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MISS ALLISON ANNOTATED BIBLIOGRAPHY
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Running head: MISS ALLISON ANNOTATED
BIBLIOGRAPHY
Running head: MISS ALLISON ANNOTATED
BIBLIOGRAPHY
Miss Allison Annotated Bibliography
Miss Allison is a flight attendant with severe anxiety, which is
starting to affect her work. In this case, it is also known that
anxiety has been an issue since childhood resulting in failed
romantic relationships and sibling relationship disputes. With
this in mind, many aspects of this paper will review anxiety as a
whole, the symptoms to the behaviors displayed, anxiety as a
kid, to how the terrorist event of 9/11 affect her and other flight
attendants, treatments that may help improve her case and her
way of life.
Simpson, H. B. (2010). Anxiety Disorders: Theory, Research,
and Clinical Perspectives. Cambridge: Cambridge University
Press. Retrieved from
http://search.ebscohost.com.ezproxy1.apus.edu/login.aspx?direc
t=true&AuthType=ip&db=nlebk&AN=329351&site=ehost-

live&scope=site
This study serves as an introduction to the domain of anxiety. It
discusses the different types of anxiety. It also includes genetic
studies done to understand the disorder at hand. Which in Ms.
Allison’s case is the main point of focus.
Weeks, M., Coplan, R., & Kingsbury, A. (2009). The correlates
and consequences of early appearing social anxiety in young
children. Journal of Anxiety Disorders, 23(7), 965–
972. https://doi.org/10.1016/j.janxdis.2009.06.006
Because Ms. Allison had anxiety as a child, this article assists
in understanding the consequences of anxiety at such a young
age. A group of students between the age of 7 and 8 was
sampled in order to grasp the relation between the behavior of a
child with anxiety while in school versus a normal behavior.
Francis, S. E., & Noël, V. (2010). Parental contributions to
child anxiety sensitivity: a review and recommendations for
future directions. Child Psychiatry And Human Development,
41(6), 595–613. https://doi-
org.ezproxy2.apus.edu/10.1007/s10578-010-0190-5
In Ms. Allisson’s case, it is told that her relationship with her
father may not have been the best. This study is included as an
attempt to analyze whether or not the father’s behavior or her
mother may have been a reason behind her developing the
anxiety disorder. As a conclusion to this study, it was found
that more research was needed in order to have better findings.
Ekeberg, O., Fauske, B., & Berg-Hansen, B. (2014). Norwegian
airline passengers are not more afraid of flying after the terror
act of September 11. The flight anxiety, however, is
significantly attributed to acts of terrorism. Scandinavian
Journal Of Psychology, 55(5), 464–468. https://doi-
org.ezproxy1.apus.edu/10.1111/sjop.12137
This study is an attempt to understand flying after the
events of 9/11. In this research, the focus was to assess if flying

had been affected after the attack. Passengers of Norwegian
airlines were surveyed and asked about their level of anxiety,
whether they were afraid or not. With this study, it was found
that the level of flying anxiety after 9/11 was quite moderate.
Lating, J. M., Sherman, M. F., & Peragine, T. F. (2006). PTSD
Reactions and Coping Responses of American Airlines Flight
Attendants Who Were Former Employees of Trans World
Airlines: Further Support of a Psychological Contagion
Effect. Brief Treatment & Crisis Intervention, 6(2), 144–
153. https://doi-org.ezproxy1.apus.edu/10.1093/brief-
treatment/mhj016
This specific study is gear toward flight attendants of
the east and west coast. It had been set up to review PTSD
amongst both groups and analyze whether a group felt safer than
the other. It also goes into what kind of help, if any, is at the
disposal of the employees after such a tragedy. This article
helps to see the set of mid of other flight attendants besides Ms.
Allisson.
Kim, S., Palin, F., Anderson, P., Edwards, S., Lindner, G., &
Rothbaum, B. (2008). Use of skills learned in CBT for fear of
flying: Managing flying anxiety after September 11th. Journal
of Anxiety Disorders, 22(2), 301–
309. https://doi.org/10.1016/j.janxdis.2007.02.006
This article is introduced in the case as a treatment option for
Allison. One hundred fifteen participants were randomly
ascribed to and accomplished eight sessions of individual CBT
treatment for fear of flying. Once treatment was over, they were
assessed later in the year to see the progress. Results showed
that those who used the skills learned in treatment were less
likely to have an episode while flying.
Wiederhold, B. K., & Wiederhold, M. D. (2005). How treatment
is conducted at the virtual reality medical center. Virtual reality
therapy for anxiety disorders: Advances in evaluation and

treatment; virtual reality therapy for anxiety disorders:
Advances in evaluation and treatment. (pp. 47-62, Chapter viii,
225 Pages). Washington: American Psychological Association,
American Psychological Association, Washington, DC.
doi:http://dx.doi.org.ezproxy2.apus.edu/10.1037/10858-004
Retrieved from https://search-proquest-
com.ezproxy2.apus.edu/docview/614171731?accountid=8289
This subject is addressing a different type of treatment
offered to clients with anxiety while flying. It goes into how to
include virtual reality into clinical practice. It describes the
steps of using virtual reality graded exposure therapy to treat
patients. It also emphasizes the benefits that virtual reality
brings to the clinical arena. A short review of the session
structure is provided.
Bor, R., Kahr, B., & Zuckerman, J. (2004). Anxiety at 35,000
feet an introduction to clinical aerospace psychology. London;
Karnac.
It is a look at the future, what may be a plausible offer
to treat someone who is having anxiety while they are flying.
The issues they may encounter and what can be put in place to
help both passengers and crew in the event they are having a
crisis.
Journal of Anxiety Disorders 23 (2009) 965–972
The correlates and consequences of early appearing social
anxiety
in young children
Murray Weeks *, Robert J. Coplan *, Adam Kingsbury
Carleton University, Ottawa, Canada

A R T I C L E I N F O
Article history:
Received 19 December 2008
Received in revised form 10 June 2009
Accepted 11 June 2009
Keywords:
Social anxiety
Early childhood development
Social adjustment
Emotional adjustment
Teachers
A B S T R A C T
Social anxiety is the fear of social situations and being
negatively evaluated by others. Most previous
studies of childhood social anxiety have employed clinical
samples of children aged 10 years and older.
The current study explored the correlates of social anxiety in an
unselected sample of young children.
Participants were n = 178 elementary school children in grade 2
(aged 7–8 years). Children were

individually administered the Social Anxiety Scale for
Children-Revised (SASC-R), as well as measures of
socio-emotional adjustment. Teachers completed measures of
children’s socio-emotional problems and
school adjustment. Results indicated that social anxiety was
positively associated with self-reported
loneliness, school avoidance, and internalizing coping, and
negatively related to school liking. However,
social anxiety was mostly unrelated to teacher-rated outcomes.
Findings are discussed in terms of use of
the SASC-R for this type of population and reasons for the
disparity between child and teacher reports of
adjustment outcomes.
� 2009 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
Social anxiety is the fear of social situations and being
negatively evaluated by others (DSM-IV, 1994). Most of the
research on childhood social anxiety has focused on clinical
populations (e.g., diagnosed with social phobia). However, a
growing body of research suggests that feelings of social
anxiety in
the absence of a diagnosable disorder are nevertheless
potentially
maladaptive for children. The few nonclinical studies of
childhood
social anxiety have focused mostly on older children and

adolescents. Much less is known about the correlates and
consequences of social anxiety in younger children. The
primary
goal of the current study was to investigate the socio-emotional
correlates of social anxiety in an unselected sample of early
elementary school children (aged 7–8 years).
1. Etiology of social anxiety in childhood
Social fears are quite stable across childhood and adolescence
(Kagan & Moss, 1962), even more so than other childhood fears
(Achenbach, 1985). Many researchers exploring the childhood
origins of social anxiety have focused on the role of biological
and
genetic factors (e.g., Warren, Schmidt, & Emde, 1999). For
example,
children are at a greater risk for developing an anxiety disorder
if
* Corresponding authors at: Department of Psychology,
Carleton University, 1125
Colonel By Drive, Ottawa, Ontario, K1S 5B6 Canada.
E-mail addresses: [email protected] (M. Weeks),
[email protected] (R.J. Coplan).
0887-6185/$ – see front matter � 2009 Elsevier Ltd. All rights
reserved.
doi:10.1016/j.janxdis.2009.06.006
the disorder is present in their parents (e.g., Beidel & Turner,
1997).
Indeed, in their metaanalysis of twin research, Beatty, Heisel,
Hall,
Levine, and La France (2002) reported a heritability quotient of
social anxiety of 65%.

