Journal of

Experimental Psychopathology
JEP Volume 2 (2011), Issue 4, 551–570
ISSN 2043-8087 / DOI:10.5127/jep.014511

Manipulating self-focused attention in children with social

anxiety disorder and in socially anxious and non-anxious
children

Hanna Kleya, Brunna Tuschen-Caffierb, Nina Heinrichsa

a
University of Bielefeld, Germany
b
University of Freiburg, Germany

Abstract
Cognitive behavioral models of social anxiety disorder (SAD) in adults suggest that self-focused attention
maintains social anxiety. However, this hypothesis has not yet been tested in children. This study
therefore examined self-focused attention in relation to social anxiety in children. Self-focused attention
was experimentally varied (internal vs. external) in 20 children with SAD, 20 children with high social
anxiety and 20 non-anxious controls while engaging in a performance task in front of two adults. As
expected, a significant group effect was found for all dependent variables, with children suffering from
social anxiety disorder reporting the highest levels of anxiety, negative mood, and negative cognitions,
and the lowest levels of self-rated performance and positive cognitions, followed by socially anxious
children and controls. A significant effect of the focus condition was that children with heightened internal
self-focus reported more anxiety, worse expected performance evaluation by others and more frequent
negative cognitions. Unexpectedly, no interaction between social anxiety group and focus condition was
found. Taken together, the results provide important preliminary evidence for the generally detrimental
role of self-focused attention on child anxiety in social situations.
© Copyright 2011 Textrum Ltd. All rights reserved.
Keywords: social anxiety disorder, social phobia, childhood, attentional focus
Correspondence to: Hanna Kley, University of Bielefeld, Department of Clinical Child and Adolescent Psychology
and Psychotherapy, Postbox 100131, 33501 Bielefeld, Germany. Email: hkley@uni-bielefeld.de
1. University of Bielefeld, Department of Clinical Child and Adolescent Psychology and Psychotherapy, Postbox
100131, 33501 Bielefeld, Germany.
2. University of Freiburg, Department of Clinical Psychology and Psychotherapy, Engelbergerstr. 41, 79085
Freiburg, Germany
Received 28-Oct-2010; received in revised form 25-Feb-2011; accepted 05-Apr-2011
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 552

Table of Contents
Introduction
Method
Design
Participants
Measures
Diagnostic assessment.
Assessment related to the Social Performance Task.
Procedure
Statistical analysis
Results
Preliminary analyses
Manipulation check
Main analyses
Anxiety.
Mood.
Self-rated performance.
Positive and negative cognitions.
Discussion
Acknowledgements
References

Introduction
Effective cognitive behavioral interventions for socially anxious adults have been developed (e.g., Clark
et al., 2006; Rapee, Gaston, & Abbott, 2009) on the basis of seminal cognitive models of the disorder
(Clark & Wells, 1995; Rapee & Heimberg, 1997). However, insights from these models have largely not
been applied to socially anxious children. The onset of social anxiety disorder (SAD) usually occurs prior
to age 18 and has been reported in children as young as age eight (Beidel, Turner, & Morris, 1999;
Kessler et al., 2005). It is therefore important to establish which psychological processes are shared by
adults and children. Such results may enable improved treatment for children (Field, Cartwright-Hatton,
Reynolds, & Creswell, 2008).
Cognitive models of SAD in adulthood postulate that several factors and processes play a role in
maintaining the disorder and hindering individuals from benefiting from “objectively” non-threatening
everyday social situations (Clark & Wells, 1995; Rapee & Heimberg, 1997). Apart from general
avoidance, specific cognitive processes and other types of behavior are assumed to maintain SAD in
adults. One is self-focused attention, which plays a significant maintaining role, according to current
cognitive models of SAD. Self-focused attention has been defined as “an awareness of self-referent,
internally generated information that stands in contrast to an awareness of externally generated
information derived through sensory receptors” (Ingram, 1990, p. 156). It is assumed that socially phobic
or anxious individuals tend to shift their attention towards internal aspects of themselves, such as
arousal, behavior, thoughts, emotions or appearance, when they enter a social situation (Bögels &
Mansell, 2004). Self-focused attention then enhances their awareness of the negative mental
representations of their self, feelings, thoughts, and physiological symptoms. Furthermore, Clark and
Wells (1995) argue that a high level of internally focused attention reduces the capacity to process
external positive feedback or information that might disconfirm dysfunctional beliefs. Self-focused
attention thus produces anxiety as individuals rely on negative evaluations of themselves and their
performance based on missed corrective experiences. Moreover, Clark and Wells (1995) propose that,
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 553

