Social anxiety disorder in Black American adolescents: Cultural considerations in conceptualization, assessment, and treatment
Published Online:June 2024https://doi.org/10.1521/bumc.2024.88.2.171
Abstract
Social anxiety disorder (SAD) is characterized by significant distress and avoidance surrounding social and performance situations, with marked interpersonal and academic impairment. This review article highlights cultural considerations relevant to the conceptualization, identification, and treatment of SAD in Black youth. Research evaluating the utility of evidence-based measures to assess SAD suggests they are culturally relevant; however, gaps in knowledge regarding the psychometric properties of even the most widely used instruments are evident. In regard to intervention, cognitive behavioral therapy (CBT) approaches hold promise, yet there is a lack of research on the use of CBT with Black adolescents. Recommendations to incorporate cultural factors into CBT are provided, and future work investigating culturally adapted interventions is needed. Finally, given significant disparities in access and utilization of mental health services among Black youth, strategies to increase treatment engagement, such as school-based services, are important to consider.
References
- . (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Google Scholar
- (2006). A heuristic framework for the cultural adaptation of interventions. Clinical Psychology: Science and Practice, 13(4), 311–316. https://doi.org/10.1111/j.1468-2850.2006.00043.x Crossref, Google Scholar
- (1996). Assessment of childhood social phobia: Construct, convergent, and discriminative validity of the Social Phobia and Anxiety Inventory for Children (SPAI-C). Psychological Assessment, 8(3), 235–240. https://doi.org/10.1037/1040-3590.8.3.235 Crossref, Google Scholar
- (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1230–1236. https://doi.org/10.1097/00004583-199910000-00011 Crossref Medline, Google Scholar
- (2017). A multilevel examination of racial disparities in high school discipline: Black and White adolescents' perceived equity, school belonging, and adjustment problems. Journal of Educational Psychology, 109(4), 532–545. https://doi.org/10.1037/edu0000155 Crossref, Google Scholar
- (2003). Screen for Child Anxiety Related Emotional Disorders (SCARED): Psychometric properties in an African-American parochial high school sample. Journal of the American Academy of Child and Adolescent Psychiatry, 42(10), 1188–1196. https://doi.org/10.1097/00004583-200310000-00009 Crossref Medline, Google Scholar
- (2013). Factor structure of measures of anxiety and depression symptoms in African American youth. Child Psychiatry and Human Development, 44(4), 525–536. https://doi.org/10.1007/s10578-012-0346-6 Crossref Medline, Google Scholar
- (2013). A biopsychosocial model of social anxiety and substance use. Depression and Anxiety, 30(3), 276–284. https://doi.org/10.1002/da.22032 Crossref Medline, Google Scholar
- (2007). Racism experiences and psychological functioning in African American college freshmen: Is racial socialization a buffer? Cultural Diversity and Ethnic Minority Psychology, 13(1), 64–71. https://doi.org/10.1037/1099-9809.13.1.64 Crossref Medline, Google Scholar
- (2018). Cognitive behavioral models, measures, and treatments for anxiety disorders in African Americans. In Chang E. C., , Downey C. A., , Hirsch J. K., , & Yu E. A. (Eds.), Treating depression, anxiety, and stress in ethnic and racial groups: Cognitive behavioral approaches (pp. 179–202). American Psychological Association. https://doi.org/10.1037/0000091-008 Crossref, Google Scholar
- (2013a). Cognitive-behavioral treatment of social anxiety among ethnic minority patients, part 1: Understanding differences. Directions in Psychiatry, 33(3), 151–157. Google Scholar
- (2013b). Cognitive-behavioral treatment of social anxiety among ethnic minority patients, part 2: Bridging the gap in treatment. Directions in Psychiatry, 33(3), 163–171. Google Scholar
- (2003). Racial identity and academic attainment among African American adolescents. Child Development, 74(4), 1076–1090. https://doi.org/10.1111/1467-8624.00593 Crossref Medline, Google Scholar
