FACULTY OF SOCIAL AND BEHAVIORAL SCIENCES Graduate School of Childhood Development and Education
Put to The Blush:
The Development of Blushing in Children at Risk for Social Anxiety Disorder
Name: Veerle van Winkoop
Address: Wagenaarstraat 145, 1093CN City: Amsterdam
Phone number: 06-53295470 Student number: 10205039
Email address: veerleming@gmail.com
Subject: Development of blushing in children at risk for social anxiety. Start: January 2017
Abstract
Blushing seems to be the hallmark of social anxiety but has only recently been related to social anxiety disorder (SAD). This study examined blushing and social anxiety in 4.5 and 7.5-year-old children with a high and low risk for SAD. Physiological blushing was studied at 4.5 and 7.5 years in relation to risk level. Second, the relation between blushing and social anxiety at 7.5 years was studied, with and without controlling for blushing at 4.5 years. Blushing was measured during multiple stages of a socially stressful task (the child sang a song in front of an audience). Social anxiety of the child was reported through questionnaires and the level of risk was based on parental SAD. Results showed that children with a risk for SAD did not blush more intense than children with a low risk for SAD. Also, children who blushed more intense at 7.5 years did not have more social anxiety than children who blushed less intense. Moreover, intense blushing at 7.5 years was (at trend level) related to less self-reported social anxiety when controlled for blushing at 4.5 years. It could be that socially anxious children show an increase in blushing at another moment in their development.
Abstract
Blozen wordt aangenomen als kenmerk van sociale angst maar is pas recentelijk gerelateerd aan sociale angststoornis (SA). Deze studie onderzocht bloosreacties en sociale angst in 4.5 en 7.5 jaar oude kinderen met een hoog of laag risico op SA. Fysiologische bloosreacties van 4.5 en 7.5 jaar oude kinderen bestudeerd in relatie tot risiconiveau.
Daarnaast zijn bloosreacties bestudeerd in relatie tot sociale angst bij 7.5 jaar oude kinderen, met en zonder corrigeren voor bloosreacties op 4.5-jarige leeftijd. De bloosreacties zijn gemeten tijdens verschillende fasen van een sociaal stressvolle taak (het kind zong een liedje voor een publiek). Sociale angst van het kind werd gerapporteerd middels vragenlijsten en risicogroepen zijn gebaseerd op ouderlijke SA. Resultaten lieten zien dat kinderen uit hoge risicogroepen niet intenser bloosden dan kinderen uit de lage risicogroep. Daarnaast is gevonden dat kinderen die intenser bloosden op 7.5-jarige leeftijd niet meer sociale angst hadden dan kinderen die minder intens bloosden. Tegen verwachtingen in werd er een trend gevonden voor intens blozen op 7.5-jarige leeftijd en minder zelf gerapporteerde sociale angst wanneer er werd gecorrigeerd voor bloosreacties op 4.5-jarige leeftijd. Mogelijk laten sociaal angstige kinderen op een ander moment in hun ontwikkeling een toename in blozen zien.
Put to The Blush: The Development of Blushing in Children at Risk for Social Anxiety Disorder
Blushing is a human response as old as mankind, but what does a blush actually mean (Karch, 1971)? In The Bible, Jeremiah blushes out of shame, though according to
Shakespeare blushing represents embarrassment and sexual arousal (Karch, 1971). In science, blush responses have been studied over decades and are related to self-consciousness and emotions like shame and embarrassment (Leary, Britt, Cutlip, & Templeton, 1992). The social-emotional and physiological aspects of blushing make it a complex characteristic. According to the existing literature, the fear of blushing belongs in the spectrum of anxiety, but it is only since the DSM-5 that blushing has been related to social anxiety disorder (SAD) (American Psychiatric Association, 2013; Pelissolo, Moukheiber, Lobjoie, Valla, & Lambrey, 2012). Now that blushing has been introduced to the DSM-5 (Bögels, et a., 2010) and is considered a physiological symptom of a mental disorder, research is needed to determine whether blushing is a risk factor for the development of SAD in childhood.
The Physiology of Blushing
The definition of a blush entails the sudden reddening of the face due to an
emotionally charged situation (Drummond, 2012). It is an involuntary response caused by the accumulation of red blood cells in the cheeks or neck. The blood vessels in the facial area are connected to the skin and the sensory nerves of the eyes, mouth and nose. The sympathetic and parasympathetic reflexes driven by these sensory nerves all have an impact on facial blood flow and thus blushing. Hormones and neurotransmitters released by emotions cause the start of a blush response (Drummond, 2012).
The accumulation of blood cells in the cheeks due to blushing can be measured in multiple ways (Shearn, Bergman, Abel, & Hinds, 1990). First, there are changes in blood flow and volume, namely blood volume pulse and blood volume (Allen, 2007). Blood volume pulse is also called the alternating current (AC). Variations in AC most likely depend on the heart rate and on vessel dilation. Blood volume is known as the direct current (DC) and represents the average level of blood in the cheeks. DC is related to the average blood volume and type of tissue the blood flows through. DC varies more slowly than AC due to vasomotor and vasoconstrictor activity (Allen, 2007). Blood volume and blood volume pulse are often measured with photoplethysmography (e.g., Allen, 2007; Nikolić, Colonnesi, de Vente, & Bögels, 2016). Increases in DC and AC implicate a blush response.