based on this internally generated information, individuals with SAD often construct negatively distorted
images of themselves which then leads to a negative impression of the self as a social object.
During the past decades, a number of studies have investigated the effects of self-focused attention on
social anxiety and associated variables, primarily among adults. Samples from these studies vary. Most
of these studies employed analogue populations of individuals scoring high or low on a range of
measures related to SAD, such as speech anxiety, test anxiety, and blushing anxiety. Moreover, patients
suffering from SAD were compared with controls or patients with other types of anxiety disorders (Bögels
& Mansell, 2004). In line with cognitive models, results of these studies indicated that individuals with
SAD or who were highly socially anxious showed more self-focused attention during social-evaluative
situations than did individuals with low-level anxiety or non-anxious individuals (Bögels & Lamers, 2002;
Mansell, Clark, & Ehlers, 2003; Mellings & Alden, 2000; Voncken, Dijk, de Jong, & Roelofs, 2010; Woody
& Rodriguez, 2000). In correlational studies, it was shown that self-focus was related to anxiety, negative
affect, negative self-assessment of performance and a higher number of negative thoughts (for review
see Bögels & Mansell, 2004; Schultz & Heimberg, 2008; Spurr & Stopa, 2002). Studies that
experimentally tested the influence of enhanced self-focused attention on various variables found that
higher levels of self-focused attention led to more social anxiety, anxious appearance and negative affect
(Bögels & Lamers, 2002; Kashdan & Roberts, 2004; Woody, 1996). The influence of self-focused
attention on social performance was also experimentally tested. It was supposed that a high level of self-
focused attention can have detrimental effects on social performance because it reduces the attentional
resources available for successful task handling. Whereas prior studies partly found a relationship
between the degree of self-focus and social performance (for review see Spurr & Stopa, 2002), recent
studies that investigated the relationship between those two variables found no negative effect of self-
focused attention on social performance (Bögels & Lamers, 2002; Voncken et al., 2010; Woody, 1996;
Woody & Rodriguez, 2000). In an experimental study from Bögels, Rijsemus, and De Jong (2002),
attentional focus was manipulated with a mirror in blushing-anxious individuals. They found that
heightened self-awareness neither led to increased fear, blushing, physiological arousal and negative
thinking nor that the increased self-awareness interfered with task performance. Bögels and Mansell
(2004) suggested that in this study blushing-anxious individuals in the self-focus condition received
corrective feedback through the reflection in the mirror, thus preventing the detrimental effects of self-
focused attention.
Finally, in most of the studies mentioned above, the detrimental effect of self-focused attention was not
specific to individuals with SAD or to socially anxious individuals but also occurred in non-anxious and
low-level anxious controls. These findings are in contrast to theoretical assumptions of recent cognitive
models from which an interaction between fear of negative evaluation and self-focused attention in
producing anxiety can be derived (Zou, Hudson, & Rapee, 2007). According to these cognitive models,
self-focused attention heightens an awareness of feared anxiety symptoms (e.g., blushing) or negative
cognitions about how one performed (e.g., “I`m boring”) in individuals with SAD. This process is
supposed to increase anxiety. In contrast, individuals with low-level social anxiety would not fear
negative evaluation by others; inward focus should not increase anxiety in them as much as in highly
socially anxious individuals. Thus, self-focused attention is assumed to induce more anxiety among
highly socially anxious individuals compared to individuals with low-level anxiety and non-anxious
individuals. This interaction was found in two studies (Kashdan & Roberts, 2004; Zou et al., 2007). For
example, Zou and colleagues (2007) compared 22 individuals with high-level blushing anxiety and 22
individuals with low-level blushing anxiety who were instructed to be under either a self-focused or a
task-focused attention condition during a five-minute conversation with a stranger. This study found an
interaction effect in which the high-level blushing anxiety group reported a higher level of social anxiety
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 554

in the self-focused condition than in the task-focused condition. Individuals with low-level blushing
anxiety, in contrast, showed no significant difference in social anxiety levels between the two conditions.
In summary, a range of studies with adult populations supports the assumption that high levels of self-
focused attention are associated with increased social anxiety, negative affect and negative self-
judgments, although some inconsistencies occurred across studies.
Recent studies referenced childhood primarily through non-clinical samples of children and adolescents.
The results suggest that a relationship between self-focused attention and social anxiety also exists in
younger populations. In a correlational study, Hodson, McManus, Clark, and Doll (2008) investigated
several of the assumed maintaining variables of the Clark and Wells’ model in a sample of 171
participants aged 11-14 years. Among other results, the authors found that highly socially anxious
children reported higher levels of self-focused attention than did low-anxiety children. In a regression
analysis, self-focused attention was a significant predictor for social anxiety. However, it is important to
note that variables were assessed without referring to a specific social situation and that the external
focus of attention was not considered. Higa, Phillips, Chorpita, and Daleiden (2008) found in their study,
involving a non-clinical sample of 175 children 9-14 years old, that there was a significant correlation
between self-consciousness and social anxiety, as well as negative affect. The same sample
participated in an experimental investigation examining the effect of self-focused attention on threat
interpretation biases (Higa & Daleiden, 2008). To assess interpretation bias, children had to rate six
ambiguous stories regarding threat. Manipulation of attention focus was conducted with a mirror.
Children were randomly allocated to either a self-focused condition with a mirror in the same room or to
a control group without mirror manipulation. However, the mirror manipulation affected neither self-
reported self-focused attention nor social anxiety. Therefore, the authors could not test their original
hypothesis. Nevertheless, a significant relationship was found between social anxiety and self-focused
attention at baseline before the task.
In sum, studies with non-clinical samples of children provide preliminary evidence for a relationship
between self-focused attention and social anxiety in younger populations. The aim of the present study
was to further explore this link. We therefore asked children to repeat a previously heard story in front of
two adults who were unfamiliar to them. This kind of situation provokes anxiety, especially for socially
anxious children (Beidel & Turner, 2007).
This study included an internal focus condition (IFC), as well as an external focus condition (EFC). In the
current literature on self-focus attention in adults, different self-focus manipulations have been used,
such as sitting in front of a mirror or video camera, being instructed to self-focus or giving a speech.
According to results from Mor and Winquist’s (2002) meta-analysis, mirror manipulation procedures are
most common but yielded considerably weaker effects than did instruction to self-focus, which yielded
the strongest effects. In line with these results, Higa and Daleiden (2008) also found no effect on
children’s focus of attention of mirror manipulation. Therefore, we decided to manipulate self-focus by an
instruction to the child to either focus attention inwards or outwards. In contrast to previous studies,
which only investigated unselected samples of children, we compared children with a SAD to socially
anxious (SA) and non-anxious (NA) children.
On the basis of the literature review, we first hypothesized that SAD children would report the highest
levels of anxiety and negative mood during the speech task. We further assumed that the SAD children
would rate their own performance the worst and report less frequently positive and most negative
cognitions during the task, followed by the SA group (not meeting criteria for a disorder) and then by the
NA children. Second, we assumed that, with increased internally focused attention (IFC), children would
report more anxiety, negative mood, worse performance ratings, and less positive and more negative
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 555

cognitions with respect to the speech task when compared with children in the external focused condition
(EFC). Finally, we expected an interaction between the focus condition and diagnostic status in that
negative effects of self-focused attention on dependent variables would be more pronounced in children
with SAD than in children with lower anxiety and non-socially anxious children.