- (2021). Prospective associations between peer functioning and social anxiety in adolescents: A systematic review and meta-analysis. Journal of Affective Disorders, 279, 650–661. https://doi.org/10.1016/j.jad.2020.10.055 Crossref Medline, Google Scholar
- (2018). Assessing the effects of the acting white accusation among Black girls: Social anxiety and bullying victimization. Journal of the National Medical Association, 110(1), 23–28. https://doi.org/10.1016/j.jnma.2017.06.016 Crossref Medline, Google Scholar
- (2020). Daily multidimensional racial discrimination among Black U.S. American adolescents. Journal of Applied Developmental Psychology, 66, 101068. https://doi.org/10.1016/j.appdev.2019.101068 Crossref Medline, Google Scholar
- (2002). School-based treatment for anxious African-American adolescents: A controlled pilot study. Journal of the American Academy of Child & Adolescent Psychiatry, 41(7), 768–775. https://doi.org/10.1097/00004583-200207000-00007 Crossref Medline, Google Scholar
- (2012). Cross-ethnic measurement equivalence of the SCARED in an outpatient sample of African American and non-Hispanic White youths and parents. Journal of Clinical Child and Adolescent Psychology, 41(3), 361–369. https://doi.org/10.1080/15374416.2012.654462 Crossref Medline, Google Scholar
- (2016). The mediating role of internalized racism in the relationship between racist experiences and anxiety symptoms in a Black American sample. Cultural Diversity and Ethnic Minority Psychology, 22(3), 369–376. https://doi.org/10.1037/cdp0000073 Crossref Medline, Google Scholar
- (2017). Culturally sensitive adaptations to evidence-based cognitive behavioral treatment for social anxiety disorder: A case paper. Cognitive and Behavioral Practice, 24(4), 459–471. https://doi.org/10.1016/j.cbpra.2016.12.003 Crossref, Google Scholar
- (2011). Anxiety symptoms in African American children: Relations with ethnic pride, anxiety sensitivity, and parenting. Journal of Child and Family Studies, 20(2), 205–213. https://doi.org/10.1007/s10826-010-9422-3 Crossref, Google Scholar
- (2007). Perceived racial discrimination and self-esteem in African American youth: Racial socialization as a protective factor. Journal of Research on Adolescence, 17(4), 669–682. https://doi.org/10.1111/j.1532-7795.2007.00540.x Crossref Medline, Google Scholar
- (2008). Evidence-based psychosocial treatments for ethnic minority youth. Journal of Clinical Child and Adolescent Psychology, 37(1), 262–301. https://doi.org/10.1080/15374410701820174 Crossref Medline, Google Scholar
- (2010). Anxiety psychopathology in African American adults: Literature review and development of an empirically informed sociocultural model. Psychological Bulletin, 136(2), 211–235. https://doi.org/10.1037/a0018133 Crossref Medline, Google Scholar
- (2021). Unpacking racial/ethnic disparities in emotional distress among adolescents during witnessed police stops. Journal of Adolescent Health, 69(2), 248–254. https://doi.org/10.1016/j.jadohealth.2021.02.021 Crossref Medline, Google Scholar
- (2009). Factor structure and psychometric properties of the Multidimensional Anxiety Scale for Children in an African American adolescent sample. Child Psychiatry and Human Development, 40(2), 287–300. https://doi.org/10.1007/s10578-009-0126-0 Crossref Medline, Google Scholar
- (2019). Understanding disciplinary disproportionality: Stereotypes shape pre-service teachers' beliefs about Black boys' behavior. Urban Education, 54(4), 471–498. https://doi.org/10.1177/0042085915623337 Crossref, Google Scholar
- (2013). The relation of racial identity, ethnic identity, and racial socialization to discrimination-distress: A meta-analysis of Black Americans. Journal of Counseling Psychology, 60(1), 1–14. https://doi.org/10.1037/a0031275 Crossref Medline, Google Scholar
- (2018). Understanding social anxiety disorder in adolescents and improving treatment outcomes: Applying the cognitive model of Clark and Wells (1995). Clinical Child and Family Psychology Review, 21(3), 388–414. https://doi.org/10.1007/s10567-018-0258-5 Crossref Medline, Google Scholar
- (2014). Discrimination and social anxiety disorder among African-Americans, Caribbean Blacks, and non-Hispanic Whites. Journal of Nervous & Mental Disease, 202(3), 224–230. https://doi.org/10.1097/NMD.0000000000000099 Crossref Medline, Google Scholar