Second, blushing can be measured with temperature sensors on the cheeks (Nikolić, de Vente, Colonnesi, & Bögels, 2016). Due to the widened veins and accumulation of blood cells in the cheeks the peripheral temperature increases. Temperature increases and AC reactivity are found to be correlated in one study, in which no correlations were found between AC and DC (Nikolić, Colonnesi, et al., 2016). These three physiological measures reflect a blush response.
The Nature of Blushing
In order to be able to blush, a sense of self-consciousness is needed (Leary, et al., 1992). Self-consciousness is a state of mind where one takes the perspective of others and looks at him- or herself (Crozier, 2004). It is assumed that self-conscious emotions start developing at the age of 2, since certain social cognitive skills are needed to reach this state of mind (Buss, Iscoe, & Buss, 1979; Colonnesi, Engelhard, & Bögels, 2010). At this age, self-consciousness refers to a sense of self and emotions like empathy and non-evaluative embarrassment (Lewis, 1995). From 3 years old, children start developing a sense of expectations, strive for goals and start to understand social rules. Also, children develop an understanding of evaluations (Lewis, 1995). From that moment on, the more complex self-conscious emotions like shame, embarrassment and guilt develop and children have the capacity to internally self-evaluate and show negative evaluative affect (Colonnesi, et al., 2010; Lewis, 1995). At least from 4.5 years old, blushing provoked by self-conscious emotions is seen in children (Nikolić, Colonnesi, et al., 2016).Younger children have, however, not been studied yet.
The development of self-conscious emotions is not complete at preschool age, though (Stegge, 2013). Older children, between 6 and 9 years old, show more embarrassment in social situations experienced as negative than younger children, between 4 and 5 years old (Colonnesi, et al., 2010). Also, older children have more developed social cognition than younger children (Dumontheil, 2016). In a study of Bennett and Gillingham (1991), younger children (5-year-olds) only reported self-conscious emotions related to a socially negative context, whereas older children attributed self-conscious emotions to a wider range of contexts, like to negative and positive social situations as well as to supportive reactions. As children grow older, the further developed self-reflection and complex representation skills allow for higher levels of self-consciousness and interpersonal understanding (Stegge, 2013).
Whether the development of self-consciousness and interpersonal understanding is accompanied by an increase in blushing frequency or intensity is unstudied. Changes in
frequency of blushing as a result of aging have been reported, though (Shields, Mallory, & Simon, 1990). Teenagers, who stated they first blushed when they were 5 years old, have reported an increase in blush frequencies over the years. Also the intensities of the blushes increased over the years according to reports of teens between 13 and 18 years old. It seems blushing changes with maturation and that an increase from early childhood to young
adulthood is present (Shields, et al., 1990). If and in what way blushing is related to the social anxiety of children is still not clear.
Blushing and Social Anxiety
The self-conscious emotions that elicit blushing are usually provoked by undesired social exposure. For example, accusations of blushing can elicit embarrassment and provoke and intensify a blush response, as well as when certain dishonest motives are unveiled (Crozier, 2001; Leary, et al., 1992). Even though blushing can appear in a positive social situation, for example when praised or feeling proud, most people experience it as awkward and fear blushing (Leary, et al., 1992; Pelissolo et al., 2012). The unpleasant and awkward feeling arises from the anxiety to be evaluated negatively by others (Glashouwer, De Jong, Dijk, & Buwalda, 2011).
The fear to be negatively evaluated is a specific characteristic of socially anxious individuals (Johnson, & Anderson, 2014). Individuals with social anxiety perceive social interactions more negatively, have a more negative self-image regarding social skills and frequently avoid social situations (Heimberg, Brozovich, & Rapee, 2010). They are more self-conscious and experience more self-self-conscious emotions (Dijk, Jong, & Peters, 2015; Nikolić, Colonnesi, de Vente, Drummond, & Bögels, 2015). Also, the heightened self-awareness and focus on negative introspective cues makes these individuals more aware of their blushing (Dijk, Voncken, & de Jong, 2009). Therefore, socially anxious children are more prone to blush (Drummond, & Su, 2012). On the other hand, blushing could be a precursor of social anxiety. The dysfunctional thoughts that may rise from the discomfort of blushing may lead to fear of blushing, avoidance of social interactions and social situations and eventually to social anxiety (Bögels et al., 2010). Also, children at risk for social anxiety show autonomic hyper arousal, like blushing, as early as in early childhood (Nikolić, de Vente, et al., 2016).
The role of physiological blushing in social anxiety has only been investigated in a high risk sample of 4.5-year-old children. The level of risk of the children for the
development of SAD was based on parental SAD status, meaning the high risk children had at least one parent with lifetime SAD and the low risk children had no parents with lifetime
SAD (Nikolić, de Vente, et al., 2016). In these children, high levels of social anxiety were related to a more intense blush response. Also, children of parents with lifetime SAD
produced more intense blush responses than children of parents without SAD. Both blushing and parental SAD are seen as important risk factors in developing and maintaining social anxiety in children (Bögels & Lamers, 2002; Nikolić, de Vente, et al., 2016).