Many theorists also suggest that a key etiological component of
the development of social anxiety is a shy or inhibited style of
temperament (e.g., Bogels & Tarrier, 2004; Chorpita & Barlow,
1998; Kagan, 1997; Kimbrel, 2008; Manassis & Bradley, 1994;
Ollendick & Hirshfeld-Becker, 2002; Rapee & Spence, 2004;
Turner,
Beidel, & Wolff, 1996). Behavioral inhibition is a
temperamental
trait that is marked by wariness and discomfort in response to
unfamiliar people and novel environments (Kagan, 1997). There
is
growing empirical evidence linking behavioral inhibition in
early
childhood to the later development of social anxiety disorder
(e.g.,
Biederman et al., 1993, 2001). There is continued debate in the
literature concerning the conceptual and empirical distinctions
between behavioral inhibition/shyness and social anxiety in
childhood (e.g., Degnan & Fox, 2007) and adulthood (Chavira,
Stein, & Malcarne (2002)). For example, it has been suggested
that
behavioral inhibition and social anxiety should regarded as
being
part of the same continuum (e.g., Rettew, 2000). However,
many
researchers maintain that temperamental shyness/inhibition is
most appropriately conceptualized as a vulnerability towards the
development later anxiety (see Rapee & Coplan, in press, for a
recent review).
Development of social anxiety has also been linked to
environmental factors such as the childrearing styles of parents.
For example, Rapee (1997) identified two childrearing-related
mailto:[email protected]

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http://dx.doi.org/10.1016/j.janxdis.2009.06.006
M. Weeks et al. / Journal of Anxiety Disorders 23 (2009) 965–
972966
responses which are important contributors to childhood
anxiety.
Parental rejection (i.e., criticism, lack of communication, lack
of
affection), and parental control (i.e., overprotective behaviors,
lack
of child-autonomy), both appear to be related to greater anxiety
in
childhood. It has also been suggested that inconsistent
childrearing
practices (i.e., contradictory parenting behaviors displayed at
unpredictable, varying times) may be related to an increase in
childhood anxiety (Kohlmann, Schumacher, & Streit, 1988).
Familial cohesion may also play a role in the development of
childhood anxiety. Indeed, anxious children tend to report less
family cohesiveness compared to nonanxious children (Stark,
Humphrey, Crook, & Lewis, 1990).
Another mechanism through which parenting might affect
social anxiety is social modeling. For instance, children are able
to
acquire anxious emotions at least partly through observing their
parents’ facial expressions in response to stressful situations
(e.g.,
Gerull & Rapee, 2002). It has been suggested that when parents
model anxious behavior, children may come to view problems
as
unsolvable, catastrophic, and dangerous (Wood, McLeod,
Sigman,

Hwang, & Chu, 2003). In this way, anxious parents may
(consciously or not) extinguish, or punish children’s
expressions
of problem-focused coping styles, and develop maladaptive
strategies to deal with problems (Whaley, Pinto, & Sigman,
1999; Wood et al., 2003).
In support of this developmental model, Coplan, Arbeau, and
Armer (2008) recently reported a moderating role of parental
characteristics in the relation between temperamental inhibition
(i.e., shyness) and emotion problems (i.e., anxiety) in early
childhood. Results indicated that relations between shyness (as
assessed at the start of the school year) and parent/teacher
ratings
of emotion problems (at the end of the school year) were
significantly stronger among children with mothers
characterized
by higher neuroticism, threat sensitivity (i.e., higher BIS), and
an
overprotective parenting style.
2. Childhood correlates of social anxiety
Socially anxiety disorder (or social phobia) is most typically
diagnosed in adolescence (Klein, 2009). It has been previously
suggested that younger children do not possess the requisite
ability to make associations between their subjective feelings of
anxiety and social situations they encounter (e.g., Morris &
Masia,
1998), and may only begin to experience social fears as the
focus of
their fears at age 14 and older (e.g., Warren & Sroufe, 2004;
Westenberg, Siebelink, & Treffers, 2001). However, in recent
years
there has been a shift towards diagnoses of social phobia in
younger children (Beidel & Turner, 2007). Moreover, both

developmental and clinical researchers have also begun to
consider the implications of elevated (but subclinical) levels of
social anxiety in early childhood (e.g., Feng, Shaw, & Silk,
2008;
Rubin, Coplan, & Bowker, 2009).
It has been argued that although young children who have
difficulty interacting with other children and adults may not
meet
diagnostic criteria for social phobia, they can be viewed as part
of
the ‘‘social anxiety spectrum’’ (Morris, Hirshfeld-Becker,
Henin, &
Storch, 2004). Moreover, given that childhood anxiety
symptoms
tend to persist through adolescence and into adulthood (Ialongo,
Edelsohn, Werthammer-Larsson, Crockett, & Kellam, 1995;
Last,
Perrin, Hersen, & Kazdin, 1996), subclinical levels of anxiety in
early childhood are now widely considered to be a risk factor
for
the later development of more significant internalizing disorders
(Banerjee & Henderson, 2001; Goodwin, Fergusson, &
Horwood,
2004; Morris et al., 2004).
Morris (2001) postulated that social anxiety in elementary
school can have negative consequences because it can hinder
the
important development of social skills, which have long been
believed to be important for children’s future development (e.g.,
Piaget, 1970). Others have suggested that due to their ‘‘meek
nature,’’ shy and anxious children may easily become
‘‘invisible’’ to
teachers (Evans, 2001; Rimm-Kaufman et al., 2002; Rimm-
Kauf-

man & Kagan, 2005). Accordingly, there has been mixed
findings
regarding the level of concordance between teacher and child
perceptions of child anxiety, with some studies reporting
moderate levels of associations (e.g., Bokhorst, Goossens, & de
Ruyter, 1995) and others reporting a lack of association (e.g.,
Cartwright-Hutton, Tschernitz, & Gomersall, 2005).
Notwithstanding, social anxiety in childhood has been asso-
ciated with a number of social-cognitive deficits and socio-
emotional problems. As compared with their nonanxious peers,
socially anxious children are more likely to anticipate negative
consequences in social interactions and display biases in their
interpretations of facial expressions (e.g., Battaglia et al., 2004;
Melfsen & Florin, 2002; Reijntjes, Dekovic, & Telch, 2007).
Moreover, social anxiety has been associated with lower percep-
tions of social acceptance, lower self-esteem, lower popularity,
and
more difficulty forming friendships (e.g., Beidel & Turner,
2007;
Bokhorst, Goossens, & De Ruyter, 2001; La Greca & Stone,
1993).
These links to socio-emotional problems are not surprising,
considering that social anxiety has been viewed as a sign of
dissatisfaction within the peer group (e.g., Asher & Wheeler,
1985).
Socially anxious children also seem to react negatively to
stressful situations. Emotional reactions in children with social
anxiety can be quite severe and contribute to a distressing
experience for the child. Children with clinical levels of social
anxiety report frequent somatic complaints such as headaches,
stomach aches, panic attacks, and frequent crying (Beidel,
Turner,
& Morris, 2000). A study by La Greca, Silverman, and
Wasserstein

(1998) suggests that socially anxious children have stronger
reactions to traumatic events. This may be due to a biological
predisposition, learned behavior, or a combination of the two.
In
any case, this finding highlights the potentially maladaptive
way
that socially anxious children experience the world. Moreover,
as
these children grow up, their social anxiety seems to become
progressively more maladaptive. Children’s feelings of anxiety
in
kindergarten have been associated with anxiety symptoms and
impairments in school achievement in grade 5 (Ialongo et al.,
1995). Also, adolescents diagnosed with social phobia are often
more severely affected than children with the same diagnosis
(Rao
et al., 2007).
3. Measuring social anxiety in children
Researchers have previously noted that the relative lack of
studies examining social anxiety in children is largely due to a
lack
of reliable age-appropriate measures of the construct (e.g.,
Beidel,
Turner, & Morris, 1995). However, a growing literature
suggests
that social anxiety indeed can be reliably measured in much
younger children (e.g., La Greca & Stone, 1993). Not
surprisingly,
there has been an increase in the number of studies examining
social anxiety in younger children, and several measures of
childhood social anxiety have been developed. However, most
assessments of childhood social anxiety, including diagnostic
interviews as well as parent- and child reports, have been
designed

for clinical populations (e.g., SPAI-C; Beidel et al., 1995).
The Social Anxiety Scale for Children-Revised (SASC-R; La
Greca &
Stone, 1993) was designed to measure subjective feelings of
social
anxiety in unselected (i.e., nonclinical) samples, although it has
also been used as a clinical diagnostic measure (Ginsburg, La
Greca,
& Silverman, 1998). Although some research suggests that the
SASC-R is only moderately correlated with other self-report
measures of childhood social anxiety (e.g., Morris & Masia,
1998), it has been suggested that this is due to the fact that
some
972 967
of these measures were designed specifically to assess clinical
social phobia, while the SASC-R was designed to assess
feelings of
social anxiety in general (Ginsburg et al., 1998).
It may be particularly important to identify social anxiety when
children are young. For example, Hirshfeld-Becker and
Biederman
(2002) argued that because young children’s brains are
developing
to a greater degree and have greater neuroplasticity, they would
be
more capable of learning new skills to help with social anxiety.
This
suggests that social anxiety intervention programs might be
particularly effective in young children (e.g., Rapee, Kennedy,
Ingram, Edwards, & Sweeney, 2005).