Method

Design
Figure 1 illustrates the design and procedures of the study. Subsequent to the assessment session (see
below for details), SAD, SA and NA children were randomly assigned to two different foci of attention
(internal or external) during a socially evaluative performance task. After listening to a story from a CD,
children were instructed to repeat the story in front of two female adult strangers. Children were asked
before (Baseline 1) and after (Baseline 2) the speech task instruction to rate their current levels of
anxiety and mood to control baseline differences between the groups and to check for their differential
responses to the instruction. The dependent variables were assessed after children completed the
speech task. The assessment included paper-pencil measures assessing children’s anxiety and mood
during the task, beliefs about how they performed, and negative and positive thoughts that they
experienced during the speech task (see below for details). To assess if the foci were successfully
directed internally or externally according to the respective instruction, children also rated the extent to
which they were internally and/or externally focused in their attention while telling the story.

Participants
Sixty children (30 girls and 30 boys) 8-13 years old (M = 10.28; SD = 1.38) took part in this experiment.
Participants included 20 children diagnosed with SAD (10 girls and 10 boys), 20 socially anxious children
(9 girls and 11 boys) and 20 non-anxious children (11 girls and 9 boys). Children were included in the
SAD condition if they met diagnostic criteria for SAD according to DSM-IV as assessed through a
structured clinical interview (Kinder-DIPS; Unnewehr, Schneider, & Margraf, 1998). If children showed
significant symptoms of social anxiety but did not meet full DSM-IV criteria for SAD, they were assigned
to the SA group. Children in the NA control group did not meet the criteria for any clinical diagnosis, nor
did they partially meet the criteria. Children were not included in any of the three groups if they displayed
any comorbidity other than a simple phobia or enuresis. One boy in the SAD group and one boy in the
SA group were diagnosed with a simple phobia. One girl in the SA group also suffered from enuresis.
The majority of children came from two-parent households in which a mother and a father (primarily the
biological father) were married and 13.4% of children were growing up in one-parent families due to a
divorce. The majority of children (83.3 %) had one or two siblings. For 18.3% of mothers and 13.3 % of
fathers, no school degree or the lowest formal qualification of Germany’s tripartite secondary school
system (8 or 9 years of schooling) was reported. Ten years of schooling were reported by 58.3% of
mothers and 51.7% of fathers, respectively. Higher education had been obtained by 23.3% of mothers
and 33.3% of fathers. Participants were recruited through child health professionals (child psychologists,
psychiatrists, and child mental health centers), family information centers and announcements on the
Internet, in local newspapers or magazines and in schools, offering participation in a project about social
anxiety. SAD and SA children were mainly referred by professionals. NA children all responded to the
advertisement. Additionally, all children received a gift worth 10 € for participation. Children with SAD
were offered free cognitive-behavioral group treatment.
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 556

telephone screening

self-and parental measures sent out via regular

mail (SPAI-C, SASC-R, CBCL)

Structured Clinical Interview (Kinder-DIPS for

group assignment)

SAD SA NA
random assignment
to condition
IFC EFC IFC EFC IFC EFC

Baseline 1: anxiety and mood

Task instruction
includes instruction to directing attention internally
or externally during task

Baseline 2: anxiety and mood

Speech task
retelling a story in front of two adults

Dependent variables:
• anxiety during task (anxiety thermometer)
• mood during task (SAM)
• self-rated performance
• expected performance evaluation
• frequency of positive & negative cognitions (SISST-PS)

control variables: internal and external focus of attention (FAQ)

Figure 1: Study design. White boxes and arrows represent the procedure. Gray boxes include the study measures.
SAD = social anxiety disorder group, SA = socially anxious group, NA = non-anxious group, IFC = internal focus
condition, EFC = external focus conditions, for abbreviations of measures see method section
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 557

Measures
Diagnostic assessment.
Diagnostic Interview for Mental Disorders in Children and Adolescents (Kinder-DIPS).
To assess the diagnosis of SAD according to DSM-IV, we used the Kinder-DIPS (Unnewehr et al.,
1998). This structured interview consists of a child interview and a parent interview. In addition to being
used to assess social phobia, the Kinder-DIPS can be used to assess all anxiety disorders, as well as
depression, attention-deficit hyperactivity disorder, opposition defiant disorders, eating disorders, and
elimination disorders. The validity and reliability of the Kinder-DIPS for the assessment of anxiety
disorders and other axis I disorders ranges from satisfying to good. Kappa coefficients for inter-rater
reliability of diagnosis categories vary from .55 to .81 (Unnewehr et al., 1998). The parent interview was
conducted with either the mother, the father or both parents together but was conducted separately from
the child. SAD diagnosis was then based on the composite information from the two separate interviews.
Trained Master-level clinical psychologists conducted the Kinder-DIPS with continuous supervision from
experts.
Additional assessments to validate group assignment included standardized self-reporting by children on
social anxiety and a parent-report for child psychopathology described below.
Social Phobia and Anxiety Inventory for Children (SPAI-C).
To assess SAD symptoms, we administered the German version of the Social Phobia and Anxiety
Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1995; Melfsen, Florin, & Warnke, 2001). The
SPAI-C is a 26-item self-report measure that assesses a range of potentially anxiety-producing situations
(e.g., reading aloud or performing in a play) and physiological, cognitive and behavioral symptoms of
SAD. Each of the items rated on a 3-point Likert scale represents the frequency with which each
symptom is experienced (0 = never, 1 = sometimes, 2 = most of the time or always). Scores range from
0 to 52. Normative data for the German population aged 8-16 years are available. In the German
version, a cutoff score of 21 is recommended to identify clinically relevant social anxiety symptoms
(Melfsen et al., 2001). Internal consistency in the present study was high (Cronbach’s alpha = .91).
Social Anxiety Scale for Children – Revised (SASC-R).
The SASC-R (La Greca & Stone, 1993; German version: Melfsen & Florin, 1997) is an 18-item measure
of social anxiety in children consisting of two 9-item subscales, “Fear of Negative Evaluation” (FNE) and
“Social Avoidance and Distress” (SAD), which we used in this experiment. Children were asked to
respond to various statements on a 5–point scale (1 = not at all to 5 = always). Total SASC-R scores
range from 18 to 90 with higher scores indicating more social anxiety. Internal consistency of the total
SASC-R scale was .90 (FNE = .91; SAD = .82).
Child Behavior Checklist (CBCL).
The 113-item German version of the Child Behavior Checklist (Achenbach, 1991; Arbeitsgruppe
Deutsche Child Behavior Checklist, 1998) was completed by parents for the assessment of their child’s
behavioral problems and social competencies. Each items is scored on a 3-point Likert scale ranging
from 0 = not true to 2 = often true. The CBCL contains eight problem syndrome scales as well as global
scales for internalizing, externalizing and overall problems. Normative data for a German population are
available. In this study, we used the subscale “anxious/depressed” (range from 0 to 28).
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 558