Social anxiety is characterized by an increase in symptoms from early childhood to adolescence (Nelemans et al., 2014; Weems & Costa, 2005). Specifically blushing is seen more in older children with social anxiety traits (Younger, Schneider, & Guirguis-Younger, 2008). Younger et al., 2008 reported in their study on characteristics of shy and socially withdrawn children from the first grade until the seventh grade. Children from the first grade did not use ‘blushing’ to characterize shy and socially withdrawn classmates. However, third graders used ‘blushing’ a few times and fifth and seventh graders used ‘blushing’ even more to describe shy and socially withdrawn children. This suggests that blushing becomes a more dominant symptom of social anxiety as children mature and blushing as a symptom of social anxiety seems to peak in adolescence (Abe & Suzuki, 1986). Even though the precise role of blushing in the development of social anxiety has not been studied widely, it seems blushing and social anxiety interact and reinforce one another.
This Study
In the present study, blush responses were studied in 4.5- and 7.5-year-old children with high or low risks for developing SAD. Whether children were at risk for SAD was based on parental SAD status. Since SAD is usually diagnosed in adolescence or later on in life, studying risk factors that are present in early childhood like blushing, social anxiety and parental SAD, could help prevent the development of the disorder and its negative behavioral outcomes like avoidance of cognitive challenges and low academic achievements (Brook & Willoughby, 2015; Hearn, Donovan, Spence, & March, 2017). Also, social anxiety disorder is highly comorbid with depression (McLaughlin & King, 2015) and can lead to social isolation (Teo, Lerrigo, & Rogers, 2013), difficulties in emotion regulation (Farmer & Kashdan, 2012), and the use of cigarettes, alcohol and cannabis (Buckner, Schmidt, Bobadilla, & Taylor, 2006; Zehe, Colder, Read, Wieczorek, & Lengua, 2013). Physiological blush responses have not yet been studied in 7.5-year-old-children with a high risk of developing SAD. Investigating physiological mechanisms of blushing in relation to social anxiety in a high risk sample will contribute to a clear view on the pathway to SAD. Therefore, physiological blush responses were studied in high and low risk children when they were 4.5-years and when they were
7.5-years. It was hypothesized that children with high risks for SAD (one or two parents with SAD) blushed more intense than children with low risks for SAD (no parents with SAD). Also, in the high risk group, it was expected that children of two parents with SAD blushed more intensely than children of only one parent with SAD, since the former children had the highest risk for SAD (Merikangas, Avenevoli, Dierker, & Grillon, 1999). Both hypothesis count for when the children were 4.5-years and when they were 7.5-years. Secondly, to clarify the development of blushing in relation to social anxiety symptoms (SAS) of children
throughout childhood, the relation between blush responses and SAS at 7.5 year were studied, with and without controlling for blush responses at 4.5 year. It was hypothesized that SAS and blushing are positively related in 7.5-year-old children, even after controlling for blushing at 4.5 years old. It was expected that blushing becomes more related to SAS of the child because blushing becomes a more dominant symptom of social anxiety when children mature
Method Sample
To conduct the present study, available data from a longitudinal study on social
development conducted at the University of Amsterdam (UvA) was used (Nikolić, Colonnesi, et al., 2016). During the longitudinal study, children and their parents were followed from birth until the child was 7.5 years old in five assessments. For this study, data of the fourth and fifth assessment was used. The sample consisted of children (N=107, 53 boys, 48.2 %) and both their parents (mothers N=107, fathers N=107) who came by the UvA Family lab at 4.5 years (M=4.44, SD=0.63) and at 7.5 years old (M=7.54, SD=0.18). The parents were recruited during the mothers’ first pregnancy through flyers provided by midwives in
Amsterdam and in cities within 50 km from Amsterdam, at baby shops within this range and at pregnancy courses. The study was also advertised nationally in magazines and on
parenthood websites. Parent had to master either the Dutch or English language to participate. The ethics review board FMG-UvA approved the study. Parents were compromised with voucher and the children with age appropriate gifts.
Design and Procedure
At 4.5 and 7.5 years old children came by the family lab at the UvA for two
assessments. The child’s SAS’s were measured at both assessments, at 4.5 years old by the parents, and at 7.5 years old by the parents and the child. Both parents were interviewed to determine if either one had been diagnosed with SAD since the birth of the child. Besides the diagnosis of SAD between 0 and 4.5 years old, past diagnoses of SAD were reported for both parents when the mothers were pregnant. The past and present SAD diagnoses were combined into a lifetime diagnose. To provoke the child’s blushing, children took part in two socially stressful tasks (more tasks were administered, but those were not relevant for this study), namely a social performance and watching back the social performance.
First, at 4.5 years old, the children performed a song of their own choice in front of their father, the test leader and a camera woman. Second, they watched back the performance afterwards. The child was given the opportunity to dress up and was introduced on stage as a pop star. Blushing was measured during baseline (2 minutes), performance (aimed for around 60 seconds), a recovery phase (2 minutes) and watching back the performance (duration of performance). After the baseline, during which the child sat on a podium, the test leader introduced the child to the audience and the child performed. After the performance, the child sat on the podium again to watch back the performance video. When the child was 7.5 years
old, the family returned to the lab for the next assessment. The child performed again, though this time without dressing up. In the audience were the father of the child, a camera woman to film the performance and the test leader. A stranger came into the room to watch back the performance. She gave excessive compliments after watching back the performance with the child and the rest of the audience. Blushing was measured during the baseline (2 minutes), performance (aimed for <60 seconds), a recovery phase (2 minutes), watching back the performance (duration of performance) and the excessive compliments. For this study only the blush data from the performance, recovery phase and watching back the performance was used to keep the blush measures of both assessments consistent. Both assessments took around 1.5 hours. Parents filled in informed consents.