To our knowledge, only two studies (Ginsburg et al., 1998;
Sandin, Valiente, Chorot, Santed, & Sanchez-Arribas, 1999)
have
used the SASC-R with children younger than 9 years of age.
Moreover, Ginsburg et al. (1998) were using a clinical sample
with
an age range of 6–11 years, and Sandin et al.’s (1999)
unselected
sample included three cohorts, only one of which was under 11
years of age. Therefore, no studies to date have used the SASC-
R to
examine social anxiety in a sample exclusively under the age of
9
years.
4. The current study
The purpose of the current study was to investigate the socio-
emotional outcomes of social anxiety in grade 2 children. Most
previous research has focused on the implications of social
anxiety
in clinical samples. We expected young children display of
heightened (but subclinical) levels of social anxiety also to be
with negative socio-emotional outcomes, including loneliness,
school avoidance, and less school liking. Also, we expected that
socially anxious children would use different and more
maladap-
tive coping strategies in response to social stressors than their
nonanxious peers. In particular, we expected that socially
anxious
children would be most likely to use internalizing coping
strategies
(characterized by excessive worrying).
We were also interested in the extent to which teacher ratings

of children’s anxiety and outcomes are associated with child
self-
reports. As mentioned previously, there is some debate in the
literature regarding the links between teacher- and self-reports
of
children’s social anxiety. For this reason (along with influence
of
shared-method variance), we expected children’s self-reported
social anxiety to be more strongly related to their self-reported
outcomes than with outcomes rated by teachers.
5. Methods
5.1. Participants
Participants in this study were n = 178 children (93 boys, 85
girls) aged 7–8 years (Mage = 7.57, S.D. = .31 years). Children
were
enrolled in grade 2 classes in 15 public schools located in
Ottawa,
Canada. The overall consent rate was calculated at just over
60%.
Children and parents were not compensated for their
participation.
The sample was 75% Caucasian, with a variety of other
ethnicities
also represented (10% Asian, 5% Black, 4% Hispanic).
Approximately
18% of mothers and 24% of fathers had completed high school
only,
69% of mothers and 62% of fathers had a college/university
degree,
and 11% of mothers and 10% of fathers also had some
postgraduate
experience. The public school board from which the sample was
drawn did not permit the collection of information regarding

parental employment status and income.
5.2. Procedures
Participants were recruited at the start of the school year
(September) via information letters sent home with children.
Consenting mothers then completed ratings of their own
personality and their children’s shyness. Children were then
interviewed individually by trained researchers on two separate
occasions (February and April). Because of the younger age of
the
children who comprised the sample in this study, we adapted the
protocol for administering the child self-report measures. For
each
measure (see below), individual items were read aloud to the
child
being interviewed. Children were asked to respond to each item
with a ‘‘yes,’’ ‘‘sometimes,’’ or ‘‘no’’ by pointing to one of
three
differently sized circles. The children all received initial
training on
using this response format and responded to several practice
items
before the assessment items were presented. Finally, near the
end
of the school year (May), teachers completed assessments of
children’s socio-emotional functioning.
5.3. Measures
Multisource assessment was employed, including maternal
ratings, individual child interviews, and teacher ratings.
Maternal reports. Mothers completed the Child Social
Preference
Scale (CSPS; Coplan, Prakash, O’Neil, & Armer, 2004). The

CSPS has
good psychometric properties and has been used in previous
studies as a parental report of child shyness and social
disinterest
(Coplan & Armer, 2005; Coplan et al., 2004, 2008). Of
particular
interest for the current study was the subscale of shyness (7
items,
a = .86, e.g., ‘‘My child seems to want to play with others, but
is
sometimes nervous to’’).
Mothers also rated their own personality using the BIS/BAS
Scales (Carver & White, 1994). This measure was designed to
assess
personality based the relative strengths of the behavioral
inhibition system (BIS) and behavioral activation system (BAS).
The BIS/BAS Scales have good validity and reliability in adult
samples (e.g., Carver & White, 1994). For the present study, we
were particularly interested in the Behavioral Inhibition System
(BIS) subscale (7 items, a = .77, e.g., ‘‘I worry about making
mistakes’’), which focuses on threat perception and orientation
towards punishment.
Child interviews. Children were interviewed individually by
trained research assistants on two separate occasions. Among
the
interview assessments was the Social Anxiety Scale for
Children-
Revised (SASC-R, La Greca, 1998). This 18-item self-report
measure
assesses three subscales of social anxiety: fear of negative
evaluation (8 items, e.g., ‘‘I worry about being teased.’’); social
avoidance and distress to novelty (6 items, ‘‘I feel shy around
kids I
don’t know.’’); and general social avoidance and distress (4

items,
e.g. ‘‘I am quiet when I’m with a group of kids.’’). This
measure has
been widely used to assess social anxiety in children aged 6–13
(e.g., Cartwright-Hutton et al., 2005; Gazelle et al., 2005;
Ginsburg
et al., 1998; Muris, Merckelbach, & Damsma, 2000; Reijntjes et
al.,
2007; Sandin et al., 1999; Storch, Eisenberg, Roberti, & Barlas,
2003). The three subscales have internal consistency between
a = .69 and .86 (La Greca & Stone, 1993). In support of the
validity
of the SASC-R, La Greca and Stone (1993) found that scores on
the
SASC-R were negatively associated with child ratings of social
acceptance and self-worth. Also, Storch et al. (2003) found
positive
correlations between SASC-R scores and self-reported
depression
and loneliness.
In the current sample, the three subscales had internal
consistency scores of: fear of negative evaluation (a = .85);
social
avoidance and distress to novelty (a = .77); and general social
avoidance and distress (a = .59). These three subscales were
highly
intercorrelated (with r’s ranging from .50 to .75, all P’s < .001).
Moreover, results from factor analysis suggested that all items
loaded a single factor. Thus, a total scale score was computed
representing social anxiety (18 items, a = .90). In the current
study,
the focus was not on any of the three subscales in particular,
and

Table 1
Descriptive statistics for study variables.
Variable Mean S.D. Range
Parent ratings
Child shyness 2.09 .73 1.00–4.14
Maternal BIS 2.98 .53 1.43–4.00
Child reports
Social anxiety 1.80 .46 1.00–3.00
Loneliness 1.41 .36 1.00–3.00
School liking 2.70 .33 1.44–3.00
School avoidance 1.87 .52 1.00–3.00
Social support coping 2.34 .38 1.25–3.00
Problem solving coping 2.38 .34 1.13–3.00
Internalizing coping 1.55 .43 1.00–3.00
Teacher ratings
Anxious with peers 1.34 .42 1.00–2.75
Prosocial with peers 2.35 .57 1.00–3.00
Excluded by peers 1.20 .41 1.00–3.00
Academic skills 3.28 .78 1.22–5.00
Table 2

Summary of hierarchical regression analyses predicting child
social anxiety from
child gender, child shyness and maternal BIS.
Variables entered R2 F DR2 DF b
Step 1 .001 <1
Child sex �.01
Step 2 .021 1.83 .021 3.69*
Child shyness .15*
Step 3 .040 2.38+ .019 3.49*
Maternal BIS .14*
* P < .05.
+ P < .08.
972968
research suggests that the total score is a valid measure of
social
anxiety (Ginsburg et al., 1998). Therefore, only the total scores
(representing overall anxiety) are reported in the results.
Also included in the interviews was the Loneliness and Social
Dissatisfaction Questionnaire for Young Children (Asher,
Hymel, &
Renshaw, 1984), consisting of 16 items (along with 8 filler
items)
related to loneliness and social dissatisfaction (a = .88, e.g.,
‘‘Do

you have kids to play with at school?’’). Children also
completed
the School Liking and Avoidance Scale (Ladd, Buhs, & Seid,
2000) to
assess school liking (9 items, a = .83, e.g., ‘‘Do you like to
come to
school?’’) and school avoidance (5 items, a = .83, e.g., ‘‘Do you
wish
you could stay home from school?’’).
Finally, children completed the Self-Report Coping Scale
(Causey
& Dubow, 1992), designed to assess the use of various coping
strategies in response to a social stressor (i.e., conflict with a
friend). Of particular interest for the current study were the
subscales assessing internalizing coping (4 items, a = .65, e.g.,
‘‘worry too much about it’’), seeking social support (8 items, a
= .73,
e.g., ‘‘ask a family member for advice’’), and problem-focused
coping
(8 items, a = .69, e.g., ‘‘try to think of different ways to solve
it’’)1.
Teacher ratings. Teachers completed the Child Behavior Scale
(CBS; Ladd & Profilet, 1996). Of particular interest for the
present
study were the subscales of anxious with peers (4 items, a = .75,
e.g.,
‘‘tends to be fearful or afraid of new things or new situations’’),
prosocial with peers (7 items, a = .93, e.g., ‘‘kind towards
peers’’),
and excluded by peers (7 items, a = .94, ‘‘peers refuse to let this
child
play with them’’). Finally, teachers provided a rating scale
assessment of child academic skills (Coplan, Gavinski-Molina,
Lagace-Seguin, & Wichmann, 2001; Coplan et al., 2008),

