Research in Developmental Disabilities 67 (2017) 94–98

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Research in Developmental Disabilities

journal homepage: www.elsevier.com/locate/redevdis

The relation between social anxiety and biased interpretations in MARK

adolescents with mild intellectual disabilities
⁎
Esther O. Houtkampa, , Mariët J. van der Molena, E. Leone de Voogdb,
Elske Saleminkb, Anke M. Kleina,b
a
Clinical, Neuro, and Developmental Psychology, VU Amsterdam, The Netherlands
b
Child Development and Education, University of Amsterdam, The Netherlands

AR TI CLE I NF O AB S T R A CT

Keywords: Background: Cognitive theories of anxiety emphasize the importance of cognitive processes in the
Mild intellectual disabilities onset and maintenance of anxiety disorders. However, little is known about these processes in
Social anxiety children and adolescents with Mild Intellectual Disabilities (MID).
Interpretation bias Aims: The aim of this study was to investigate interpretation bias and its content-specificity in
Content-specificity
adolescents with MID who varied in their levels of social anxiety.
Adolescence
Method and procedures: In total, 631 adolescents from seven special secondary schools for MID
filled in questionnaires to measure their levels of social anxiety. They also completed the
Interpretation Recognition Task to measure how they interpret ambiguous situations.
Outcomes and results: Adolescents with higher self-reported levels of social anxiety interpreted
ambiguous scenarios as more negative than adolescents with lower self-reported social anxiety.
Furthermore, this negative interpretation was specific for social situations; social anxiety was
only associated with ambiguous social anxiety-related scenarios, but not with other anxiety-re-
lated scenarios.
Conclusions and implications: These findings support the hypothesis that socially anxious ado-
lescents with MID display an interpretation bias that is specific for stimuli that are relevant for
their own anxiety. This insight is useful for improving treatments for anxious adolescents with
MID by targeting content-specific interpretation biases.

What this paper Adds?

Cognitive theories of fear and anxiety emphasize the importance of cognitive processes in the onset and maintenance of anxiety disorders.
However, little is known about these processes in children and adolescents with Mild Intellectual Disabilities (MID). This paper is the first
study that examines the relation between biased cognitive processes and anxiety in adolescents with MID. The purpose of this study was to
determine whether socially anxious adolescents with MID display an interpretation bias and whether this bias is specific for scenarios related
to social situations. The results show that socially anxious adolescents with MID indeed display an interpretation bias and that this bias is
specific for social situations. Theoretically, this paper indicates that adolescents with MID show biased cognitive processes that are similar to
adolescents with average IQ scores. These results provide evidence for the applicability of the cognitive social anxiety model to adolescents
with MID. Clinically, this insight is useful for improving treatments for anxious adolescents with MID by targeting content-specific inter-
pretation biases. Treatments aimed at specific biased cognitive processes may be potentially more effective than generic treatment programs.

⁎
Corresponding author at: Clinical, Neuro and Developmental Psychology, VU University, Van der Boechorststraat 1, 1081BT Amsterdam, The Netherlands.
E-mail address: esther.houtkamp@hotmail.com (E.O. Houtkamp).

http://dx.doi.org/10.1016/j.ridd.2017.06.003
Received 18 November 2016; Received in revised form 4 April 2017; Accepted 8 June 2017
Available online 30 June 2017
0891-4222/ © 2017 Elsevier Ltd. All rights reserved.
E.O. Houtkamp et al. Research in Developmental Disabilities 67 (2017) 94–98