Assessment related to the Social Performance Task.

Anxiety thermometer.
The illustrated anxiety “thermometer” was scaled with 0 indicating “not fearful at all” to 10 indicating “very
fearful”. At three times during the study session, children were asked to rate their level of anxiety on the
anxiety thermometer. For controlling baseline anxiety differences, we administered the anxiety
thermometer prior to the speech task instruction (Baseline 1) and once afterwards (Baseline 2).
Immediately after completion of the speech task, we administered the anxiety thermometer for a third
time (now as dependent measure). Participants were told to retrospectively rate the anxiety they
experienced during the speech task.
Self-Assessment Manikin.
To assess mood in terms of positive or negative affect, we used a modified version of the Self-
Assessment Manikin (SAM; Bradley & Lang, 1994) at the same three time points as the anxiety
thermometer. The original version is an instrument assessing valence, arousal and dominance in
response to an object or event. Similarly to the anxiety thermometer, this instrument is more appropriate
for the assessment of affects in children because anchors are illustrated with cartoon figures portraying
mood or emotional reactions. In this experiment, children rated on a 5-point Likert scale four SAM-items
to indicate how unhappy/nervous/annoyed/unsatisfied or happy/calm/pleased/satisfied they felt both
before (Baseline 1) and after (Baseline 2) the task instruction. After finishing the speech task, children
rated their mood during the performance task. For each time point, a total “mood score” was computed,
ranging from -2 to 2 with higher scores reflecting higher levels of positive mood.
Self-rated performance.
After completing the task, children had to rate their performance on two items (in accordance with
Spence, Donovan, & Brechman-Toussaint, 1999). On the first item, children were asked to indicate their
own performance evaluation (“How well do you think did you tell the story?”). We asked them on a
second item to rate their expected performance evaluation by others (“Imagine other children had been
watching you during the task: What would they think about your performance?”). We used a 5-point
Likert scale that parallels the German school grading system (1 = best evaluated performance to 5 = the
worst evaluated performance).
Social Interaction Self-Statement Test - Public Speaking.
(SISST-PS; Diaz, Glass, Arnkoff, & Tanofsky-Kraff, 2001). Following the speech task, we used the
SISST-PS to assess the frequency of positive and negative cognitions during the performance task. The
original SISST-PS, a modified version of the Social Interaction Self-Statement Test (SISST; Glass,
Merluzzi, Biever, & Larsen, 1982), was designed to assess positive and negative thoughts during a
public speaking situation and consists of 15 negative and 15 positive self-statements. Participants have
to rate the frequency with which they experienced each item relative to a prior social situation on a 5-
point Likert scale. We translated relevant items into German, following Brislin’s (1970) guidelines. Due to
content and economic factors, we only adopted 8 positive (e.g., “I feel pretty good about my
performance”) and 8 negative (e.g., “What I say will probably sound stupid”) self-statements. We used a
4-point Likert scale (0 = never to 3 = very often) to assess frequency. Scores of the subscales may range
0-24. In a pilot study, we found good psychometric properties (Kley, 2005). Cronbach’s alpha for positive
cognitions subscale was .81 and .79 for negative cognitions subscale in this pilot study. Item-total
correlations were between .33 and .75. In the present study, Cronbach’s alpha was .90 for the positive
cognitions subscale and .89 for the negative cognitions subscale.
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 559

Focus of Attention Questionnaire (FAQ; Woody, 1996).

The FAQ was used after finishing the speech task to assess whether the attention manipulation was
successful. The FAQ is a self-report measure and consists of two 5-item subscales designed to assess
the extent of self-focused attention (FAQintern) and other-focused attention to the environment or an
interaction partner (FAQextern) following a social situation. For the current experiment, the questionnaire
was translated into German and linguistically adapted for children. Children were instructed to indicate
on a 5-point Likert scale (1 = not at all to 5 = the whole time) to what extent they attended to certain
aspects of the situation during renarration (e.g., “I was focusing on what I would say or do next” or “I was
focusing on the other person’s appearance or dress”). In studies with adults, the FAQ demonstrated
sensitivity to self-focus manipulation (Kashdan & Roberts, 2004; Woody & Rodriguez, 2000). The FAQ
has not yet been validated for use with children, but there is at least some evidence for acceptable
internal consistency (Higa & Daleiden, 2008; Hodson et al., 2008). In the present study, Cronbach’s
alpha was .80 for FAQintern and .63 for FAQextern.