including
language, reading/writing, math, science, motor skills, and
reason-
ing (9 items, a = 92.).
6. Results
6.1. Predicting social anxiety scores
Parental education was not significantly associated with the
child anxiety subscales or the total score. As such, this variable
was
not controlled for in subsequent analyses. Descriptive statistics
for
the study variables are displayed in Table 1.
The goal of the first set of analyses was to explore the role of
child sex, child shyness, and maternal BIS in the prediction of
child
social anxiety. A hierarchical regression analysis was computed,
with social anxiety serving as the dependent variable. At Step 1,
child sex (dummy coded) was entered into the equation,
followed
by child shyness at Step 2, and maternal BIS at Step 3. Results
are
summarized in Table 2.
There was no significant sex difference in self-reported social
anxiety. Controlling for child sex, child shyness was
significantly
and positively related to social anxiety. Furthermore, beyond
the
contribution of these two variables, maternal BIS was also
significantly and positively associated with child social anxiety.
Thus, both child shyness and maternal BIS were significant
(albeit

modest) predictors of child social anxiety.
6.2. Outcomes of socially anxious children
The goal of the next set of analyses was to explore the socio-
emotional outcomes of social anxiety in young children. In this
regard, we created a group of socially anxious children (n = 31,
19
boys, 12 girls) whose social anxiety scores on the SASC-R were
greater than 1 S.D. above the mean, and a comparison group of
1 Although the internal consistencies of these scales were
somewhat modest in
the present sample, they are consistent with the previous results
reported by
Causey and Dubow (1992).
nonanxious children (n = 95, 50 boys, 45 girls) whose social
anxiety
scores were below the mean. We then computed a series of
2(Sex) � 2(Group) Multivariate Analyses of Variance to
explore
Group differences in child self-report and teacher-rated
outcomes.
The first MANOVA included measures of child loneliness,
school
liking, and school avoidance. Results indicated only a
significant
multivariate main effect of Group (F(3,119) = 20.49, P < .001).
Results from subsequent univariate analyses demonstrated a
significant effect of Group for child loneliness (F(1,121) =
54.73,
P < .001, h2 = .311), school liking (F(1,121) = 5.98, P < .05,
h2 = .047), and school avoidance (F(1,121) = 9.90, P < .01,
h2 = .076). Relevant means are displayed in Fig. 1a. As

compared
to their nonanxious peers, socially anxious children reported
significantly more loneliness and school avoidance, and signifi-
cantly less school liking.
The next MANOVA included measures of child coping
strategies, including internalizing, seeking social support, and
problem-focused coping. Again, results indicated only a
significant
multivariate main effect of Group (F(3,119) = 8.670, P < .001).
Results from subsequent univariate analyses demonstrated a
significant effect of Group for internalizing coping (F(1,121) =
23.45, P < .001, h2 = .162), a marginally significant effect for
seeking support (F(1,121) = 3.25, P < .08, h2 = .026), and no
significant effect for problem solving (F(1,121) < 1, ns).
Relevant
means are displayed in Fig. 1b. As compared to their
nonanxious
peers, socially anxious children reported using significantly
more
internalizing coping and a somewhat greater tendency seek
social
support when dealing with a social stressor.
The next MANOVA included teacher ratings of child anxiety,
exclusion by peers, and prosocial behaviors. For these
measures,
results indicated only a significant multivariate main effect of
Sex
(F(3,102) = 6.36, P < .01). Results from subsequent univariate
Fig. 1. Group means comparing socially anxious and nonanxious
children in terms
of: (a) loneliness, school liking, and school avoidance and (b)

internalizing, seeking
social support, and problem-focused coping.
972 969
analyses demonstrated only a significant effect of Sex for
prosocial
behavior (F(1,104) = 16.10, P < .001, h2 = .134), indicating that
teachers rated girls (M = 2.56, S.D. = .45) as more prosocial
with
peers than boys (M = 2.15, S.D. = .59).
The final analysis concerned Group differences in teacher
ratings of child academic skills. Results of the ANOVA
indicated
only a significant effect of Group (F(1,104) = 5.60, P < .05,
h2 = .162), indicating that teachers rated socially anxious
children
(M = 2.93, S.D. = .86) as less academically skilled than
nonanxious
children (M = 3.37, S.D. = .73).
7. Discussion
The goal of the current study was to investigate the socio-
emotional correlates of social anxiety in an unselected sample
of
7–8-year-old children. Our findings suggested that younger
children are indeed able to provide internally consistent and
valid
self-reports of social anxiety. Moreover, higher levels of social
anxiety at this age period were also associated with indices of
socio-emotional difficulties.
7.1. Assessing social anxiety in younger children

As previously noted, lack of research addressing nonclinical
social anxiety in childhood has been largely due to a lack of
age-
appropriate measures. Our findings provide some initial
evidence
to suggest that the SASC-R can be used as an appropriate
measure
of social anxiety in 7- and 8-year-old children (the youngest
nonclinical sample in the literature to date). To begin with, the
factor structure and internal consistency scores of the SASC-R
were
consistent with previous findings in older samples (e.g.,
Ginsburg
et al., 1998; La Greca & Stone, 1993).
As well, children’s self-reported social anxiety from the SASC-
R
was significantly related to both child temperamental shyness
and
maternal BIS (i.e., threat perception). Shyness is seen an
important
temperamental contributor to the etiology of social anxiety
(e.g.,
Biederman et al., 2001; Hudson & Rapee, 2001). Moderate
associations noted in the present study are consisted with
previous
research linking shyness and anxiety in childhood and
adolescence
(e.g., Coplan et al., 2008; Muris, Meesters, & Blijlevens, 2007)
and
support the distinction between these two constructs (Rapee &
Coplan, in press).
We also found that social anxiety was related to maternal BIS,
which is consistent with previous research regarding the
socializ-

ing influence of parents in the development of social anxiety
(e.g.,
Hudson & Rapee, 2004). For example, children whose mothers
display anxious behaviors are more likely to experience worry
(e.g.,
Brown & Whiteside, 2008). However, this relation also supports
the
biological component of social anxiety, in that maternal char-
acteristics such as behavioral inhibition are likely passed on
through genetics to a degree.
Taken together, these conceptually consistent associations
between social anxiety and indices of both child temperament
and
maternal personality can be taken as preliminary evidence of the
convergent validity of the SASC-R with this age group.
7.2. Correlates of early social anxiety
Overall, our findings indicate that children who reported
greater feelings of social anxiety also tended to experience
other
difficulties in socio-emotional functioning. These results add to
the
growing literature suggesting that feelings of social anxiety can
have negative implications, even in the absence of a diagnosed
clinical anxiety disorder. For example, socially anxious children
in
our sample reported feeling more lonely than their nonanxious
peers. This finding is in keeping with previous research
suggesting
that socially anxious children are less popular and have more
difficulty forming friendships (e.g., Bokhorst et al., 2001; La
Greca &
Stone, 1993).

Moreover, our results also suggest that socially anxious
children are not enjoying the time they spend at school. Socially
anxious children were more likely to report disliking school and
wanting to avoid school in comparison to nonanxious children.
These results are also not surprising considering La Greca and
Stone’s (1993) findings as to difficulty socially anxious
children
have in forming friendships. The school setting is often the
primary
context for the building of friendships at this age, and therefore
we
would expect socially anxious children not to enjoy spending
time
in a context where they find it so difficult to make friends.
Also,
previous research has suggested that social anxiety in childhood
is
associated with school refusal (Elliott, 1999; Heyne, King, &
Tonge,
2004). It is also worth noting that the school adjustment
problems
of anxious children were not limited to the social realm.
Socially anxious children also report more negative coping
styles in response to social stressors. In comparison to
nonanxious
children, socially anxious children indicated they would be
more
likely to employ internalizing strategies that include worry and
self-blame. This type of maladaptive coping may be particularly
problematic for young children already at risk for social
anxiety.
For example, Findlay, Coplan, and Bowker (2009) recently
reported
that internalizing coping mediated the relation between shyness
and self-reported coping in later childhood. These authors

suggested that shy children who cope with social stress by
engaging in self-blame or ruminating may exacerbate already
existing feelings of social anxiety and thus may be at increased
risk
for later difficulties.
Finally, teachers rated socially anxious children as less
academically skilled than nonanxious children, supporting pre-
972970
vious research (e.g., Ialongo et al., 1995). Socially anxious
children
may actually exhibit poor academic performance as compared to
nonanxious children. Of course, this might be due to an actual
deficit in academic skill, as well as an inability to reach
academic
potential, because of a fear to participate in class (Coplan &
Arbeau,
2008). Alternately, teachers may tend to perceive a lack of
academic skill in socially anxious children because of a
preexisting
schema of how a ‘‘good’’ student should behave. Socially
anxious
children may tend to exhibit characteristics which do not fit
with
this schema, and may therefore be viewed as having less
academic
ability as a result. In support of this notion, Hughes, Coplan,
Bosaki,
and Rose-Krasnor (2009) recently reported that elementary
school
teachers rated shy students described in hypothetical vignettes
as