1. Introduction

Social anxiety disorder is highly prevalent in children and adolescents with Mild Intellectual Disabilities (MID) and is reported as
one of the most common forms of social distress in this population (Dekker & Koot, 2003; Emerson, 2003). Social anxiety disorder
often develops during adolescence and is marked by the persistent fear of social or performance situations (American Psychiatric
Association, 2013). Although treatments for child- and adolescent anxiety have shown good efficacy, at least 40% of children and
adolescents continue to have a diagnosis after treatment (James et al., 2013). Moreover, studies related to the treatment of anxiety
disorders in adolescents with MID are scarce, but the general conclusion is that treatments are less effective in individuals with MID
compared to individuals with an average IQ (e.g. see Dagnan & Jahoda, 2006). To develop potentially more effective treatments for
social anxiety disorder in adolescents with MID, more insight into underlying processes of their anxiety seems important.
Over the past two decades, several underlying processes have been defined as maintaining and possibly causing anxiety disorders,
including cognitive processes (for a review, see Mathews & MacLeod, 2005). According to theories that describe the importance of
cognitive processes (e.g., Beck, Emery, & Greenberg, 1985), socially anxious adults and children have anxiety-related schemata.
These schemata direct processing resources towards threat-relevant information, resulting in cognitive biases related to attention,
interpretation and memory (e.g., Clark & Wells, 1995; Rapee & Heimberg, 1997). There are indeed numerous studies that reported
evidence for the existence of cognitive biases in adolescents (for an overview, see Hadwin & Field, 2010) and there is also some
evidence that these biased cognitions are content-specific (e.g. Bögels & Zigterman, 2000; Klein et al., 2012, 2014). For example,
adolescents who are socially anxious presumably interpret ambiguous stimuli that are related to social situations in a negative way
(interpretation bias), while other ambiguous stimuli, for example related to spiders, are not negatively interpreted.
To investigate the causal role of such threat-related biases and the potential to alleviate symptoms by reducing biases, Cognitive
Bias Modification for Interpretations (CBM-I) training paradigms have been developed (for a review, see MacLeod & Mathews, 2012).
Positive effects on interpretation bias and anxiety have been found in adolescents (Salemink & Wiers, 2011). These positive effects
were specifically found in adolescents with lower levels of cognitive control or working memory capacity (Salemink & Wiers, 2012).
As adolescents with MID have difficulties in making use of their working memory (Van der Molen, Van Luit, Van der Molen, &
Jongmans, 2010), CBM-I might be particularly relevant here as an alternative approach in treatment. However, a prerequisite for the
relevance of CBM-I is the presence of an interpretation bias. Furthermore, insight into the consent-specificity of this bias is important
to target specific biases efficiently. Unfortunately, up to now, there are no published studies that examine the existence of inter-
pretation biases related to anxiety in adolescents with MID. Therefore, it is still unclear whether socially anxious adolescents with
MID interpret ambiguous situations in a negative way comparable to adolescents with an average IQ. There are several studies that
concluded that individuals with MID have similar coping strategies during difficult situations as individuals without MID (Da Costa,
Larouche, Dritsa, & Brender, 2000; Fanurik, Koh, Schmitz, Harrison, & Conrad, 1999; Kurtek, 2016; Madland, Feinmann, & Newman,
2000). These findings might suggest that similar biases in information processing might also play a role in adolescents with and
without MID.
Therefore, the focus of the current study was to investigate interpretation bias and its content-specificity in a group of adolescents
with MID who varied in their levels of social anxiety. Based on theoretical conceptualization and findings in adolescents with an
average IQ, we hypothesized that adolescents with higher levels of social anxiety would display a stronger negative interpretation
bias. Furthermore, we expected that this bias would be specific for social anxiety-related situations.

2. Methods

2.1. Participants

A sample of 740 adolescents was recruited from seven special secondary schools in the Netherlands. Indication criteria for these
schools are limitations in intellectual functioning (IQ-scores between 55 and 80) and adaptive behavior, including significant dys-
functions in conceptual, social and practical skills (American Psychiatric Association, 2013; Schalock et al., 2010). After passive
consent had been granted by the adolescents and their parents, a total of 631 children (364 boys) participated in this study. All
adolescents were between 12 and 18 years old (M = 14.35, SD = 1.46). The ethics committee of the University of Amsterdam, the
Netherlands, approved this study. The current study was part of a large community-based project on adolescent anxiety (Klein et al.,
2016a; Klein et al., 2016b).