Measures
Blush Response. At both assessments, blushing was measured through temperature,
blood volume, and blood volume pulse in the cheeks (Nikolić, de Vente, et al., 2016). Temperature was measured unilaterally by a platinum PT1000 temperature sensor on the child’s cheek attached close to the infrared probe of the plethysmograph transducer. Signals were transformed into data and analyzed using Vsrrp98 software (Molenkamp, 2011). Blood volume and blood volume pulse were measured through an infrared-reflective
photoplethysmograph transducer that reported AC and DC reactivity. AC signals represented blood volume pulse amplitude (0.5 Hz, 36 dB/oct) and the DC signals reported the blood volume (0.75 Hz, 12 dB/oct). Both signals were converted into arbitrary values between 0 and 65535. To prevent skin characteristics from influencing the data, relative scores were
computed, representing the relative increase of blushing during the performance and watching back the performance as compared to baseline in percentage (Drummond et al., 2007). These relative AC, DC and temperature scores were used in the analyses.
Child’s Social Anxiety Symptoms. The Social Anxiety Subscale of the Preschool
Anxiety Scale Revised was used to measure SAS at 4.5 years old (PAS-R; Edwards, Rapee, Kennedy, & Spence, 2010). The Social anxiety subscale consisted of 7 items, for example ‘My child is afraid to go up to a group of children to join their activities’, ‘Worries that he/she will do something to look stupid in front of other people’ and ‘Is afraid of meeting or talking to unfamiliar people’. Every item is rated by the parent on a scale from 0 = not at all true to 5 = very often true. The subscale had good internal consistency with a Cronbach’s Alpha of .92 for the total scale and .89 for the social anxiety scale (Edwards et al., 2010). The mothers and fathers scores were correlated (r= .50) and therefore were averaged into a composite score,
the parental PAS-R score. The reliability of the subscale in this sample was good with a Cronbach’s alpha of .90. The joint PAS-R score was created by standardizing the scores of the father and mother and computing the average score. The joint PAS-R score was used for the analyses.
The Dutch revised version of the Screen for Child Anxiety Related Emotional Disorders-71 was used to measure SAS at 7.5 years old (SCARED-71; Bodden, Bögels, & Muris, 2009). The Social Phobia subscale of the SCARED-71 consisted of 9 items. The 9 items contain anxiety symptoms on interaction with unfamiliar and familiar people. The parents filled in how frequent the child experienced the anxiety symptoms with the help of a 3-point Likert scale, with 0= almost never, 1= sometimes and 2= often. In the general
population, the social anxiety scale had a Cronbach’s Alpha of .91 for mothers and .89 for fathers (Bodden et al., 2009). Mothers and fathers scores in this sample were correlated (r= .64) and therefore were averaged in a composite score, the parental SCARED-71 score. The reliability of the scale in this sample was good, with a Cronbach’s alpha of .90. The composite score was created by standardizing the scores of the father and mother and computing them together. The joint SCARED-71 score was used for the analyses.
Finally, The Picture Anxiety Test (PAT; Dubi & Schneider, 2009) was used to
measure SAS from the child’s perspective. The social anxiety scale of the PAT consisted of 3 pictures relevant for social anxiety, which was adequate for the age of our sample of children. The total score for the three pictures, ranging from 0 to 2, was used for the analyses.
Reliability of the complete PAT (17 pictures) in the general population is good, with a Cronbach’s Alpha of .78 (Dubi & Schneider, 2009). The specific social anxiety scale in this sample had an acceptable reliability with a Cronbach’s Alpha of .65.
Parent’s Social Anxiety Disorder. To measure the presence of SAD, the Anxiety
Diagnostic Interview Schedule for adults was administered (ADIS-A; Brown, Barlow, & Di Nardo, 1994). This semi structured interview is qualified to diagnose different anxiety
disorders and was conducted twice by experienced interviewers. First during the pregnancy of the mother to determine past diagnoses and for the second time when the child was 4.5 years old to determine a present diagnosis or diagnose between pregnancy and 4.5 years. The two diagnoses were combined into a lifetime SAD status. The ADIS Clinician Severity Scale is a 9-point scale used to determine the severity of the diagnoses, going from 0 ’not at all’ clinical to 8 ‘very, very much’ clinical. When parents had a score of 4 or higher, the diagnosis was considered clinical SAD. The inter-interview agreement for the SAD status was high (95% to 100%). The clinical SAD status was used to form three groups. The first group consisted of
children without parents with SAD, the second group of children with one parent with SAD and the third group of children with two parents with SAD. These three groups were used in the analyses.