being less intelligent, having poorer academic skills, and having
more learning difficulties than comparison and more
‘‘talkative’’
children.
Taken together, these results suggest that young socially
anxious children are beginning to develop not only negative
feelings, but maladaptive ways of coping with such feelings.
Our
findings suggest that socially anxious children are unhappy with
their peer relations, and specifically that they are more likely
than
other children to feel lonely. They also seem to feel less
positive
about their experiences at school and seem to cope with stress
mainly through worrying. In addition, socially anxious children
are
perceived as less academically skilled, perhaps because they are
less willing to participate in class due to the combination of
anxious feelings and a dislike for school.
Teacher perceptions. Although socially anxious children gen-
erally self-report negative socio-emotional adjustment, fewer
differences among anxious and nonanxious children were found
for teacher ratings. This might be somewhat expected because
of
shared-method variance (i.e., stronger associations should be
evident between self-reported social anxiety and other child
self-
report variables). However, teachers did not rate socially
anxious
children as being more anxious, more excluded by peers, or less
prosocial than nonanxious children.
There is some evidence to suggest that teachers are indeed
aware of anxiety symptoms among children in their class.

For example, Layne, Bernstein, and March (2006) found that
children who were identified as being more anxious by their
teachers had higher levels of anxiety as compared to those
children who were not rated as anxious. It is important to note
the mean age of their sample was 8.7 years, which lends further
support to the idea that social anxiety not only is salient at this
age, but can also be reliably identified by an external source
(e.g.,
teachers). However, it has also been argued that teachers are
less
accurate at assessing internalizing problems, particularly in
early
childhood (Rimm-Kaufman et al., 2002; Rimm-Kaufman &
Kagan,
2005).
Notwithstanding, we found evidence of an incongruity
between teacher ratings and self-reports of the socio-emotional
adjustment of socially anxious children. Reasons for this incon-
gruity are not clear, although there are at least two plausible
explanations. First, socially anxious children may indeed be
experiencing negative outcomes at school which teachers are
unable to detect. If this is the case, there may be several
subsequent explanations for why teachers are not noticing these
outcomes. For instance, teachers may be unaware of subtle
nuances of children’s peer relations as many important interac-
tions are played out in the schoolyard (e.g., Ostrov & Crick,
2007),
where teachers are much less likely to be present. Alternately,
socially anxious children may not want teachers to know about
their negative experiences, perhaps because they feel embar-
rassed or ashamed. Indeed, some research suggests that anxious
children often hide emotional problems around parents and
teachers (e.g., Dadds, Perrin, & Yule, 1998; Pina, Silverman,
Saavedra, & Weems, 2001). Regardless, there are potentially
important implications of teachers’ failure to detect such

maladjustment. For example, teachers who are unaware of social
anxiety among children in their class may be less likely to
provide
help and assistance to socially anxious children experiencing
socio-emotional difficulties.
The second possibility is that socially anxious children are
exhibiting cognitive distortions, whereby their experiences in
the
social context of school are negatively biased. This possibility
is
supported by the research suggesting that anxious children’s
negative perceptions of their own social skills are not related to
the
perceptions of objective observers (e.g., Cartwright-Hutton et
al.,
2005). Indeed, individuals diagnosed anxiety disorders tend to
exaggerate the severity of their social ineptitude (e.g., Eysenck,
1999). Moreover, anxiety disorders are often accompanied by
heightened threat perception and biases in the subjective
interpretations of social experiences (e.g., Alden, Taylor,
Mellings,
& Laposa, 2008; Bar-Haim, Lamy, Pergamin, Bakermans-
Kranen-
burg, & van IJzendoorn, 2007; Muris, Jacques, & Mayer, 2004).
However, regardless of the ‘‘accuracy’’ of socially anxious
children’s perceptions, their negative interpretation of their
social
circumstances provides yet another indicator of the need for
early
intervention.
7.3. Limitations and future directions
The current study provided some preliminary evidence of the
utility of using the SASC-R in with younger children. However,

our
findings should be regarded as the ‘‘first step’’ in this process.
For
example, although the SASC-R was shown to have a
conceptually
interpretable factor structure and be internally consistent, the
reliability of this measure (i.e., test–retest) still needs to be
established. As well, we adapted the protocol for administering
the
SASC-R to be used as an interview assessment. Although this
altered measure appeared to demonstrate comparable psycho-
metric properties to the ‘‘pencil and paper’’ version — there
may be
subtle differences due to this alternate method of administering
the test that should be explored further in subsequent research.
Moreover, although theoretically consistent associations
between
social anxiety scores and other measures provided some
evidence
of the convergent validity of the SASC-R with this age group,
additional assessments of validity are still required. For
example, it
would be helpful to also establish the discriminant validity of
this
measure by demonstrating stronger associations between the
SASC-R and other assessments of social anxiety as compared to
other anxiety problems (e.g., separation anxiety) and
internalizing
difficulties (i.e., depression).
Our results suggest that socially anxious children in an
unselected sample are at increased risk for socio-emotional
difficulties. Notwithstanding, the correlational nature of the
data
does not allow for conclusions regarding the causal links among
variables. For example, it is possible that children who have

experienced loneliness and school avoidance go on to report
more
social anxiety. Longitudinal research is needed in order to
provide
stronger support for the findings.
As well, as mentioned earlier, relations between children’s self-
reports of social anxiety and adjustment outcomes were likely
heightened because of shared-method variance. The use of
additional sources of assessment (e.g., peer ratings, naturalistic
observations) would help to clarify the nature of the
‘‘disconnect’’
between child self-reports and teacher ratings. However,
previous
research has suggested that child ratings of behavioral and
emotional problems (including social anxiety) are often only
modestly correlated to teacher and parent ratings (e.g., Cole,
Hoffman, Tram, & Maxwell, 2000; Kristensen & Torgersen,
2006).
This suggests that perhaps the differences between teacher and
972 971
child ratings of adjustment outcomes cannot be explained fully
by
the particular measures used in the current study.
Regardless, the fact that socially anxious children are also
reporting greater loneliness, more maladaptive social problem
solving, and negative attitudes towards school should be
concerning to parents and teachers. Ultimately, there should be
a focus on helping teachers identify social anxiety in the
classroom,
as well as helping to reshape potential cognitive distortions of

socially anxious children. Teachers can be taught to recognize
the
signs of underlying social anxiety and to look for potential
adjustment problems in children who exhibit anxiety in the
classroom. In order to help children, future research can focus
on
prevention programs by using the methods of cognitive behavior
therapy, which involves the reevaluation of unhealthy
cognitions.
The idea that cognitive distortions may shape the perceived
maladjustment of socially anxious children deserves further
investigation. Understanding the degree to which socially
anxious
children exaggerate their negative outcomes will help
researchers
to evaluate the relative importance of child reports versus
reports
from parents, teachers, and peers. Investigating this idea may
also
bring nonclinical social anxiety research into the realm of
cognitive
psychology and to broaden our understanding of how social
anxiety affects the minds and behaviors of children.
The finding that teachers rated socially anxious children as less
academically skilled also deserves further investigation. Future
studies could include several measures of academic achievement
in order to clarify whether socially anxious children are indeed
demonstrating deficits in academic ability and performance, or
whether teachers merely perceive these deficits in the absence
of
any actual school-related problems.
The issue of social anxiety in early childhood has largely been
overshadowed by clinical research with adult populations. This

research adds to the growing literature on childhood social
anxiety, and highlights the importance of examining not only
clinical populations of children, but also those children who are
showing early signs of social anxiety. Our hope is that this
research
will add to the knowledge needed to develop effective home-
based
and school-based interventions for socially anxious children.
Acknowledgements
This research was supported by a Social Science and
Humanities
Research Council of Canada grant to author Coplan. The authors
wish to thank Kim Bowen, Kathleen Hughes, Lindsay
McCullough,
Christina Picket, Kim Rowan, and Jenna Robinson for their help
in
the collection and coding of data.
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Use of skills learned in CBT for fear of flying:
Managing flying anxiety after September 11th
Simon Kim
a
, Frances Palin
a
, Page Anderson
a,*, Shannan Edwards
a
,
Gretchen Lindner
a
, Barbara Olisov Rothbaum
b
a