2.2. Instruments and procedure

Interpretation Recognition Task (IREC-T; Salemink & van den Hout, 2010; Salemink & Wiers, 2011; Van der Molen & Salemink,
2017). Interpretation bias was measured with the IREC-T that was based on the Recognition Task developed by Van der Molen and
Salemink (2017). First, adolescents were asked to read/listen to the instructions and to respond to the different scenarios on a private
computer (one of the assistants read the instructions and the scenarios of the IREC-T out loud, because some adolescents had reading
problems). Adolescents were asked to imagine themselves as the central character of each scenario. After reading/listening to a
scenario, they were asked to answer a comprehension question with ‘yes’ or ‘no’ on the computer screen. After that, the scenario was
repeated and the adolescents were asked to indicate the likeliness of the negative interpretation question on a 4-point-likert scale
(1 = very small, 4 = very great; see Table 1 for sample scenarios of both categories).
As mentioned above, we used a set of 16 scenarios based on Van der Molen and Salemink (2017) that was divided into two

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Table 1
Sample stories of the Interpretation Recognition Task (IREC-T).

Question Answer options

1 IREC-T social scenario

A You walk on your own down the street and see a group of classmates talking. When you pass the Did you walk with a friend down the 1. Yes
group, they start laughing. street? 2. No
B You walk on your own down the street and see a group of classmates talking. When you pass the The chance is… 1. Very small
group, they start laughing. 2. Small
3. Great
What is the chance that they start laughing because they find you strange? 4. Very great

2 IREC-T other anxiety scenario

A You ride in the street where you live. When you’re almost at home, an ambulance with a loud Are you running? 1. Yes
siren drives into your street… 2. No
B You ride in the street where you live. When you’re almost at home, an ambulance with a loud The chance is… 1. Very small
siren drives into your street… 2. Small
3. Great
What is the chance that something bad has happened to your parents? 4. Very great

different categories to test for content-specificity; 8 scenarios were related to social anxiety, and 8 scenarios were related to other
anxieties. The original task of Van der Molen and Salemink (2017) consisted of 7 social anxiety items. We therefore adapted the
ending of scenario 10 (in the original task) to make it related to social anxiety. Some scenarios were slightly adapted to make them
easier (use of short sentences and simple words). Two mean scores were then calculated separately for each scenario category.
Internal consistency was good (α = 0.71) for the social anxiety scenarios and average (α = 0.63) for the other anxiety scenarios.
Social Anxiety Scale for Children – Revised (SASC-R; La Greca & Stone, 1993; Koot & Mesman, 2001). The SASC-R is a self-report
questionnaire measuring symptoms of social anxiety with 18 items on a five-point rating scale ranging from ‘not at all’ to ‘all the time’
(min = 18; max = 90). The validity and reliability of the SASC-R are satisfactory (La Greca & Stone, 1993). Internal consistency in
the current sample was excellent (α = 0.93). To make sure that the adolescents with MID understood the questions correctly, some
possibly difficult words were explained in brackets and if they had questions they could ask the research assistant or the teacher. For a
few adolescents, the questions were read out loud in a one-on-one situation due to reading problems.
The experiment took place in the IT-classroom at each school accompanied by the teacher and two trained assistants. Besides
preforming the IREC-T and filling in the SASC-R, participants also completed some other questionnaires and tasks unrelated to the
current manuscript. Testing took about 60 min and adolescents received a pen as reward.

3. Results

For descriptives, see Table 2. All correlations were controlled for gender because of gender differences on the IREC-T (F (1, 628)
= 12.57, p < 0.001) and the SASC-R (F (1, 624) = 46.11, p < 0.001). As expected, we found significant correlations between the
SASC-R and both subcategories of the IREC-T (social anxiety scenarios: r = 0.34, p < 0.001; other anxiety scenarios: r = 0.18 and
p < 0.001). This means that adolescents who reported higher social anxiety, also interpreted the ambiguous scenarios more nega-
tively than adolescents with lower social anxiety.
Next, a regression analysis was used to examine if the social anxiety items and the other anxiety items of the IRECT-T were able to
independently predict scores on the SASC-R (see Table 3). We also included Gender in order to control for this variable. The model
was significant, F (3, 622) = 39.67, p < 0.001 and it explained 16.1% of the variance in self-reported social anxiety. Only Gender

Table 2
Means and Standard Deviations for the Interpretation Recognition Task – social
items (IREC-T social), Interpretation Recognition Task – other anxiety items (IREC-T
other anxiety) and the Social Anxiety Scale for Children – Revised (SASC-R) sepa-
rately for boys and girls.