Data-analyses
Preliminary analysis. To inspect the characteristics of the data a preliminary analysis
was conducted. Patterns in the missing data were inspected as well as missing values on the independent variables in relation to the dependent variables. General characteristics like means, medians, skewness and kurtosis were analyzed by creating frequency and descriptive tables. Correlations between variables used for the analyses and group differences based on gender were inspected. Normality of the variables was checked by inspecting histograms with displayed normal distribution and the standardized skewness. Variables were seen as nonnormally distributed when the standardized skewness was higher than 3.29 or lower than -3.29 (Field, 2013). The data was inspected in boxplots and seen as outliers when values were higher or lower than 3 standard deviations away from the mean value (Howell, 1998).
Variables with outliers were winsorized, which entails that outliers take the highest or lowest value within the normal range of the variable (Shete et al., 2004). Analyses were repeated with and without outliers to check if the results were similar.
Statistical analyses. For the first research question, physiological blush responses of
the 4.5 and 7.5-year-old children were studied in the high and low risk groups. To test the first research question, a series of 3 repeated measure ANOVA analyses were performed for blood volume, blood volume pulse and blush temperature of the child at 4.5 years old during
performance, recovery and watch back, all relative to baseline, as dependent variables and risk level for the development of SAD as independent variable. Another 3 repeated measure ANOVA analyses were performed for blood volume, blood volume pulse and blush
temperature of the child at 7.5 years old during performance, recovery and watch back as dependent variables and SAD status of the parents as independent variable. In the total of 6 repeated measure ANOVA’s, the phase (performance, recovery and watch back) served as a repeated within factor and risk level based on parental SAD served as the between factor. For the first part of the second question, the relation between blush responses and SAS at 7.5 year were studied. A series of 3 repeated measure ANOVA’s were performed for blood volume, blood volume pulse and blush temperature of the child at 7.5 years old during performance, recovery and watch back as dependent variables and SAS reported by the parents as
blood volume, blood volume pulse and blush temperature of the child at 7.5 years old during performance, recovery and watch back as dependent variables and SAS reported by the child as independent variable. For the second part of the second research question, the relation between blush responses and SAS at 7.5 year were studied taking blush responses at 4.5 year into account. A series of partial correlations showed if the relation blood volume, blood volume pulse and blush temperature at 7.5 years old during performance, recovery and watch back and SAS scores of the child at 7.5 years old (reported by child and parents) had
additional explained variance after controlling for blush measures at 4.5 years old. It was not possible to perform repeated measure ANOVA’s for the last analysis, since the controlling variables, blush responses at 4.5 years old, were also repeated measures and changed with phase. A variable that changes with phase can not be a covariate in a repeated measure ANOVA (Fan & Zhang, 2017). In all analyses an alpha level of .05 was used to test significance, unless stated differently. Bonferroni corrections were made in the post-hoc analyses of all repeated measure ANOVA’s to correct for multiple testing.
Results Preliminary analysis
To inspect characteristics of the data, a preliminary analysis was conducted. First, a missing value analysis was performed. Of all the data, 55% was missing. The Little’s MCAR test was not significant, χ2(390, N=107) =394.87, p=.422, meaning the data was missing at random and no missing patterns in the data were found. To see if missing scores on blush measures at 4.5 and 7.5 years old were related to higher social anxiety, missing data on blush scores was either labeled as ‘missing due to not performing’ or ‘missing due to electrode failure’ and children with and without missing data were compared. Missing data due to a missing performance of the child at 7.5 years old was related to higher social anxiety at 7.5 years old reported by the parents, t(77)=2.71, p=.008, but not to higher social anxiety at 7.5 years old reported by the child itself t(69)=-.08, p=.940. Missing data due to a missing performance of the child at 4.5 years old was not related to higher social anxiety reported by the parents at 4.5 and 7.5 years. A trend was found, though, for missing blush data at 4.5 due to the child not performing and higher social anxiety reported by the child at 7.5 years old, t(69)=1.82, p=.072. Of the 107 participating parents, six fathers and one mother failed to complete the ADIS-A interview, resulting in six missing combined lifetime SAD diagnoses. Three groups were formed based on parental SAD status and used for the analyses. The first group consisted of children without parents with SAD (N=27), the second group of children with one parent with SAD (N=35) and the third group of children with two parents with SAD (N=39). From the 107 participating children, 55 children had complete blush data at 4.5 years and 71 children at 7.5 years. General characteristics of ordinal data and continuous data (Table 1) were inspected. Group differences based on gender were found on relative blood volume pulse levels during the recovery phase at 4.5 years old, t(53)=2.25, p=.029. Boys had a higher blood volume pulse during the recovery phase than girls. Also a trend was found for a gender based group difference in self -reported social anxiety at 7.5 years old, t(78)=-1.83, p=.072, girls reported more social anxiety than boys. The PAS-R was significantly correlated with the PAT and SCARED-71. Between the PAT and SCARED-71 scores a positive trend was found. Correlations between all variables are shown in Table 2. Variables that were non-normally distributed and had a standardized skewness higher than 3.29 or lower than -3.29 were log-transformed. Log-transformations improved normality adequately for all skewed variables. After the log-transformation, outliers were detected. To keep participants with outliers in the sample, variables with outliers (regular or log-transformed) were winsorized.
Primary analyses were conducted with the regular variables. If conducting the analyses with the winsorized variables made a significant difference, this was noted.