- (2014). Identifying the common elements of treatment engagement interventions in children's mental health services. Clinical Child and Family Psychology Review, 17(3), 283–298. https://doi.org/10.1007/s10567-013-0163-x Crossref Medline, Google Scholar
- (2013). Understanding the behavioral determinants of mental health service use by urban, under-resourced Black youth: Adolescent and caregiver perspectives. Journal of Child and Family Studies, 22(1), 107–121. https://doi.org/10.1007/s10826-012-9668-z Crossref Medline, Google Scholar
- (2010). Family matters: The role of mental health stigma and social support on depressive symptoms and subsequent help seeking among African American boys. Journal of Black Psychology, 36(4), 458–482. https://doi.org/10.1177/0095798409355796 Crossref Medline, Google Scholar
- (2012). “We're going through a lot of struggles that people don't even know about”: The need to understand African American males' help-seeking for mental health on multiple levels. American Journal of Men's Health, 6(5), 354–364. https://doi.org/10.1177/1557988312441520 Crossref Medline, Google Scholar
- (2018). Prevalence and patterning of mental disorders through adolescence in 3 cohorts of Black and White Americans. American Journal of Epidemiology, 187(11), 2332–2338. https://doi.org/10.1093/aje/kwy144 Crossref Medline, Google Scholar
- (2007). Interrater reliability of the Anxiety Disorders Interview Schedule for DSM-IV: Child and parent version. Journal of the American Academy of Child and Adolescent Psychiatry, 46(6), 731–736. https://doi.org/10.1097/chi.0b013e3180465a09 Crossref Medline, Google Scholar
- (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36(4), 554–565. https://doi.org/10.1097/00004583-199704000-00019 Crossref Medline, Google Scholar
- (2023). Impact of race-based discrimination on social anxiety symptoms among people of color: Comparing interracial anxiety and general social anxiety. Journal of Psychopathology and Behavioral Assessment, 45(4), 10231033. https://doi.org/10.1007/s10862-023-10070-8 Crossref, Google Scholar
- (2016). Can school counselors deliver cognitive-behavioral treatment for social anxiety effectively? A randomized controlled trial. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 57(11), 1229–1238. https://doi.org/10.1111/jcpp.12550 Crossref Medline, Google Scholar
- (2018). Helping students overcome social anxiety: Skills for academic and social success. Guilford Press. Google Scholar
- (2023, April 16). Treatment barriers to engaging Black adolescents with anxiety in school-based intervention: Qualitative data from student and parent interviews [Symposium]. Anxiety and Depression Association of America Conference, Washington, D.C. Google Scholar
- (2024). A university-community partnership to develop a culturally responsive school intervention for Black adolescents with social anxiety. School Mental Health, 1–14. Advance online publication. https://doi.org/10.1007/s12310-024-09658-6 Google Scholar
- (2003). The Liebowitz Social Anxiety Scale for Children and Adolescents: An initial psychometric investigation. Journal of the American Academy of Child and Adolescent Psychiatry, 42(9), 1076–1084. https://doi.org/10.1097/01.CHI.0000070249.24125.89 Crossref Medline, Google Scholar
- (2014). Diversity considerations in the assessment and treatment of social anxiety disorder. In Weeks J. W. (Ed.), The Wiley Blackwell handbook of social anxiety disorder (pp. 223–246). Wiley Blackwell. https://doi.org/10.1002/9781118653920.ch11 Crossref, Google Scholar
- (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989. https://doi.org/10.1016/j.jaac.2010.05.017 Crossref Medline, Google Scholar
- (2021). Healing interpersonal and racial trauma: Integrating racial socialization into trauma-focused cognitive behavioral therapy for African American youth. Child Maltreatment, 26(1), 17–27. https://doi.org/10.1177/1077559520921457 Crossref Medline, Google Scholar
- (2023). Adolescent social anxiety: Bridging cognitive and social behavioral perspectives through a developmental lens. In Martin C. R., , Patel V. B., , & Preedy V. R. (Eds.), Handbook of lifespan cognitive behavioral therapy: Childhood, adolescence, pregnancy, adulthood, and aging (pp. 89–100). Elsevier. https://doi.org/10.1016/B978-0-323-85757-4.00042-0 Crossref, Google Scholar