Procedure
After recruitment, potential participants for the study were screened using a brief telephone interview as
a first contact with the parent. Families of children who met inclusion criteria for the study were sent a
questionnaire package containing SPAI-C, SASC-R, CBCL and an informed consent sheet and invited
for the structured interview. During the assessment session (1-2 hours), parents and children were
separated. From a total of 63 children, one from each group refused to participate in the experiment
following the diagnostic session. Children were randomly assigned to either the internal or external self-
focus condition. After becoming acquainted with the experimenter, children were asked to rate their
current anxiety and mood (Baseline 1) to assess baseline differences between groups. After that, they
listened to a recorded story (duration: 9 minutes) from a CD and were then instructed to repeat the story
in the neighboring room in front of two adult strangers. The instruction was imbedded in the following
cover story: the aim of the study is to test how well one can do two things at the same time. In the
internal self-focus condition (IFC), children were instructed to tell the story and simultaneously monitor
their feelings, thoughts and body sensations. As a reminder, children wore a chest strap and a supposed
heart rate monitor watch. In contrast, children in the external focus condition (EFC) were instructed to
watch for things and persons (e.g., what clothes people were wearing) in the room while telling the story.
After the speech task instruction, children were asked to rate their anxiety and mood again (Baseline 2)
to control for baseline differences in response to the instruction. The experimenter then accompanied the
child to the neighboring room, indicating the exact position where the child should stand in front of the
two sitting strangers and then left the room. The confederates had standardized questions, should the
child not say anything or if there was a break of longer than 15 seconds. Narration needed to last at least
three minutes. Adult confederates were blind to group (SAD, SA, NA) and focus (IFC, EFC). The task
would automatically end if a child narrated for longer than five minutes. After speech task completion, the
child returned to the room where the experimenter was waiting. The child was then asked to rate the
following dependent measures: anxiety thermometer, SAM, performance items, SISST-PS with respect
to the performance task, and FAQ for manipulation check. The meeting ended when the child was
debriefed and had chosen a gift. A local ethic committee approved the study.

Statistical analysis
To examine pre-differences between groups, we used χ2 tests to compare frequencies with respect to
gender, number of siblings, parents’ educational level and family status. Analyses of variance (ANOVA)
were used to test group differences with respect to age, social anxiety (SPAI-C and SASC-R-Scores)
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 560

and parent report of child psychopathology (CBCL-Score). Baseline differences in anxiety and mood and
all hypotheses were tested with group × condition as between-participant factors. Separate analyses of
covariance (ANCOVA) were conducted for the dependent variables of anxiety and mood during the
speech task, with Baseline 1 measures both of anxiety and mood as covariates, respectively. ANOVAs
examined differences in performance ratings and positive and negative cognitions during the
performance task. Following ANCOVA and ANOVA, pairwise comparisons were conducted. All analyses
were conducted using PASW Statistics 18.

Results

Preliminary analyses
The three groups (SAD, SA, NA) did not differ regarding age (Table 1), gender, χ2(2) = .40, p = .82,
number of siblings, χ2(6, n = 60) = 7.85, p = .25, family status, χ2(2, n = 60) = 2.02, p = .36, or
educational level of their parents (mothers: χ2(4) = 3.33, p = .50; fathers: χ2(4) = 5.54, p = .24).
Standardized social anxiety measures indicated that SAD-children reported the highest levels of social
anxiety compared to SA and NA children. Furthermore, SA children had significantly higher social
anxiety scores than did NA children. However, SA and NA children did not differ with respect to FNE
scores. Mean scores for participants’ characteristics and the results of group comparisons are shown in
Table 1.

Table 1: Means and standard deviations (in parenthesis) of child and parent measures and group differences with
social anxiety disorder (SAD), socially anxious (SA) and non-anxious children (NA)

(1) SAD (2) SA (3) NA F(2, 57) p Comparisons

Age 10.85 (1.23) 9.95 (1.47) 10.05 (1.28) 2.76 .07

SPAI-C 23.69 (6.32) 17.86 (4.05) 9.66 (7.17) 27.67 < .001 (1) > (2) > (3)

SASC-R 55.15 (10.01) 43.27 (8.73) 35.48 (9.97) 21.35 < .001 (1) > (2) > (3)

FNE 28.70 (7.55) 20.89 (6.20) 18.97 (6.17) 11.96 < .001 (1) > (2), (3)

SAD 26.45 (4.54) 22.39 (4.65) 16.53 (5.01) 22.15 < .001 (1) > (2) > (3)

AD (CBCL) 11.28 (6.28) 7.69 (4.01) 7.84 (4.21) 3.38 .04 (1), (2), (3)

Note. SAD = social anxiety disorder group; SA = socially anxious group; NA = non-anxious group; SPAI-C = Social Phobia and
Anxiety Inventory for Children, SASC-R = Social Anxiety Scale for Children –Revised; FNE = Fear of Negative Evaluation Scale;
SAD = Social Avoidance and Distress Scale; AD = Anxious/depressed subscale from Child Behavior Checklist; Multiple
comparison procedure (Bonferroni) was conducted.
> = significantly greater than.

Furthermore, potential differences prior to the task depending on experimental condition were tested with
ANOVAs, using baseline anxiety and mood scores (Baseline 1 + 2) as dependent variables. At Baseline
1, no significant differences with respect to focus condition (FC) were found. However, after receiving the
task instruction with the experimental manipulation, children already reported more anxiety (Baseline 2)
in the IFC. Differences between mood scores did not reach significance (see Table 2). Significant group
effects were found for both anxiety measures at Baseline 1 and Baseline 2 and for mood at Baseline 2.
This indicates that for socially anxious children, the session itself was associated with more anxiety and
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 561

worsened mood. To control pre-differences, we entered Baseline 1 measures of anxiety and mood as
covariates into the analyses.