Blush Responses in High and Low Risk Children
To answer the first research question, blush responses of children at 4.5 and 7.5 years old were studied in the high and low risk groups. The results showed that, at 4.5 years old, a trend was found and blush responses of the children seemed to differ between the three groups, but only for blood volume as a measure (see Table 3). However, post-hoc Bonferroni tests showed the three groups did not differ significantly in their relative blood volume scores during the performance, recovery or watch back phase (see Figure 1). Also, when conducting the analyses with the winsorized variables, the trend effect for blood volume disappeared, F(4,58)=1.78, p=.145.
Secondly, blushing of the child was studied at 7.5 years old. The results showed that at 7.5 years old, blush responses of the children did not differ significantly between the three groups (see Table 4). The analyses were also conducted with the winsorized variables, but this did not change the results for children at 7.5 years old.
Blushing in Relation to the Child’s SAS
To answer the second question, blushing of the child was studied in relation to their SAS at 7.5 years old. For the primary analyses, blushing of the child was studied in relation to their SAS at 7.5 years old by conducting repeated measure ANOVA’s. These analyses
showed no significant results, meaning that in this sample, blushing at 7.5 of the child was not related to their SAS reported by their parents or themselves (see Table 5 and Table 6).
Conducting the repeated measure ANOVA’s with the winsorized variables did not change these results.
Second, the relation between blood volume, blood volume pulse and blush
temperature at 7.5 years old during performance, recovery and watch back and SAS of the child was analyzed controlling for blushing at 4.5 years. As shown in Table 7, blushing of the child at 7.5 years old was negatively correlated to social anxiety reported by the child after controlling for blushing at 4.5 years old, but only when looking at blood volume during the performance. The result was marginally significant. Against expectations, these results indicated that children with a higher blood volume during their performance reported less SAS, after controlling for their blood volume at 4.5, which means that the expected increase
in blushing as a symptom of social anxiety did not occur between 4.5 and 7.5 years old. Conducting the partial correlations with the winsorized variables did not change these results.
Discussion
The aim of the present study was to clarify the relation between blushing and social anxiety in a sample at risk for SAD. Therefore, blush responses and social anxiety were studied in 4.5 and 7.5-year-old children with a high or low risk for developing SAD. The main results showed that children with a high risk for developing SAD did not blush more intense than children with a low risk for developing SAD. Also, children with more intense blush responses at 7.5 years old did not have higher levels of social anxiety than children with less intense blush responses. Though, against expectations, more intense blushing was marginally related to lower self-reported social anxiety when blushing at 4.5 years old was taken into account. This indicates that more social anxiety is associated with a slight decrease in
blushing between 4.5 and 7.5 years old. It could be that the socially anxious children show an increase in blushing at another moment in their development.
The first results showed the three groups of children did not differ in their blush responses at 4.5 and 7.5 years old and the first hypothesis was rejected. These results are not in line with the results of a previous study that used the same sample of children as this study and found that parents with lifetime SAD had children who blushed more than children of parents without SAD (Nikolić, Colonnesi, et al., 2016). Alternatively, the absence of the relation in this sample could be due to the formation of three groups instead of two groups based on parental SAD status. Due to the large percentage of missing blush data, group sizes based on parental SAD status could vary from six to 27, leading to a lack of power to detect a small effect (Field, 2005).
Second, the results showed that, without controlling for blushing at 4.5 years old, children who blushed more intense at 7.5 years old did not have more social anxiety than children blushed less intense, meaning this hypothesis was also rejected. This was not in line with the expectation that blushing becomes a more dominant symptom of social anxiety as children mature (Abe & Suzuki, 1986; Younger et al., 2008). A reason that these findings are not in line with the existing literature could lie in the blush measurements used in this study. Previous studies found a strong relation between social anxiety and self-perceived blushing, but only a small relation for social anxiety and physiological blushing (Nikolić et al., 2015). Again, a lack of power due to a large percentage of missing data might be the reason that a small effect was not detected (Field, 2005).
When looking at the relation between blushing at 7.5 years old and social anxiety controlling for blushing at 4.5 years old, an unexpected result was found. Against the
7.5 years controlled for blushing at 4.5 years reported less social anxiety (self-report). Therefore, this hypothesis was also rejected. As a previous study showed, the relation between blushing and social anxiety can be moderated by positive and negative shyness (Nikolić, Colonnesi, et al., 2016). Children who blush more and show negative shyness (an unsuccessful coping mechanism in fearful situations) tend to be more socially anxious. On the other hand, children who blush more and show positive shyness (an adaptive mechanism in social situations) tend to be less socially anxious. An explanation for the unexpected result in this study could be that the children who performed at both 4.5 and 7.5 years old and had no missing data were the children who showed positive shyness and less social anxiety. This is also in line with the finding that missing blush data was related to higher social anxiety of the child.
Interestingly, social anxiety and missing blush data were not only related at 7.5 years old. A trend was found for missing data at 4.5 years old due to not performing the social task and higher self-reported social anxiety at 7.5 years old. This implicated that children who were too anxious to do the socially stressful task at 4.5 developed more social anxiety at 7.5 years than the children that did do the socially stressful task. Another notable result was the trend that girls reported more social anxiety than boys at 7.5 years old. This is in line with the existing literature which states that girls are more capable to form and maintain intimate friendships, but also experience greater social anxiety due to rejection in those friendships (MacKinaw-Koons & Vasey, 2000). There have not been studies that reported on this gender difference in children as young as 7.5 years old (social anxiety mostly develops in
adolescence) (Lu et al., 2015), so this study is the first to present this outcome.
