Summary of article published in the Journal of Child Psychology and Psychiatry, Vol. 42, No. 1, pp. 127-140, 2001
Social phobia, a common problem in children and adolescents, has recently gained serious attention in clinical practice and research. Social phobia is defined as "a marked and persistent fear of social or performance situations in which embarrassment may occur" (according to the Diagnostic and Statistical Manual (IV) of the American Psychiatric Association, 1994, p. 411). Children or adolescents with social phobia become so disabled by the fear of other people's reactions and expectations that they avoid situations in which they fear that evaluation by others might occur.
Diagnosing social phobia in children and adolescents (DSM-IV)
A diagnosis of social phobia requires that 1) an individual, when exposed to the feared social situation, must invariably experience anxiety and must recognize that this anxiety is excessive or unreasonable, 2) the individual experiences intense distress while in the feared situation or avoids it, 3) the social phobia interferes significantly with the person's normal routine, social activities, or occupational/academic functioning, and 4) the fear or avoidance of social situations cannot be due to the direct physiological effects of a substance or general medical condition or be better accounted for by another mental disorder.
The diagnosis of social phobia in children emphasizes the following important developmental differences between children and adults:
- A child with social phobia must show the capacity for age-appropriate social relationships with familiar people, and his or her anxiety must occur in peer contexts, not just with adults.
- The anxiety brought on by social situations may be evidenced in children by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
- Due to limitations of cognitive and perceptual skills in young children, children with social phobia need not recognize that their fear in social situations is excessive or unreasonable.
- Under the age of 18 years, there must be evidence of the social fears existing for a minimum of six months.
Studies estimate rates of social phobia in youth at approximately 1-9%, depending on the age and gender. While studies have reported cases of social phobia in children as young as 8 years, it is more frequently diagnosed in adolescents. One study found that the average age of onset of social phobia falls between 11.3 and 12.3 years. Thus, social phobia appears to be a common problem that typically emerges in pre-adolescence; early recognition offers an opportunity for prevention and treatment.
Developmental pathways to social phobia
Normative developmental factors Children as young as 6 months through 3 years of age commonly show anxiety in the forms of stranger and separation anxiety. Some young children, when confronted with a new social situation, throw tantrums, cling to a familiar person, avoid contact, refuse to take part in group play, and become overly vigilant. By late childhood and early adolescence, children's fears of social evaluation of academic and social performance are forefront. Although at some point during their adolescence all youth will experience some level of anxiety about being judged in school or social situations, obviously not everyone goes on to develop pathological levels of social anxiety (i.e., social phobia).
Temperamental factors A predisposition to timidity and nervousness has been believed to be a matter of inborn temperament. The majority of recent research in the role of temperamental factors in the development of social phobia focuses upon behavioral inhibition (BI). BI refers to a temperamental style that is characterized by reluctance to interact with and withdrawal from unfamiliar settings, people or objects. In infants, BI is typically manifest as irritability, in toddlers as shyness and fearfulness, and in school age children as cautiousness, reticence and introversion. BI includes reactions that can be seen in behavior, such as interrupting of ongoing behavior, ceasing vocalization, comfort seeking from familiar persons, and retreat from and avoidance of unfamiliarity. BI also includes reactions that are physiological, such as stable high heart rate, acceleration of heart rate to mild stress, pupillary dilation, and increased salivary cortisol. Overall, evidence to date suggests that a behaviorally inhibited temperament may predispose a child to the development of high social anxiety, although BI has yet to be definitively identified as a necessary precursor to the development of the clinical syndrome social phobia.
Physiological factors Researchers have just begun to explore the physiology of social phobia, and studies have been primarily conducted with adults. When facing phobic situations, socially phobic individuals commonly experience such symptoms as blushing, racing heart, sweating, and increased respiration, all of which are reactions associated with the autonomic nervous system (ANS). However, the few studies that have examined ANS functioning in socially phobic individuals have provided mixed results.
Other research has examined the function of the amygdala, a small region in the forebrain involved in the output of conditioned fear responses, e.g., freezing up behavior, blood pressure changes, stress hormone release, and the startle reflex. Hypersensitivity in the neural circuitry that centers on the amygdala may be responsible for behavioral inhibition in children. The application of currently developing neuroimaging technologies to children and adolescents may prove to be especially useful in elucidating the continuities and differences between social phobia in youngsters and in adults.