Table 2: Means, standard deviations (in parenthesis) of control variables and FAQ subscales for manipulation
check and results of ANOVAs

M (SD) F tests

control
SAD SA NA group focus condition
variable

IFC EFC IFC EFC IFC EFC F(2, 54) p F(1, 54) p

Anxiety 2.9 2.25 2.00 1.70 .73 .33

5.75 .005 8.2 .37
Baseline 1 (2.61) (2.55) (2.16) (1.57) (.79) (1.00)

Anxiety 6.75 6.25 5.70 4.00 2.27 .78

28.81 < .001 5.13 .03
Baseline 2 (2.14) (3.20) (2.36) (1.49) (1.68) (1.39)

Mood 1.00 1.25 1.30 1.45 1.57 1.61

2.78 .07 .85 .36
Baseline 1 (.67) (8.34) (.69) (.44) (.55) (.47)

Mood .02 .44 .53 .65 .84 1.33

7.15 .002 3.45 .07
Baseline 2 (.43) (.76) (.70) (.73) (.85) (.77)

17.17 14.50 13.00 8.90 11.09 8.33

FAQintern 16.51 < .001 12.06 < .001
(3.59) (4.24) (3.97) (2.92) (3.56) (2.55)

11.00 14.63 10.70 12.70 9.91 13.67

FAQextern .67 .51 13.31 < .001
(3.59) (2.20) (3.56) (1.25) (2.63) (5.15)

Note. SAD = social anxiety disorder group; SA = socially anxious group; NA = non-anxious group; IFC = intern focus condition;
EFC = extern focus condition; anxiety measured by anxiety thermometer (range from 0 to 10), mood measured by Self-
Assessment Manikin (range from -2 to 2); FAQ = Focus of Attention Questionnaire (subscales range from 5 to 25); No
interaction effects were found (all p > .05).

Manipulation check
To validate our attentional focus manipulation, the FAQ was administered after the speech task.
ANOVAs were conducted for the FAQintern and FAQextern with group and focus condition as between
subject factors. Significant main effects of focus condition (IFC vs. EFC) were found for both subscales.
The IFC was associated with greater self-focus and the EFC with greater externally directed attention
during the task. Thus, the manipulation was successful in producing the intended foci of attention. In
addition, there was a group effect for FAQintern, but not for FAQextern (see Table 2). Pairwise comparisons
indicated the highest self-focus attention during the task in SAD children, compared with the other
groups (p < .001). In both experimental conditions, social anxiety measured with the SPAI-C predicted
greater internally focused attention, IFC: F(1, 31) = 12.26, p = .001, R2 = .28; EFC: F(1, 26) = 13.13, p =
.001, R2 = .34, but not externally focused attention IFC: F(1, 32) = 1.67, p = .21, R2 = .05; EFC: F(1, 26) =
.76, p = .39, R2 = .03. No interaction effects between group and focus condition were found.

Main analyses
Table 3 shows means and standard deviations of dependent variables for SAD, SA and NA groups in
IFC and EFC as well as results for main effects from ANCOVAs and ANOVAs.
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 562

Table 3: Means, standard deviations (in parenthesis) of dependent variables and results of ANCOVAs and
ANOVAs

M (SD) F tests

Dependent
SAD SA NA group focus condition
variable

IFC EFC IFC EFC IFC EFC F(2, 54) p η2 F(1, 54) p η2

Anxiety during 7.58 6.25 5.90 3.50 2.55 .67

a 25.13 < .001 .49 12.56 .001 .19
task (2.07) (2.19) (2.42) (1.72) (1.75) (1.32)

Mood during -.27 .22 .42 .60 .93 1.44

a 10.00 < .001 .27 3.42 .07 .06
task (.69) (.82) (.79) (.80) (.54) (.69)

Self-rated 3.58 3.50 2.90 2.60 2.54 2.00

11.68 < .001 .30 2.10 .16 .04
performance (.90) (.76) (.99) (.84) (.69) (.71)
Expected
3.67 3.13 3.00 2.80 2.55 2.11
performance 9.78 < .001 .27 3.98 .05 .07
(.65) (.64) (.94) (.79) (.52) (.93)
evaluation
Frequency of
5.83 8.00 12.20 10.00 10.27 12.33
positive 3.62 .03 .12 .21 .65 .004
(4.65) (4.87) (5.81) (5.29) (5.48) (8.05)
cognitions
Frequency of
13.83 11.75 7.60 4.90 5.00 2.10
negative 36.14 < .001 .57 7.97 .007 .13
(2.92) (3.73) (4.72) (3.28) (2.10) (3.70)
cognitions
Note. SAD = social anxiety disorder group; SA = socially anxious group; NA = non-anxious group; IFC = intern focus condition;
EFC = extern focus condition; anxiety measured by anxiety thermometer ranged from 0 to 10, mood measured by Self-
Assessment Manikin ranged from -2 to 2, range of performance items was from 0 to 5, frequency of positive and negative
cognitions measured by SISST-PS (range from 0 to 24).
a
ANCOVAs with anxiety or mood Baseline 1 as covariate were conducted, respectively. Both covariates were significant (p <
.007) and error degrees of freedom were reduced to 53.
No interaction effects were found (all p > .05).

Anxiety.
To test our hypothesis that social anxiety group status and heightened self-focus is associated with
increased anxiety during the speech task, an ANCOVA was conducted with group and focus condition as
between-subjects factors. Anxiety score at Baseline 1 was entered as the covariate. Significant main
effects on levels of anxiety were found both for social anxiety group and for focus condition. However,
contrary to the hypothesis, no significant group × focus condition interaction effect emerged, F(2, 53) =
.52, p = .60, η2 = .02. As expected, pairwise comparisons showed that SAD children experienced
significantly more anxiety during the task than did SA children. SA children reported significantly more
anxiety than did NA children during the task (all p < .002).

Mood.
To test the hypothesis that social anxiety group status and heightened self-focused attention are both
associated with increased negative mood, an ANCOVA with mood score as the dependent variable was
conducted. Social anxiety group and focus condition were between-participants factors, and mood score
at Baseline 1 was the covariate. A significant group effect was found, indicating that SAD and SA
children reported worse mood, compared to NA children. NA children experienced the most positive
mood during the task and differed significantly from the two other groups (pairwise comparisons p < .01).
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 563

SAD and SA children did not differ from each other in mood scores. The focus manipulation did not
reach significance, and no interaction was found, F(2, 53) = .45, p = .64, η2 = .02.

