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Behavioral Inhibition in Preschool Children At Risk Is a Specific Predictor of Middle Childhood Social Anxiety: A Five-Year Follow-up

Hirshfeld-Becker, Dina R. PhD; Biederman, Joseph MD; Henin, Aude PhD; Faraone, Stephen V. PhD; Davis, Stephanie BA; Harrington, Kara MS; Rosenbaum, Jerrold F. MD

Journal of Developmental & Behavioral Pediatrics: June 2007 - Volume 28 - Issue 3 - p 225-233
doi: 10.1097/01.DBP.0000268559.34463.d0
Original Article

Objective: Behavioral inhibition (BI) to the unfamiliar represents the temperamental tendency to exhibit fearfulness, reticence, or restraint when faced with unfamiliar people or situations. It has been hypothesized to be a risk factor for anxiety disorders. In this prospective longitudinal study, we compared the psychiatric outcomes in middle childhood of children evaluated at preschool age for BI.

Method: The baseline sample consisted of 284 children ages 21 months to 6 years, including offspring at risk for anxiety (children of parents with panic disorder and/or major depression) and comparison offspring of parents without mood or major anxiety disorders. They had been assessed for BI using age-specific laboratory protocols. We reassessed 215 of the children (76.5%) at 5-year follow-up at a mean age of 9.6 years using structured diagnostic interviews.

Results: BI specifically predicted onset of social anxiety. The rate of lifetime social anxiety (DSM-IV social phobia or DSM-III-R avoidant disorder) was 28% versus 14% (odds ratio [OR] = 2.37; 95% confidence interval [CI]: 1.10–5.10) in inhibited versus noninhibited children. BI significantly predicted new onset of social phobia among children unaffected at baseline (22.2% vs 8.0% in inhibited versus noninhibited children (OR = 3.15, 95% CI: 1.16–8.57). No other anxiety disorders were associated with BI.

Conclusion: BI appears to be a temperamental antecedent to subsequent social anxiety in middle childhood. Children presenting with BI should be monitored for symptoms of social anxiety and may be good candidates for preventive cognitive behavioral strategies.

Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts.

This study was supported by NIMH grant R01 MH047077-13.

Received March 2006; accepted August 2006.

Address for reprints: Dina R. Hirshfeld-Becker, Ph.D., Massachusetts General Hospital Clinical and Research Program in Pediatric Psychopharmacology, 185 Alewife Brook Parkway, Suite 2000, Cambridge, MA 02138; e-mail:

© 2007 Lippincott Williams & Wilkins, Inc.