Georgia State University, Atlanta, GA, USA
b
Emory University School of Medicine, Atlanta, GA, USA
Received 2 August 2006; received in revised form 12 February
2007; accepted 19 February 2007
Abstract
Although there is evidence that cognitive behavioral therapy
(CBT) is effective in the treatment for fear of flying (FOF),
there are
no studies that specifically examine which skills taught in
treatment are being used by clients after treatment is completed.
This
study examines whether participants report using skills taught
in treatment for FOF after treatment is completed and whether
the
reported use of these skills is associated with reduced flying
anxiety in the face of fear-relevant event, the September 11th
terrorist
attacks, and over the long-term. One hundred fifteen
participants were randomly assigned to and completed eight
sessions of
individual CBT treatment for FOF. Fifty-five participants were
reassessed in June 2002, an average of 2.3 years after treatment.
Surveys were also collected from 33 individuals who did not
receive treatment for FOF. Results indicated that treatment
completers

were more likely to report using skills taught in treatment than
individuals who had not received treatment. In addition, self-
reported
use of skills among previously treated individuals was
associated with lower levels of flying anxiety. These findings
suggest that use
of skills taught in CBT treatment is associated with reduced
flying anxiety in the face of a fear-relevant event and over the
long term.
# 2007 Elsevier Ltd. All rights reserved.
Keywords: Use of skills; CBT; Fear of flying
Journal of Anxiety Disorders 22 (2008) 301–309
1. Introduction
Whereas there are several studies demonstrating the
long-term effectiveness of cognitive behavioral therapy
(CBT) for fear of flying (FOF), to our knowledge, there
are no studies that specifically examine which skills
taught in treatment are utilized by clients who
experience FOF. The lack of research linking use of
* Corresponding author at: Georgia State University,
Department of
Psychology, P.O. Box 5010, Atlanta, GA 30302-5010, USA.

Tel.: +1 404 651 2850; fax: +1 404 651 1391.
E-mail address: [email protected] (P. Anderson).
0887-6185/$ – see front matter # 2007 Elsevier Ltd. All rights
reserved.
doi:10.1016/j.janxdis.2007.02.006
skills to long-term treatment outcome for FOF is an
important gap in the literature given that CBT
emphasizes teaching clients transferable skills (Hollon,
2003). Moreover, competence with such therapy
skills is presumed to contribute to long-term positive
treatment outcomes. The current study examines
whether skills taught in treatment for FOF are used
by participants after treatment is completed in the face
of a fear-relevant event, the September 11th terrorist
attacks, and is associated with reduced flying anxiety
over the long-term.
Cognitive-behavioral therapy is effective in the
treatment for FOF, a common experience estimated to
affect 25 million adults in the United States and nearly

http://dx.doi.org/10.1016/j.janxdis.2007.02.006
S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–
309302
10–40% of the adults in industrialized countries
(Arnarson, 1987; Ekeberg, 1991; Nordlund, 1983;
Deran & Whitaker, 1982). A variety of CBT methods
(e.g. systematic desensitization, flooding, implosion,
and relaxation) has been found to yield reductions in
flying anxiety after treatment (Beckham, Vrana, May,
Gustafson, & Smith, 1990; Denholtz & Mann, 1975;
Haug et al., 1987; Howard, Murphy, & Clarke, 1983;
Ost, Brandberg, & Alm, 1997; Solyom, Shugar,
Bryntwick, & Solyom, 1973; Van Gerwen, Diekstrra,
Arondeus, & Wolfger, 2004). In general, these studies
utilized cognitive behavioral approaches to treatment,
incorporating a combination of psychoeducation,
cognitive restructuring, and some form of exposure.
More recently, use of virtual reality as a tool in treating

individuals with flying anxiety has been examined and
has demonstrated positive post-treatment outcomes in
case studies (North, North, & Coble, 1997; Rothbaum,
Hodges, Watson, Kessler, & Opdyke, 1996; Smith,
Rothbaum, & Hodges, 1999; Wiederhold, Gevirtz, &
Widerhold, 1998), as well as both uncontrolled (Botella,
Osma, Garcia-Palacios, Quero, & Banos, 2004) and
controlled (Maltby, Kirsch, Mayers, & Allen, 2002;
Rothbaum, Hodges, Smith, Lee, & Price, 2000;
Rothbaum et al., 2006) trials.
There are few research studies examining long-term
CBT treatment outcomes for FOF and the results from
such studies are mixed. Several studies of treatments
using in-vivo and virtual reality exposure have reported
maintenance of treatment gains for at least one year
(Doctor, McVarish, & Boone, 1990; Rothbaum,
Hodges, Anderson, Price, & Smith, 2002; Rothbaum
et al., 2006). One study found that treatment gains were

maintained at 3-year follow-up after virtual reality
exposure (VRE) treatment (Wiederhold & Wiederhold,
2003). However, this study had a very small sample size
(N = 28), and participants’ self-report of flying after
treatment was the only outcome measure. In addition, in
a well-controlled study comparing the effects of VRE
and placebo in the treatment of FOF (Maltby et al.,
2002), treatment gains for participants in the VRE
group were not maintained at 6-month follow-up.
Recently, Anderson et al. (2006) examined the long-
term efficacy of CBT for clients with FOF, after Sept
11th. These individuals originally participated in two
well-controlled, randomized clinical trials for the
treatment of FOF (Rothbaum et al., 2000, 2006) that
compared virtual reality exposure to standard exposure
in-vivo treatments. Results from this follow-up study
showed that treatment gains were maintained, or
improved upon, an average of 2.3 years after treatment

for both virtual reality and standard exposure (Anderson
et al., 2006) providing some evidence for the long-term
benefit of CBT for FOF, and sustainability after a
significant fear-relevant event.
What may account for the sustainability of treatment
gains? Although there is clear evidence that CBT
provides short-term gains for FOF and some evidence
that these gains are enduring, the components under-
lying these enduring effects are unclear. Skill acquisi-
tion has been identified as one important component of
CBT treatment, along with changes in cognition,
enhanced coping, and exposure (Prins & Ollendick,
2003). CBT’s emphasis on skill learning is based on
cognitive theories of self-regulation and motivation, and
on the assumption that clients are problem-solvers and
self-motivators (Brewin, 1996). A general assumption
of CBT is that ‘‘prior learning is currently having
maladaptive consequences, and that the purpose of
therapy is to reduce distress or unwanted behavior by

undoing this learning or by providing new, more
adaptive learning experiences’’ (Brewin, 1996, p. 34).
Presumably, the skills learned in treatment contribute to
adaptive learning experiences, as well as the main-
tenance of such adaptive learning.
Thus, CBT therapists deliberately work to build
skills among their clients by emphasizing active
participation and psychoeducation so that clients may
become their own therapist once treatment is terminated
(Beck, 1995; Hollon, 2003). The aim is for clients to
develop transferable skills that can be used to cope with
new problems that arise after the end of therapy
(Westbrook & Hill, 1998), and increase the probability
that they will have effective tools at their disposal when
they are needed in the future in order to manage
emotional responses to stress (Barber & DeRubeis,
1989; Hollon, 2003).
Despite the emphasis CBT places on teaching clients

skills (Westbrook & Hill, 1998), for anxiety disorders
there is a dearth of studies looking at relations between
skills taught in therapy, their use once treatment has
ended, and its association with positive treatment
outcomes. No studies could be identified that specifi-
cally examine the use of skills learned in treatment and
long-term outcomes for FOF. However, research on
social phobia and depression suggests that clients who
systematically apply what they have learned in therapy
are more likely to make progress in treatment (e.g.,
Persons, Burns, & Perloff, 1988), as well as maintain
their treatment gains in the long-term (e.g., Edleman &
Chambless, 1995; Helbig & Fehm, 2004; Young
Weinberger, & Beck, 2001). In addition, research
shows associations between the amount of practice
clients engage in during treatment and the benefits they
S. Kim et al. / Journal of Anxiety Disorders 22 (2008) 301–309

303
achieve from exposure therapy (Barlow, O’Brien, &
Last, 1984; Michelson, Mavissakalian, Marchione,
Dancu, & Greenwald, 1986). Finally, a recent study
found that increased coping skills were significant long-
term predictors of treatment outcomes for alcohol
dependence (Litt, Kadden, Cooney, & Kabela, 2003).
Given the lack of research examining whether clients
report using skills learned in therapy after treatment,
and associations between use of skills and positive long-
term outcomes for FOF, the purpose of this study is to
examine whether participants previously treated for
FOF with CBT report using skills learned in treatment
to manage flying anxiety after a fear-relevant event. We
also examine whether self-reported use of skills learned
in treatment is associated with flying anxiety over the
long-term. In the current study, clients were taught three
skills in treatment, namely, breathing retraining, talking
back to negative thoughts, and continuing to fly.