- (2012). The acting White accusation, racial identity, and anxiety in African American adolescents. Journal of Anxiety Disorders, 26(4), 526–531. https://doi.org/10.1016/j.janxdis.2012.02.006 Crossref Medline, Google Scholar
- (2010). Assessing the effects of experiencing the acting White accusation. Urban Review, 42(2), 102–122. https://doi.org/10.1007/s11256-009-0130-5 Crossref, Google Scholar
- (2014). Assessing social anxiety in African American youth using the Social Phobia and Anxiety Inventory for Children. Journal of Abnormal Child Psychology 42(2), 311–320. https://doi.org/10.1007/s10802-013-9775-3 Crossref Medline, Google Scholar
- (2012). Indicated prevention and early intervention for childhood anxiety: A randomized trial with Caucasian and Hispanic/Latino youth. Journal of Consulting and Clinical Psychology, 80(5), 940–946. https://doi.org/10.1037/a0029460 Crossref Medline, Google Scholar
- (2003). The antecedents and implications of interracial anxiety. Personality and Social Psychology Bulletin, 29(6), 790–801. https://doi.org/10.1177/0146167203029006011 Crossref Medline, Google Scholar
- (2012). A meta-analysis of the cross-cultural psychometric properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C). Journal of Anxiety Disorders, 26(1), 182–188. https://doi.org/10.1016/j.janxdis.2011.11.002 Crossref Medline, Google Scholar
- (2016). A comprehensive meta-analysis of cognitive-behavioral interventions for social anxiety disorder in children and adolescents. Journal of Anxiety Disorders, 42, 105–112. https://doi.org/10.1016/j.janxdis.2016.05.008 Crossref Medline, Google Scholar
- (2021, December 10). America's public school teachers are far less racially and ethnically diverse than their students. Pew Research Center. https://www.pewresearch.org/short-reads/2021/12/10/americas-public-school-teachers-are-far-less-racially-and-ethnically-diverse-than-their-students/ Google Scholar
- (2020). A luta continua: Next steps for racism research among Black American youth. Child Development Perspectives, 14(4), 244–250. https://doi.org/10.1111/cdep.12388 Crossref, Google Scholar
- (1998). Multidimensional model of racial identity: A reconceptualization of African American racial identity. Personality and Social Psychology Review, 2(1), 18–39. https://doi.org/10.1207/s15327957pspr0201_2 Crossref Medline, Google Scholar
- (1996). Anxiety Disorders Interview Schedule for DSM-IV (Vol. 1). Oxford University Press. https://doi.org/10.1111/cpsp.12169 Google Scholar
- (1999). Treating anxiety disorders in children with group cognitive-behaviorial therapy: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67(6), 995–1003. https://doi.org/10.1037//0022-006x.67.6.995 Crossref Medline, Google Scholar
- (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37(1), 105–130. https://doi.org/10.1080/15374410701817907 Crossref Medline, Google Scholar
- (2001). Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: Child and parent versions. Journal of the American Academy of Child and Adolescent Psychiatry, 40(8), 937–944. https://doi.org/10.1097/00004583-200108000-00016 Crossref Medline, Google Scholar
- (2011). Race is not neutral: A national investigation of African American and Latino disproportionality in school discipline. School Psychology Review, 40(1), 85–107. https://doi.org/10.1080/02796015.2011.12087730 Crossref, Google Scholar
- (2018). Increasing access to care by delivering mental health services in schools: The school-based support program. School Community Journal, 28(1), 129–144. Google Scholar
- (2016). Culturally relevant diagnosis and assessment of mental illness. In Breland-Noble A., , Al-Mateen C. S., , & Singh N. N. (Eds.), Handbook of mental health in African American youth (pp. 21–35). Springer International Publishing/Springer Nature. https://doi.org/10.1007/978-3-319-25501-9_2 Crossref, Google Scholar
- (2013). Assessing anxiety in youth with the multidimensional anxiety scale for children. Journal of Clinical Child and Adolescent Psychology, 43(4), 566–578. https://doi.org/10.1080/15374416.2013.814541 Crossref Medline, Google Scholar
- (2016). The aetiology and maintenance of social anxiety disorder: A synthesis of complimentary theoretical models and formulation of a new integrated model. Journal of Affective Disorders, 203, 84–100. https://doi.org/10.1016/j.jad.2016.05.069 Crossref Medline, Google Scholar
