contacts
show that both socially anxious and non-anxious students do not like their socially
anxious counterparts (Blöte et al. 2012; Verduin and Kendall 2008). It is still pos-
sible that socially anxious students who are familiar with each other will support
and protect each other from the negative effects of victimization in the classrooms.
For example, they may make friends or form a “crowd” which may help them to be
more assertive or to be less affected by peer victimization. New studies are needed
to draw any firm conclusions about this and other classroom effects on socially
anxious students.
Cognitive Factors
The previous sections show that there is quite substantial evidence for negative
treatment of socially anxious youth by their age peers, both familiar and unfamiliar,
as compared to non-anxious youth. That is, socially anxious youth are more likely
to be rejected, neglected, and victimized. In contrast, the cognitive theories of SAD
(Clark and Wells 1995; Rapee and Heimberg 1997) place more emphasis on the
negative perceptions socially anxious individuals have of social situations and their
own performance in these situations. Several empirical studies show that socially
anxious youth indeed have negative social perceptions. Compared to non-anxious
youth, they interpret ambiguous social cues in a negative way (e.g., Blöte et al.
2014; Miers et al. 2008; Vassilopoulos and Banerjee 2008) and engage in negative
interpretations or evaluations of their own behavior in social situations (Alfano et al.
2006; Inderbitzen-Nolan et al. 2007; Miers et al. 2009, 2011; Ranta et al. 2014).
One of the main questions to arise out of the cognitive approach is whether the
negative perceptions of socially anxious individuals are based on a “kernel of truth”
(Norton and Hope 2001) or are biased relative to an objective source of information.
Cognitive theories imply that social experiences and feedback from other persons in
social situations influence the development of negative perceptions of one’s own
social performance. Given the evidence reviewed in section “Social interactions
with classmates” that socially anxious youth experience more negative social inter-
actions at school, this would suggest that negative social perceptions in socially
anxious youth are, at least to some degree, warranted. Indirect evidence for the
kernel-of-truth hypothesis was provided in a study on the social perceptions of high
socially anxious students and their classmates (8th–10th graders; aged 13–18 years).
All pupils in a class were asked to imagine an oral presentation situation in their
class where they or their classmates give a presentation (Blöte and Westenberg
2007). They then filled in a questionnaire how they saw themselves treated in such
a situation and how hypothetical classmates showing either fearful or relaxed behav-
ior were treated. The socially anxious students reported that they felt negatively
treated by classmates when giving a speech. These perceptions seemed warranted as
their classmates also perceived that the behavior towards the hypothetical socially
anxious (fearful) students in their class was more negative compared to class behav-
ior towards students who were nonsocially anxious (i.e., relaxed) (Blöte and
Westenberg 2007).
Direct evidence for the kernel-of-truth hypothesis could be provided by a direct
comparison between self-evaluations of high and low socially anxious youth with
evaluations of peer observers. If high socially anxious youth would evaluate them-
selves as poorer with respect to social performance than their low-anxious counter-
parts while the peer observers would not perceive a difference between these groups,
then we could speak of biased self-perceptions (Miers et al. 2009). Alternatively, if
the peer observers would also perceive a difference between high- and low-anxious
youth, the negative perceptions would be warranted, supporting the “kernel-of-
truth” notion.
We are not aware of a study that has compared the self-evaluations of socially
anxious youth with evaluations of peer observers. However, some studies have
investigated whether socially anxious youth have negatively biased perceptions of
their social performance using the performance evaluations of adult observers as a
standard. In terms of appearing nervous during a social performance situation, stud-
ies consistently show that socially anxious youth perceive themselves as looking
more nervous than do adult observers of these socially anxious youth (e.g.,
Cartwright-Hatton et al. 2005; Inderbitzen-Nolan et al. 2007; Miers et al. 2009).
Thus, socially anxious youths’ negative perceptions of their nervous behavior seem
to be unwarranted.
When comparing self- to observer evaluations of social skills, a negative bias
may not apply to all socially anxious youth. Miers et al. (2009) investigated high
and low socially anxious youth’s (aged 9–17 years) evaluations of social perfor-
mance during a short speech. The speeches were recorded and shown to indepen-
dent adult observers who evaluated the performance using the same questionnaire
as the participants. When analyzing the whole high socially anxious group, Miers
et al. (2009) found that participants and observers were in agreement about the
poorer social skills of high socially anxious youth. This suggested that the percep-
tions of high socially anxious youth were warranted. However, the authors also split
the high socially anxious group into two groups using the observers’ performance
evaluations: those with a good speech performance and those with a poor speech
performance. This analysis showed that the negative self-perceptions were justified
only for the socially anxious youth who had a poor speech performance. In contrast,
for the socially anxious youth whose performance was judged as good, their nega-
tive perceptions were unwarranted. Hence, the “kernel-of-truth” hypothesis seems
to apply only to socially anxious youth who are indeed less socially skilled (as
determined by adult observers).
In sum, with regard to the way they are treated by peers, the negative cognitions
of socially anxious adolescents seem partly warranted and partly colored by internal
processes. Socially anxious adolescents rightly expect negative responses from oth-
ers. Based on these expectations, they interpret neutral responses in a negative way.
As far as adolescents’ self-perceptions of social performance are concerned, they
are “incorrect” in thinking that they make a nervous impression (more nervous than
others), and some of them are right in evaluating their own social performance as
poor. Socially anxious adolescents who perform well may have negatively biased
self-perceptions, whereas poor performing socially anxious adolescents may be cor-
rect in judging their performance as poor.
It seems important that future studies make a direct comparison between self-
evaluations of performance, on the one hand, and performance evaluations by peers
(using the same measure) on the other hand. In this way, we can better investigate
whether the negative self-perceptions are based on a kernel of truth or are biased.
Implications: How to Break the Vicious Cycle?
The school environment, and more specifically the formal classroom situation,
clearly presents a real challenge to socially anxious adolescents. A number of these
adolescents experience considerable distress at school and try to avoid distressing
classroom situations. In some cases, socially anxious adolescents may show a more
severe form of avoidance by refusing to go to school altogether. Moreover, studies
indicate that school refusers with AD or SAD have poorer school attendance and
that SAD among school-refusing adolescents is often treatment resistant. In all, this
chapter sketches a rather bleak picture of the school experiences of socially anxious
students.
What makes successful interventions for socially anxious students particularly
difficult is that these students not only think that they perform poorly in social
situations but that some of them actually are less socially skilled, less confident,
and less expressive and consequently elicit negative responses from peers. At first
glance, peers see them as different and reject them. Later on, when social
relationships are being formed, socially anxious students may be victimized.