Specific theoretical underpinnings for these skills
include cognitive change as a result of adaptive self-
talk (e.g., Meichenbaum, 1977) and habituation to the
feared stimulus by means of exposure (Foa & Kozak,
1986). We hypothesize that: (1) participants who
received treatment for FOF will more likely report
using skills taught in treatment than a comparison group
of non-anxious individuals who have not received
treatment for FOF, (2) participants treated with CBT for
FOF will be more likely to report using skills learned in
treatment (‘‘taking relaxing breaths,’’ ‘‘talking back to
negative thoughts,’’ and ‘‘continuing to fly’’) than skills
not learned in treatment (‘‘trying to put it out of my
mind/distracting myself,’’ ‘‘talking to friends and
family,’’ ‘‘gathering information about increased secur-
ity measures,’’ and ‘‘listening to the media’’) to manage
flying anxiety after September 11th and (3) among
treatment completers, those who report using skills

taught in treatment will show lower levels of flying
anxiety after September 11th than those who reported
not using skills taught in treatment.
2. Methods
2.1. Participants
All individuals who completed treatment for the fear
of flying across two studies (n = 115) were contacted by
mail in June, 2002. In order to attempt to recruit a
demographically matched convenience comparison
group, treatment completers were sent two copies of
the surveys with two postage-paid return envelopes and
were asked to complete one survey and to give the
second survey to a friend who had never had treatment
for the fear of flying (comparison group). Potential
participants were asked not to complete the ques-
tionnaires together. Participation by comparison group
participants was anonymous, as no identifying informa-
tion beyond basic demographics (current age, sex, race,

martial status, income level) was collected.
To have participated in the original treatment studies,
individuals met current DSM-IV criteria for either
specific phobia, situational type (i.e., FOF), panic
disorder with agoraphobia in which flying was the
feared stimulus, or agoraphobia without a history of
panic disorder, in which flying was the feared stimulus,
as measured by the Structured Clinical Interview for the
DSM-IV (SCID; First, Spitzer, Gibbon, & Williams,
1995). All assessments were conducted by a licensed
psychologist, who was blind to the type of treatment
received. A subset of interviews was rated by another
licensed psychologist, achieving a kappa coefficient of
.94, indicating excellent inter-rater reliability (Roth-
baum et al., 2006).
Of the 115 potential participants who completed
treatment across the two trials, 7 participants’ packets
were returned unopened, and current addresses were

unable to be located. Of the 108 potential treatment
respondents, 55 individuals completed the question-
naires (51% retention). The majority of these respon-
dents received a primary diagnosis of specific phobia,
situational type (flying; 87%, n = 48). The remaining
respondents received a primary diagnosis of panic
disorder with agoraphobia (11%, n = 6) and agorapho-
bia (2%, n = 1). With regard to co-morbidity, sixty
percent received one current diagnosis (n = 33), 26%
(n = 14) received two diagnoses, 13% (n = 7) received
three diagnoses, and 2% (n = 1) received four diag-
noses.
Of the 108 potential comparison group respon-
dents, 33 individuals completed the questionnaires
(31% retention). Respondents were excluded if they
reported direct exposure to the September 11th
terrorist attacks. Comparison group participants were
excluded if they had previous treatment for fear

of flying. One comparison group respondent was
excluded due to prior treatment for fear of flying and
one treatment respondent was excluded due to direct
exposure to the September 11th terrorist attacks.
Treatment completers and comparison group partici-
pants did not differ across age, education, marital
status, race, and income. Respondents were on
average 40 years of age, well-educated (on average
17 years of schooling), married (59%), Caucasian
(92%), and middle-to-upper-income (71% reported >
$50K/year).
309304
2.2. Treatment
All treatment and follow-up assessments for the
original treatment studies were completed prior to
September 11th, 2001. The treatment was identical for
each of the two trials, which is detailed elsewhere
(Rothbaum et al., 2000, 2006). In brief, participants

were randomly assigned to VRE or SE for eight
individual sessions over 6 weeks. Treatment consisted
of four sessions of anxiety management training (for
both groups), including breathing relaxation, cognitive
restructuring, and thought-stopping, followed either by
exposure to a virtual airplane (VRE) or an actual
airplane at the airport (SE), according to a treatment
manual. VRE was conducted in a therapist’s office
according to a treatment manual (Rothbaum & Hodges,
1999). Patients wore a head-mounted display with
stereo earphones that provided visual and audio cues
consistent with being inside the passenger compartment
of an airplane. During VRE sessions, participants could
taxi, take-off, fly in calm and turbulent weather and land
in the virtual airplane. SE was conducted at the airport
and was spent exposing patients to pre-flight stimuli
(e.g., ticketing), to an elevated coordination center
tower, and to sitting on a stationary airplane.

2.3. Measures
2.3.1. Flying anxiety
The Questionnaire on Attitudes Toward Flying
(QAF, Howard et al., 1983) assesses various aspects
of FOF including: longevity of FOF, treatment history,
and attitudes concerning flying. It includes a 36-item
subsection that asks the participant to rate level of fear
toward different flying situations (e.g., ‘‘The noise of
the engine suddenly increases’’) using a 0–10 scale. The
range of scores is 0–360, with higher scores represent-
ing higher levels of anxiety. Test-retest reliability has
been reported as .92, and split-half reliability as .99. The
QAF-Fear Item (QAF-Fear) is a single item taken from
the QAF, which asks the participant to rate current fear
of flying from 0 (‘‘no fear’’) to 10 (‘‘the most extreme
amount of fear that is possible for you to feel’’). It is
used as a face-valid measure of FOF.
The Fear of Flying Inventory (FFI, Scott, 1987) is a

33-item measure assessing fear of flying intensity, in
which participants rate how much they would be
distressed by various aspects of flying (e.g., ‘‘Take-
off’’) on a scale of 0 (‘‘not at all’’) to 8 (‘‘very severely
disturbing’’). Scores range from 0 to 264. Scott (1987)
has reported test-retest reliability for 15 wait-list
patients as .92, and has demonstrated its sensitivity to
change after treatment. Both the FFI and the QAF are
correlated with clinician-administered measures of
flying anxiety (Rothbaum et al., 2000).
2.3.2. Use of skills
The Fear of Flying after September 11
th
, 2001
questionnaire was developed for the purposes of this
study. This questionnaire asks individuals to indicate
‘‘whether you used any of the following anxiety
management skills after September 11th to deal with
anxiety about airplane travel.’’ The skills specifically

taught during treatment included: ‘‘taking relaxing
breaths’’; ‘‘talking back to negative thoughts’’; and
‘‘continuing to fly.’’ Other skills not taught in treatment
included: ‘‘trying to put it out of my mind/distracting
myself’’; ‘‘talking to friends and family’’; ‘‘gathering
information about increased security measures’’; and
‘‘listening to the media.’’ Individuals were asked to
indicate all that applied.
3. Results
3.1. Treatment and comparison group
In order to address the first hypothesis, multiple
Chi-square analyses were conducted to assess if the
proportion of individuals who endorsed using specific
skills differed in the treatment versus the comparison
group. Of the skills taught in treatment, individuals who
completed CBT were significantly more likely to have
taken ‘‘relaxing breaths’’ (x
2
(1, N = 88) = 10.52,

p < .01) and to have ‘‘talked back to their negative
thoughts’’ (x
2
(1, N = 88) = 5.95, p < .05) to deal with
their anxiety than individuals in the comparison group.
No significant differences were found between treat-
ment completers and the comparison group on
‘‘continuing to fly.’’ Of the skills not taught in treatment,
no significant differences were found between treatment
completers and the comparison group on ‘‘trying to put
it out of my mind/distracting myself,’’ ‘‘talking to
friends and family,’’ ‘‘gathering information about
increased security measures,’’ or ‘‘listening to the
media’’ ( p > .05). Table 1 shows the percentage of
treatment completers and the comparisons using the
various skills.
3.2. Use of skills and anxiety levels among
treatment completers
To address the second hypothesis, a paired samples t-

test was conducted to assess whether clients treated with
CBT for FOF used anxiety management skills taught in
305
Table 1
Percentage of participants using various skills after September
11th
Anxiety management skills Treatment
completers
(n = 55) (%)
Comparison
group
(n = 33) (%)
Taught in treatment
‘‘Taking relaxing breaths’’ 65 33
‘‘Talking back to negative thoughts’’ 60 36
‘‘Continuing to fly’’ 38 39
Not taught in treatment

‘‘Trying to put it out of mind my
mind/distracting myself’’
51 36
‘‘Talking to friends and family’’ 33 24
‘‘Gathering information about
increased security measures’’
20 10
‘‘Listening to the media’’ 10 15
therapy more than other potential anxiety management
skills that were not taught in therapy. More specifically,
the average number of skills taught in treatment that was
used by the clients was compared to the mean of skills
not taught in treatment. The results indicate that skills
taught in treatment (‘‘taking relaxing breaths,’’ ‘‘talking
back to negative thoughts,’’ and ‘‘continuing to fly’’)
were significantly more utilized than skills not taught in
treatment (‘‘trying to put it out of my mind,’’ ‘‘talking
to friends and family,’’ ‘‘gathering information
about increased security measures,’’ ‘‘listening to the

media’’), t(50) = 5.60, p < .01. Furthermore, among
those respondents who previously had completed
treatment in the original treatment outcome studies,
psychiatric comorbidity was not related to self-reported
use of skills taught in treatment F (3,48) = .39, p > .05.
Table 2
Summary statistics for hierarchical multiple regression analyses
Outcome variable Predictor variables Change statistics
F-test R
Talking back to negative thoughts
Sept. 11th FFI 1. Post FFI 12.77
**
.2
2. Talking back 11.88
**
.1
Sept. 11th QAF 1. Post QAF 15.83
**
.2
**