Several limitations of the present study need to be addressed. First of all, the lifetime SAD diagnoses of the parents were based on SAD diagnoses until the child was 4.5 years. This means that parents who were diagnosed with SAD between the 4.5 and 7.5 years old assessment still had the label ‘no SAD’ when the children were 7.5 years old. Therefore, it could have been that the groups of children based on parental SAD formed at 7.5 years old were somewhat less reliable and children unfairly received the label ‘no parental SAD’. Secondly, the sample consisted mostly of Dutch participants (more than 90% of the parents) that were highly educated and had relatively good incomes (most parents had a salary higher than 2000 euro) (De Vente, Majdandzic, Colonnesi, & Bogels, 2011). This means the
socioeconomic status of the sample was fairly high and the results can not be broadly
generalized. Another limitation entails a form of selection bias (Pannucci & Wilkins, 2010). It seemed that children who refused to participate in the socially stressful task had somewhat
higher social anxiety. This led to missing knowledge on blush responses of the group the highest on the spectrum of social anxiety and as a consequence, to an underestimation of the predicted differences and associations.
Besides its limitations, this study also had several strong points. First, the studied relations have not yet been examined in children of 7.5 years old and therefore this study provides new information in the field. Blushing has only recently been related to SAD and included in the DSM-5 as a symptom of SAD, so it should be studied widely (American Psychiatric Association, 2013). Also, previous studies did not look at the difference between children with one parent with SAD and children with two parents with SAD in relation to blushing, while it is clear that children of two parents with SAD are at a higher risk (Cooper & Murray, 2008; Merikangas, et al., 1999).
Future studies should address the relations between social anxiety and different
measures of blushing, since the literature implies there is an inconsistent relationship between these concepts. Physiological blushing, observed blushing and self-perceived blushing all relate different to SAS. By addressing al these aspects of blushing in one study, it will be clear which aspects is the most predictive of social anxiety. Another suggestion is to continue the longitudinal studies into blushing to capture the different developmental periods for blushing in social anxiety. This study indicated there was no increase in blushing between 4.5 and 7.5 years old. Though, it could be blushing in socially anxious children only starts to increase close to puberty (Abe & Suzuki, 1986). On a more clinical level, studying social anxiety in young children could help in the prevention of SAD and its negative outcomes like insecurity, being intolerant for uncertainty, avoiding cognitive challenges and having low academic achievements (Brook & Willoughby, 2015; Hearn, Donovan, Spence, & March, 2017). More knowledge on the precursors of social anxiety in education together with more focus on these precursors in upbringing could help prevent the negative developmental outcomes of social anxiety.
Concluding, this study contributes knowledge to the existing body of literature on blushing and social anxiety development in childhood. It indicated that in childhood, children at high or low risk for SAD development did not differ in their blush intensity. Also,
increased blush intensity was found not to be related to social anxiety in children. Moreover, this study provides the first indication that blushing might decrease in socially anxious children between the age of 4.5 and 7.5 years. Blushing seems to be a human characteristic that is more complex than just reddening of the face and further research has to explore its development in socially anxious children.
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Table 1. Descriptives.
Variable N Mean Std.
Dev.
SAD of the parent ADIS-A 101 1.12 .80
SAS of the child reported by parents PAS-R 107 5.00 .87 at 4.5 years
SAS of the child reported by parents SCARED-71 97 -.01 .93
at 7.5 years reported by child PAT 82 .67 .61
Blushing of the child Blood volume pulse
Performance
55 .26 .11
at 4.5 years Recovery 55 .49 .16
Watch back 45 .22 .08
Blood volume Performance 41 .26 .06
Recovery 42 .52 .08
Watch back 34 .27 .03
Temperature Performance 57 .25 .01
Recovery 53 .50 .02
Watch back 45 .25 .01
Blushing of the child Blood volume pulse
Performance
71 .58 .62
at 7.5 years Recovery 70 1.84 1.51
Watch back 69 .67 .73
Blood volume Performance 69 .27 .11
Recovery 69 1.17 .44
Watch back 67 .33 .11
Temperature Performance 71 .25 .01
Recovery 70 1.02 .02
Table 2. Pearson Correlations for All Variables.