In sum, these students are trapped in a vicious cycle of social anxiety, negative
expectations about their social performance and how peers will respond to their
performance, actual negative peer responses, and, as a result, increased social
anxiety.
It is a complex task to break this vicious cycle, because so many aspects of the
socially anxious student and their environment are involved: not only their social
skills but also their social cognitions; not only their behavior, but also their physical
appearance; and not only these factors on their own, but also the transactions
between them. In view of this multiplicity of factors, effective interventions should
address a variety of factors, notably negative thinking, poor social skills, as well as
physical appearance features. In addition to a change towards less negative thinking,
learning more expressive behavior and wearing more attractive clothing and hair-
style may diminish the immediate negative response from peers and create a more
positive halo effect. Improved social skills and greater physical attractiveness may
also support more positive self-perceptions. Furthermore, the school context would
ideally be included in the intervention, since an established pattern of negative
social interactions is not easily changed by changes in just one of its participants.
Teachers could play an important role by modeling supportive behavior towards
socially anxious students and facilitating positive responses from socially anxious
students’ peers. In order for interventions to have a positive effect, socially anxious
students need the opportunity to practice newly learned behavior in their classroom
without being bullied or laughed at.
Regarding school refusal, no prospective studies have yet been reported which
identify social anxiety as a risk factor for school refusal. Social anxiety should be
studied in this respect, together with school- and family-based factors that might
exacerbate or mitigate against the development of school refusal among socially
anxious youth. To our way of thinking, the apparent link between social anxiety and
school refusal calls for indicated prevention interventions for school refusal, target-
ing youth with social anxiety. Interventions which help improve socially anxious
youth’s social connection may help prevent school refusal. In indirect support of
this, Alfano et al. (2009) found that decreases in loneliness mediated treatment-
related improvements in socially anxious children and adolescents. Because of the
inherently social nature of schooling and the increased importance of being able to
“fit in” with the peer group (Holmbeck et al. 2012); reduced loneliness may be
especially important for school-refusing adolescents. A related factor is friendship
quality. Baker and Hudson (2013) found that children and young adolescents (aged
7–13 years) who reported higher friendship quality were more likely to be free of
anxiety disorder 6 months following CBT for anxiety. The role of friendship quality
will be especially important in interventions to prevent or treat school refusal among
socially anxious youth. Because bullying and teasing have also been linked with
school refusal (Egger et al. 2003); they require specific attention at the individual
level (e.g., social skills training addressing assertiveness) and at the school level
(i.e., school-based prevention and response to bullying).
Future Studies
As far as research on social anxiety in students is concerned, there is a lack of