.1
Sept. 11th QAF-fear 1. Post QAF-fear 5.42
*
.1
*
.1
Continuing to fly
Sept. 11th FFI 1. Post FFI 12.05
**
.2
2. Flying 13.01
**
.1
Sept. 11th QAF 1. Post QAF 15.25
**
.2
2. Flying 20.00
**
.2
Sept. 11th QAF-fear 1. Post QAF-fear 5.09

*
.1
2. Flying 17.76
**
.2
Note. FFI: fear of flying questionnaire. QAF: questionnaire on
attitudes abo
*
alpha < .05. **alpha < .003.
Finally, to address the third hypothesis, separate
hierarchical multiple regression analyses were con-
ducted to assess the relation between potential anxiety
management skills, including those taught and not
taught in treatment, and fear of flying anxiety after
September 11th (FFI, QAF, QAF-fear). ‘‘Gathering
information about increased security measures’’ and
‘‘listening to media’’ not taught in treatment were
excluded from these analyses due to low rates of
endorsement.
Preliminary analyses revealed a significant associa-
tion between post-treatment anxiety scores on the FFI,

QAF, and QAF-fear and post-September 11th anxiety
scores (r = .48, .51, .29, p < .05). As such, post-
treatment anxiety scores were statistically controlled in
all subsequent analyses.
For each regression, the post-treatment anxiety score
was entered in Step 1 (e.g., Post FFI) and the anxiety
management skill was entered in Step 2 (e.g., ‘‘relaxing
breaths’’). The post-September 11th anxiety score was
entered as the dependent variable (e.g., September 11th
FFI). Consequently, 15 separate regressions were run.
As such, a Bonferroni correction was conducted to
address the multiple comparisons made, which required
a p-value (alpha = .05) less than .003 for significance.
‘‘Talking back to negative thoughts’’ significantly
predicted FFI (F (1, 48) = 11.88, p < .003), QAF (F (1,
49) = 12.65, p < .003), and QAF-fear (F (1, 47) = 5.55,
p < .05) (Table 2). Above the effect of post-treatment
anxiety scores, ‘‘talking back to negative thoughts’’
accounted for 16, 16, and 10% of the variance in
FFI, QAF, QAF-fear scores, respectively. Similarly,

Unstandardized coefficient Standardized coefficient
2
b S.E. of b Beta
1 .56
**
.14 .46
6 -37.78
**
10.96 �.40
4 .55
**
.13 .48
6 �58.83** 16.54 �.40
0 .43
*
.18 .32
0 �1.80* .77 �.31
0 .47
**
.14 .38
7 �39.11** 10.83 �.42
4 .42
**

.13 .34
2 �72.05** 16.11 �.49
0 .19
*
.17 .14
5 �3.10** .73 �.53
ut flying. QAF-fear: questionnaire on attitudes about flying,
fear item.
309306
Table 3
Mean post-September 11th anxiety scores for treatment
completers
Measures Talking back to negative thoughts, mean (S.D.)
Continuing to fly mean (S.D.)
Yes No Yes No
FFI 61.39 (34.11) 98.72 (55.37) 49.24 (31.13) 93.97 (46.63)
QAF 99.01 (59.47) 160.74 (77.60) 71.81 (43.05) 157.70 (68.94)
QAF-fear 4.58 (2.26) 6.37 (3.44) 3.30 (1.98) 6.66 (2.64)
Note. FFI: fear of flying questionnaire. QAF: questionnaire on
attitudes about flying. QAF-fear: questionnaire on attitudes

about flying, fear item.
‘‘continuing to fly’’ significantly predicted FFI (F (1,
47) = 13.04, p < .003), QAF (F (1, 48) = 20.00,
p < .003), and QAF-fear (F (1, 46) = 17.76, p < .003)
(Table 3). Above and beyond the variance accounted for
by post-treatment anxiety scores, ‘‘continuing to fly’’
accounted for 17, 22, and 25% of the variance in FFI,
QAF, and QAF-fear scores, respectively. For all
measures, ‘‘talking back to negative thoughts’’ and
‘‘continuing to fly’’ were associated with lower levels
of anxiety (Table 3). In contrast, ‘‘taking relaxing
breaths,’’ a skill taught in treatment was not associated
with post September 11th flying anxiety. All skills not
taught in treatment including, ‘‘trying to put it out of my
mind/distracting myself’’ and ‘‘talking to friends and
family’’ were not significantly associated with post-
September 11th anxiety scores on any of the measures
( p > .05).
4. Discussion
Given the lack of research examining whether

clients report using skills learned in therapy, and
associations between use of skills and positive long-
term outcomes for FOF, the purpose of this study was to
examine whether participants previously treated for
FOF with CBT reported using skills learned in
treatment (‘‘talking back to negative thoughts,’’
‘‘taking relaxing breaths,’’ and ‘‘continuing to fly’’)
to manage flying anxiety after a fear-relevant event. We
also examined whether self-reported use of skills
learned in treatment was associated with flying anxiety
over the long-term.
Results suggested that individuals who completed
CBT were significantly more likely to report using
‘‘talking back to negative thoughts’’ and ‘‘taking
relaxing breaths’’ as anxiety management skills than
individuals who had not received treatment. No
differences were found between the groups on whether
they continued to fly. In addition, no significant

differences were found between the two groups for
skills not taught in treatment (‘‘trying to put it out of my
mind/distraction myself,’’ ‘‘talking to friends and
family,’’ ‘‘gathering information about increased secur-
ity measures,’’ and ‘‘listening to media’’).
The results also indicated that clients treated with
CBT were more likely to report using skills taught in
treatment than skills not taught in treatment to manage
flying anxiety. Hierarchical multiple regression ana-
lyses revealed that of the skills taught in treatment,
‘‘talking back to negative thoughts’’ and ‘‘continuing to
fly’’ accounted for significant variance in post-
September 11th flying anxiety levels. However, ‘‘taking
relaxing breaths,’’ and skills not taught in treatment
(‘‘trying to put it out of my mind/distracting myself,’’
‘‘talking to friends and family,’’ and ‘‘gathering
information about increased security measures’’ and
‘‘listening to media’’), did not account for a significant

amount of variance in post-September 11th flying
anxiety levels.
On the whole, these results provide support for the
emphasis that CBT places on educating clients to become
their own therapist by teaching them skills that can be
used once treatment is terminated (Beck, 1995). Indeed,
not only were clients more likely to report using skills
taught in treatment than skills not taught in treatment to
manage flying anxiety, two of the three skills taught in
treatment (‘‘talking back to negative thoughts’’ and
‘‘continuing to fly’’) were associated with lower levels of
flying anxiety after a fear-relevant event and in the long-
term (an average of 2.3 years after treatment).
In this study, ‘‘continuing to fly’’ accounted for the
greatest amount of variance in flying anxiety scores
after September 11th (17–25%). However, of the three
skills taught, this skill was endorsed the least by
treatment completers (38%), though it is notable that it

is equal to the rate at which it was endorsed by controls
(39%). These findings highlight the importance of
encouraging clients to engage in continued exposure
after treatment is completed. An important question for
researchers to address is how therapists can encourage
clients to engage in exposure.
Of the three skills taught in treatment, ‘‘taking
relaxing breaths’’ was a not significant predictor of
flying anxiety. This finding is congruent with recent
307
trends in the anxiety literature questioning the role of
breathing retraining as an effective component of
treatment protocols for anxiety disorders (e.g., Craske,
Rowe, Lewin, & Noriega-Dimitri, 1997; Schmidt et al.,
2000). Some researchers have suggested that breathing
retraining acts as a safety behavior that interferes with
corrective learning experiences, and may result in less

complete recovery from treatment and a greater risk of
relapse (Schmidt et al., 2000) within the emotional
processing views of fear reduction (Foa & Kozak,
1986). In this study, ‘‘taking relaxing breaths’’ was not
significantly associated with neither poorer treatment
outcome, nor positive treatment outcomes. The fact that
participants in this study most often endorse ‘‘taking
relaxing breaths’’ highlights the importance of con-
tinued research on what functions as a safety behavior
that inhibits recovery, versus what functions as an
anxiety management technique that facilitates recovery.
The findings related to ‘‘taking relaxing breaths’’
also raise the question of how to differentiate between
an anxiety management skill and a safety behavior.
Indeed, given that relaxed breathing could interfere with
the benefits of exposure for FOF, is it possible that
cognitive restructuring could serve a similar purpose? It
may be important to consider the function of such skills.

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