1 2 3 4 5 6 7 8 9 10 11
1. SAD parents -
2. SASa reported by parents -.19† -
3. SASb reported by parents -.18† .69** -
4. SASb reported by child -.15 .31** .26* -
5. AC performancea .10 .17 .21 .16 - 6. AC recoverya -.01 .09 .08 -.08 .41** - 7. AC watch backa .05 .07 -.19 -.01 .40** .48** - 8. DC performancea -.11 -.16 -.20 -.06 .07 .09 .21 - 9. DC recoverya -.44** -.05 -.08 .23 -.21 .01 .23 .28† - 10. DC watch backa -.31† -.12 -.18 .33 .06 .25 .15 .20 .64** - 11. Temperature performancea .02 .24† .32* .25 .20 .02 .01 -.10 -.16 -.02 - 12. Temperature recoverya -.21 .30* .34* .27 .28 .03 .08 -.01 .16 .04 .79**
13. Temperature watch backa .04 .39** .49** .06 .21 .12 -.06 -.12 -.18 .00 .80**
14. AC performanceb .08 .03 .13 .11 -.13 -.09 -.21 -.09 -.18 -.08 -.06 15. AC recoveryb .02 -.05 .04 -.17 -.13 -.16 -.18 -.03 -.17 -.08 -.02 16. AC watch backb .06 .03 .10 .07 -.12 -.16 -.22 -.07 -.17 -.17 -.01 17. DC performanceb -.17 -.08 .03 -.12 -.13 -.12 -.29 -.10 .05 -.24 -.10 18. DC recoveryb -.12 -.13 -.00 -.08 -.15 -.14 -.26 -.16 -.08 -.20 -.10 19. DC watch backb -.05 -.12 -.06 -.05 -.16 -.12 -.30 -.21 -.04 -.32 -.09 20. Temperature performanceb .13 .05 -.01 -.11 .33* .15 .38* .18 -.04 .36† .04 21. Temperature recoveryb .13 .13 .07 .02 .45** .23 .44* .21 -.11 .14 .11
22. Temperature watch backb .18 -.02 -.01 -.18 .47** .27† .50** .23 -.14 .06 .24
12 13 14 15 16 17 18 19 20 21 22
12. Temperature recoverya -
13. Temperature watch backa .75** -
14. AC performanceb -.06 -.09 - 15. AC recoveryb -.01 -.06 .88** - 16. AC watch backb -.01 -.08 .93** .91** - 17. DC performanceb -.16 .01 .50** .45** .50** - 18. DC recoveryb -.16 -.04 .63** .66** .70** .83** - 19. DC watch backb -.20 -.07 .52** .52** .57** .85** .88** - 20. Temperature performanceb .06 .15 .02 -.01 -.02 -.01 -.10 -.12 - 21. Temperature recoveryb .10 .19 -.06 -.12 -.10 -.21 -.19 -.24 .81** -
22. Temperature watch backb .14 .28 -.08 -.11 -.08 -.17 -.15 -.17 .73** .87** -
Note.
a.= at 4.5 years old b.= at 7.5 years old
†. Trend in correlation at the 0.1 level (2-tailed). *. Significant correlation at the 0.05 level (2-tailed). **. Significant correlation at the 0.01 level (2-tailed).
Table 3. Repeated Measure ANOVA’s for Blushing at 4.5 Years in High and Low Risk Groups.
Variables N Wilks’ Λ df error df F value sig. P. Eta Sq.
Blood volume pulsea 43 .89 4 78 1.25 .305 .06
Blood volumea 33 .77 4 58 2.07 .096† .13
Temperaturea 43 .97 4 78 .35 .844 .02
†. Trend in group difference at the 0.1 level (2-tailed). *. Significant group difference at the 0.05 level (2-tailed). a. During performance, recovery and watch back.
Table 4. Repeated Measure ANOVA for Blushing at 7.5 Years in High and Low Risk Groups. Variables N Wilks’ Λ df error df F value sig. P. Eta Sq.
Blood volume pulsea 66 .97 4 126 .46 .766 .02
Blood volumea 63 .90 4 118 1.68 .160 .05
Temperaturea 66 .91 4 124 1.50 .206 .05
†. Trend in group difference at the 0.1 level (2-tailed). *. Significant group difference at the 0.05 level (2-tailed). a. During performance, recovery and watch bac
Table 5. Repeated Measure ANOVA’s for Blushing at 7.5 Years and SAS Reported by Parents. Variables N Wilks’ Λ df error df F value sig. P. Eta Sq.
Blood volume pulsea 69 1.00 2 66 .04 ,962 .00
Blood volumea 66 .97 2 63 .96 ,389 .03
Temperaturea 69 1.00 2 66 .17 ,844 .01
†. Trend at the 0.1 level (2-tailed). *. Significant at the 0.05 level (2-tailed).
Table 6. Repeated Measure ANOVA for Blushing at 7.5 Years and SAS Reported by the Child. Variables N Wilks’ Λ df error df F value sig. P. Eta Sq.
Blood volume pulsea 62 .94 2 59 2.02 .141 .06
Blood volumea 59 .98 2 56 .66 .521 .02
Temperaturea 62 .97 2 59 .86 .430 .03
†. Trend at the 0.1 level (2-tailed). *. Significant at the 0.05 level (2-tailed).
Table 7. Partial Correlations for Blushing at 7.5 Years and SAS of the Child Controlling for Blushing at 4.5 Years Old.
SAS
Variable reported by child reported by parents
Blood volume pulse Performance -.01 .18
Recovery -.11 .09
Watch back -.10 .04
Blood volume Performance -.41† .01
Recovery -.09 .03
Watch back -.05 -.05
Temperature Performance -.09 -.04
Recovery -.25 -.15
Watch back .03 -.01
†. Trend at the 0.1 level (2-tailed). *. Significant at the 0.05 level (2-tailed).
Figure 1. Trend for the interaction between blood volume during the performance, recovery and watch back and risk level of the children.