Self-rated performance.
For each of the two items, we expected a main effect for social anxiety group and focus condition, as
well as an interaction between the two factors. The first two-way ANOVA with group and focus condition
as between-subject factors yielded a significant main effect of the group. Subsequent pairwise
comparisons showed that SA and NA children evaluated their own performance significantly better than
did SAD children (both ps < .01). SA and NA children therefore did not differ significantly in their own
performance evaluation. Contrary to our hypothesis, there was neither an effect of focus condition, nor
an interaction effect, F(2, 54) = .38, p = .69, η2 = .01.
However, as predicted, an ANOVA including the ratings of expected performance evaluation by others
as dependent variable showed significant main effects for both group and focus condition. Again, no
interaction effect occurred, F(2, 54) = .26, p = .77, η2 = .01. SAD children anticipated the most-negative
performance evaluation by other children, followed by SA children and NA children, as significant
pairwise comparisons indicated. Furthermore, the results indicated that expected performance
evaluation was rated more poorly (i.e., higher scores) by children in the IFC than in the EFC.

Positive and negative cognitions.

We hypothesized that children with SAD would report fewer positive and more negative cognitions,
followed by the SA and then the NA groups. Children in IFC would also report fewer positive and a
greater number of negative cognitions, compared to children in EFC, during the task. We conducted two
separate ANOVAs with group and focus condition as between-subject factors and frequency of positive
and negative cognitions as dependent variables. For positive cognitions, a significant group effect was
found, indicating that the less socially anxious the children were, the more positive cognitions they
reported. However, pairwise comparisons showed that NA and SA children only differed significantly
from SAD children (all ps < .03). Main effects of focus condition or an interaction, F(2, 54) = .93, p = .40,
η2 = .03, were not found.
In contrast, the results indicated a significant group effect and a significant effect of focus condition for
negative cognitions as outcome measure. Again, no interaction was found, F(2, 54) = .07, p = .93, η2 =
.003. Thus, as predicted, the more socially anxious children were and the higher their self-focused
attention, the more frequently they reported negative cognitions. All pairwise comparisons were
significant (all ps < .05).
Figure 2 illustrates mean anxiety during the task for SAD, SA and NA children in focus conditions as a
representative example. The other significant effects (for expected performance evaluation by others and
negative cognitions) were very similar.
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 564

10
9 SAD
8 SA

anxiety during task

7 NA
6
5
4
3
2
1
0
IFC EFC

focus condition

Figure 2: Mean anxiety during the task for SAD, SA and NA children in IFC and EFC.

Discussion
The aim of the present study was to examine the role of attention focus in childhood social anxiety. For
this purpose, we exposed children with SAD, socially anxious children, and non-anxious children to a
social performance task and manipulated their focus of attention. Based on previous findings regarding
childhood SAD (e.g., Spence et al., 1999), it was predicted that children with SAD, compared with the
socially anxious and non-anxious group, would experience more anxiety, worse mood, and fewer
positive and more negative cognitions during the performance task. The results from group comparisons
supported this assumption, replicating earlier findings about childhood SAD. Furthermore, in line with our
hypotheses and consistent with previous studies (Alfano, Beidel, & Turner, 2006; Inderbitzen-Nolan,
Anderson, & Johnson, 2007; Miers, Blöte, Bokhorst, & Westenberg, 2009), we found that high levels of
social anxiety were associated with worse self-evaluated performance ratings and worse expected
evaluation of performance by others. However, due to the lack of observer rated social performance, it
cannot be concluded whether lower performance ratings are based on cognitive biases or on realistic
evaluations of real performance deficits.
Based on cognitive models of SAD (Clark & Wells, 1995; Rapee & Heimberg, 1997) and the empirical
evidence described above, we hypothesized that induced self-focused attention would detrimentally
affect anxiety, mood, self-rated performance and valence of cognitions during the social performance
task. The focus condition was found to significantly affect anxiety, expected performance evaluation by
others and negative cognitions. Accordingly, and consistent with findings in literature on adults, our
results suggest that increased self-focus in children also leads to more self-reported anxiety and
negative cognitions during a social performance task. In addition, it was found that, immediately after
manipulation of attentional focus, children in the internal focus condition (IFC) reported more anticipatory
anxiety before the task. This is in line with results from Woody and Rodriguez (2000) who also found that
adults with and without SAD anticipated more anxiety in a self-focusing speech condition than in an
external focusing condition. In contrast to previous findings documenting a relationship between self-
focused attention and negative affect (Gendolla, Abele, Andrei, Spurk, & Richter, 2005; Higa & Daleiden,
2008; Mor et al., 2010; Mor & Winquist, 2002), the effect of self-focused attention on mood was not
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 565