Mean(s) (SD)

IREC-T social
Girls 18.95 (4.18)
Boys 17.69 (3.99)

IREC-T other anxiety

Girls 18.15 (3.40)
Boys 17.54 (3.50)

SASC-R
Girls 37.47 (13.99)
Boys 30.57 (11.44)

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Table 3
Regression analysis: prediction Social Anxiety Scale for Children – Revised (SASC-R) score from Gender and the two categories of the
Interpretation Recognition Task (IREC-T).

Criterion variable R2 Predictor Beta

SASC-R 0.26
Gender 0.21*
IREC-T social 0.22*
IREC-T other anxiety −0.01

* p < 0.001.

(B = 0.22, p < 0.001) and the social items of the IREC-T (B = 0.30, p < 0.001) were significant predictors. This means that only the
social items of the IREC-T were able to significantly predict social anxiety; the interpretation bias was thus specific for social si-
tuations.

4. Discussion

This study is the first to investigate if adolescents with Mild Intellectual Disabilities (MID) who have varying levels of social
anxiety display an interpretation bias and whether this bias is specific for social anxiety-related situations. As expected, we found that
adolescents with higher self-reported levels of social anxiety display more negative interpretations than adolescents with lower scores
on social anxiety. Moreover, we found that this bias was specific for social anxiety-related situations. These results are in line with the
findings in adolescents with an average IQ (e.g., Miers, Blöte, Bögels, & Westenberg, 2008) and cognitive theories that state that
socially anxious adolescents interpret social ambiguous situations as more threatening and display biased cognitions for stimuli
related to their anxiety only (e.g., Beck, 1976).
The current study has a number of limitations that need to be acknowledged. First, the current study used an unselected sample.
Future studies are needed that include selected samples or clinical samples to confirm the current findings. Second, due to the lack of
validated measures in this population, we used non-validated measures. Even though the measures had good internal consistencies
and we found the expected relation between the SASC-R and the IREC-T, more research is needed to validate the REC-T and the SASC-
R for this population. Third, even though the adolescents included in our study all had MID, we did not measure their IQ scores. It
might be that intellectual functioning moderated the relation between cognitive bas and social anxiety. Future studies should
therefore measure levels of IQ to assess this possible moderating effect. Finally, it should be mentioned that given the cross sectional
nature of this study, this study is not able to demonstrate causality i.e. cognitive biases could be, at least in part, a consequence of
anxiety rather than causing it. Clearly more studies are needed that focus on the direction of this effect.
In sum, based on our results, we recommend studying the specificity of biases in adolescents with MID, as it seems that ado-
lescents with higher levels of anxiety, do indeed show specific fear-related interpretations, just like adolescents with an average IQ.
Furthermore, we found that the IREC-T may be a useful instrument for assessing the specificity of cognitive processes in adolescents
with MID who vary in their levels of social anxiety. Future research of childhood anxiety should therefore assess the specificity of
other potential biases in adolescents with MID, for instance in attention and memory processes. Furthermore, the present results
support cognitive models in children and adults with an average IQ and argue for the use of the same models in adolescents with MID.
Clearly more research is needed before firm conclusions can be drawn, but our results might indicate that existing treatment, in-
cluding CBM procedures, might also be applicable for adolescents with MID.

Funding

This work was supported by Heeren Loo and Netherlands Foundation for Mental Health.

Acknowledgements

We thank the seven special secondary schools, the adolescents, their parents and teachers who participated in the study.
Furthermore, we would like to thank Marlissa Papa, Samantha Roetink, Raisa Daamen, and Amber Borra for their assistance with
collecting the data. All authors state that there is no declaration of interest.

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