knowledge about potential moderators and mediators in the link between social
anxiety and victimization. We need to know more about the moderating role gender
plays in this link. A number of studies found that the effect of victimization on
social anxiety and, reversely, of social anxiety on victimization is different for boys
and girls. Unfortunately, until now, the findings are ambiguous with regard to how
gender affects the link between social anxiety and victimization. There is also a lack
of knowledge about which factors give rise to victimization of some socially anx-
ious students but not others and which factors may protect socially anxious students
against the harmful effects of victimization.
Finally, it seems important to focus on same-aged peers as observers and judges
of socially anxious students’ behavior, because (a) students will behave differently
in interactions with same-aged peers than with adults, for example, showing social
skills during interactions with adults which they do not show during interactions
with peers; (b) students’ social interactions are mostly with classmates and not
adults/teachers; and (c) same-aged peers are likely to have different standards for
appropriate behavior and appearance relative to adults. In view of the high degree of
socially anxious students’ distress and avoidance encountered when they give a
speech in class, an oral presentation task may provide a good opportunity to study
social anxiety in students.
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Social Anxiety and The School Environment of Adolescents

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Social Anxiety and the School

During the school week, adolescents ordinarily spend somewhere between

A.W. Blöte, PhD (*) • A.C. Miers, PhD •

© Springer International Publishing Switzerland 2015 151

The Manifestation of Social Anxiety in the School Setting

Distress and Avoidance in Specific School Situations

Remarkably, the school-related situations associated with “asking the teacher a

Social Anxiety and School Absenteeism

Stronger evidence comes from a number of community-based cross-sectional

Social Anxiety and School Refusal

than with generalized anxiety disorder (n = 7) or separation anxiety disorder (n = 9)

treatment (68 % of school-time attended). Interestingly, adolescent school refusers

Factors Explaining Social Anxiety in the School Setting

Social Interactions with Classmates

Factors in the Socially Anxious Student

Erath et al. (2007) ascertained whether social skills and withdrawal-disengagement

as looking friendly and speaking in a clear voice, and of overt nervousness, as

Peer Group Factors

Role of Gender in the Relation Between Social Anxiety

Conclusion and Discussion of Social Interactions

Social anxiety Social performance Rejection

Social anxiety Social performance Victimization

Social anxiety Victimization

of social anxiety on victimization and, in turn, also of victimization on social anxiety

Implications: How to Break the Vicious Cycle?

relationships are being formed, socially anxious students may be victimized.

As far as research on social anxiety in students is concerned, there is a lack of

Berg I, Nichols K, Pritchard C (1969) School phobia—its classification and relationship to

Ranta K, Tuomisto MT, Kaltiala-Heino R, Rantanen P, Marttunen M (2014) Cognition,

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