significant in the present study. Finally, in contrast to our hypothesis, we found no effect of focus
condition on self-rated performance. The results are, however, consistent with several studies on adult
SAD, which also failed to find a direct correlation between self-focused attention and self-rated social
performance (e.g., Woody & Rodriguez, 2000). Voncken and colleagues (2010) found in their study a
relationship between poorer observer-rated social performance and negative beliefs, but not with self-
focused attention.
Moreover, our results show that children in the IFC expected others to rate their performance worse than
did children in the EFC. This could be explained by the fact that self-focused attention increases
awareness of feelings, thoughts or bodily sensations and socially anxious individuals may use these
sensations to infer how they appear to others in a social situation (Spurr & Stopa, 2002). Finally, as
mentioned above, the absence of observer ratings of social performance during the speech task in our
study do not allow us to determine whether internal focus of attention leads to cognitive biases or to real
performance deficits. The cognitive models of social anxiety in adulthood propose that socially anxious
individuals do not generally lack adequate social skills. Nevertheless, socially anxious individual believe
that they do lack social skills, which impairs their confidence in social situations. Empirical findings
suggest the existence of a social skills deficit in socially anxious children (e.g., Spence et al., 1999) but
also a negative cognitive bias according to self-rated performance (Cartwright-Hatton, Tschernitz, &
Gomersall, 2005). Our results of lower self-rated social performance could therefore be explained by a
real performance deficit during the task or by a cognitive bias.
Even though past results regarding an interaction effect between social anxiety level and self-focused
attention are mixed, self-focused attention should theoretically have a greater detrimental effect in SAD
or socially anxious individuals than in non-anxious individuals (Zou et al., 2007). Contrary to predictions
of cognitive models of SAD in adulthood and our hypothesis, we found no interaction effect between
group and focus condition. However, these findings are in line with results from Bögels and Lamers
(2002) and Woody and Rodriguez (2000) showing that self-focused attention has detrimental effects for
both socially anxious and non-anxious individuals. Additionally, Mor et al. (2010) investigated in a diary
study with adolescents the relationship between self-focused attention and negative affect in depression
and anxiety. They conclude from their findings that self-focused attention is or may be maladaptive
regardless of its valence. They thus deduce that the detrimental effects of self-focused attention are not
limited to when it is directed toward negative self-aspects or occurs during negative events. It is not yet
clear what factors make self-focus maladaptive or adaptive. Vassilopoulos and Watkins (2009), for
example, investigated in high and low socially anxious individuals the potentially differential effects of
experiential and analytic self-focused attention as a possible factor for determining how adaptive self-
focus is.
In sum, our results provide further support for the hypothesis that self-focused attention is a relevant
factor of SAD in youth (Higa & Daleiden, 2008; Hodson et al., 2008). They also suggest that self-focused
attention may play an important role in maintaining the disorder. Self-focused attention was found to
negatively affect anxiety, expected performance evaluation by others and frequency of negative
cognitions during the social performance task, which is consistent with results in adults. It is noteworthy
that these effects can already be found in 8-13-year-old children, because certain cognitive symptoms
are usually more common in older socially phobic youth (Alfano et al., 2006).
This is one of the first studies investigating the role of self-focused attention in a clinical sample of
children with SAD. Nevertheless, a number of limitations must be noted. First, the sample size in each
cell is small due to the use of three groups and two foci. The sample size did not allow analyses of
subgroups or of potential differences associated with age or gender, although studies have already
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 566

provided preliminary evidence that females may show more self-focused attention than males (Higa &
Daleiden, 2008; Higa et al., 2008; Mor et al., 2010). Because children are often confronted with retelling
a story in school, the selected task was ecologically valid. However, the adult audience for the speech
task limits the generalizability of results because situations with same-age peer audiences are more
likely in children’s everyday life. Specifically for this reason, we asked the children to evaluate their
performance from their own and from others’ perspective, instructing them to imagine the others to be
children. The lack of observer ratings of social performance is an important limitation of the study and
must be addressed in future research.
Although our manipulation check showed that children in the IFC reported more internally focused
attention than in the EFC, we do not know exactly how our manipulation worked because we had no
control condition without manipulation. Thus, it remains unclear whether the manipulation was successful
in both directions or only in one of the two. However, despite randomized allocation to the focus
condition, it cannot be definitely precluded that children already differed in their focus of attention before
manipulation. This addresses a general problem of baseline measurement in the context of attentional
focus manipulations. Typically, assessment includes only retrospective rating of attentional focus
direction according to a specific, past situation (e.g., Woody, 1996; Zou et al., 2007). Asking about the
current attentional focus prior to a specific instruction is likely to affect the direction and may therefore
bias the attentional manipulation. Furthermore, it can be assumed that the speech task itself was likely to
generate a higher degree of self-focus in general, as seen in the literature about adults (Mor & Winquist,
2002). A difficulty in studies manipulating self-focused attention is that the manipulation itself also
possibly influences social threat or fear of negative evaluation (Bögels & Mansell, 2004). This seems
plausible, especially if participants are instructed to focus on several feared symptoms, like blushing in
blushing-anxious individuals. Our results showed that children in the internal focus condition already
reported more anxiety directly after having been instructed about the task and while attending to their
feelings, thoughts and body sensations. In contrast to other studies, children were not instructed to
especially focus on special symptoms that they feared to show, like blushing. It is more likely that the
instruction made the attention immediately shift inwards and increased participants’ awareness of
anticipatory anxiety. In general, it is not yet clear whether fear of showing visible anxiety symptoms is
prevalent in children suffering from social anxiety. Apart from this trait, social anxiety measured with the
SPAI-C was generally predictive for higher levels of self-focused attention during the task. This is in line
with the described results from adults. Further investigation is also needed regarding the role of
attentional focus and the association with attention bias towards threat (Schultz & Heimberg, 2008). It is
proposed that self-focused attention can have negative effects because it detracts attention from the
environment and thus may impair an individual’s problem-solving ability or experience of corrective
experiences. In contrast to this, our results indicated that there is a significant group difference only in
self-focused and not in external focused attention. It thus remains unclear whether socially phobic
children really showed a decreased attention to the environment in a threatening situation.
Independently from these considerations, self-focused attention is present in many emotional disorders.
Therefore, future studies should investigate whether our findings are specific to children with social
phobia or whether they are common in other childhood disorders as well (Harvey, Watkins, Mansell, &
Shafran, 2004).
Overall, our findings have important implications for social phobia treatment in childhood, especially if
they can be replicated in future studies. They suggest that self-focused attention is related to social
anxiety, or, rather, self-focused attention may cause social fears in a specific social situation. Therefore,
attention retraining techniques should be considered as treatment components for children suffering from
social phobia that may reduce social anxiety levels and could be used for prevention in high-risk
 Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 551–570 567

populations. As the direction of attentional focus can be shifted by verbal instruction, as it was in our
study, it may be sufficient to verbally direct socially phobic or anxious children’s attention away from
themselves toward the task at hand during exposure to anxiety producing situations.

Acknowledgements
This work was supported by the Christoph-Dornier-Foundation.
We thank Alexandra Wächter-Nikoloudis and Thomas Ehring for their valuable comments and
suggestions.

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