Twin studies. Taken as a whole, studies using twins to determine whether genetics play a significant part in the development of social phobia are inconclusive. Some twin studies have examined the heritability of shyness and social fears rather than the clinical disorder social phobia. Overall, these studies suggest that genetics play a modest to moderate role in the development of symptoms and temperamental traits associated with social phobia.
Family studies. Studies examining the rates of social phobia in the offspring or in other first-degree relatives of socially phobic individuals show that social phobia rates in relatives are higher than in the relatives of individuals with other anxiety disorders or no disorder. Overall, these studies suggest that social phobia is at least moderately familial and possibly specific in its transmission. However, family studies cannot specifically sort-out the relative contributions of genetic influences and family environmental influences on the development of a disorder. Thus, the mechanisms behind this familial connection in social phobia still need clarification.
Parenting/family environment factors Research indicates that parent characteristics and family environment, through such mechanisms as modeling of avoidant responses and restricted exposure to social situations, are likely to have at least a moderate effect on the development of social phobia in children and adolescents. It appears likely that if the parent's own anxiety is communicated to the child, a cycle is established in which parent and child reinforce each other's anxiety. Controlling/overprotecting and less affectionate parenting styles have been found to be associated with social phobia in adult offspring, although the cause and effect relationship between these characteristics and social phobia is unclear. A major gap in this area is research that uses children with social phobia or children at high risk for social phobia, and this needs to be filled before the developmental impact of parental and family factors can be specified.
General subtypes of social phobia
The current diagnostic system specifies two types of social phobia : 1) "Generalized," if the individual's fear encompasses most situations, and 2) "Non-generalized" social phobia, sometimes also described as "discrete," "circumscribed," "limited," or "performance," when social anxiety is limited to a few specific contexts (e.g., eating in front of others, writing, public speaking). In order to differentiate between subtypes, a thorough assessment of an individual's anxiety in many different types of social situations is necessary.
Subtypes in children and adolescents Two studies provide preliminary evidence for distinct social phobia subtypes in adolescent and young adult populations. These studies specifically found that generalized socially phobic adolescents (those who experience anxiety across many social situations) appear to be distinguishable from those who have non-generalized social phobia (experience anxiety in only one or two social contexts) by earlier age of onset, greater level of impairment, greater risk for developing co-morbid disorders, greater parental psychopathology, separation difficulty during childhood, and behavioral inhibition. However, further studies are needed not only to validate these findings but, also, to see if subtypes exist in preadolescents with social phobia.
Relationship of social phobia to other problems
Consistent findings of research focused on youth with social phobia are high rates of co-existence among social phobia and other anxiety disorders, mood disorders, ADHD, and substance abuse disorders. Social phobia often precedes the development of coexisting conditions. However, research suggests that individuals who develop major depression prior to the onset of social phobia have a significantly better chance of recovery than do those who report an onset of depression following the social phobia. Overall, studies suggest that youth with social phobia and coexisting disorders are significantly compromised by a disabling psychiatric pattern that can extend into adulthood.
Consequences of social phobia
Children and adolescents with social phobia fear a range of situations and activities including speaking, eating, writing, or performing in front of others, initiating or maintaining conversations, attending parties and after-school activities, speaking to authority figures, acting in an assertive manner, and informal social situations. Additionally, affected youth suffer from high levels of dysphoria, loneliness, and general anxiety . Children with social phobia (ages 7 to 14 years) are found to have impaired social skills relative to non-anxious controls. Both adolescent males and females reporting high levels of social anxiety feel less accepted and supported by peers, and also less romantically attractive to others. Overall, findings suggest that social anxiety may interfere specifically with the development of close interpersonal relationships, especially for girls.
Although work done with shy adolescents (not diagnosed) indicates that shy youth are at risk for suicide attempts, the relationship of social phobia to suicidal ideation or attempts in youth has not yet been directly studied. Social phobia in adults is associated with increased suicide attempts.
Over the long term, social phobia is associated with a number of personal costs for affected individuals and their support systems, including impairments in role functioning and quality of life. As with other severe psychiatric conditions, social phobia is associated with failure to complete high school in females, and failure to enter and complete college in males and females. Beyond costs at the individual level, truncated educational attainment is associated with a number of adverse life-course and societal consequences including less training of the workforce, decreased participation and functioning in civic activities, and greater demands on the social welfare system. Thus, the potential consequences of the disorder are broad, impacting the emotional, occupational and social functioning of the individual over the long term, with individuals suffering functional impairments in the areas of school, social relations, family life, and employment.
Treatment of social phobia in youth
Cognitive Behavioral Treatment Treatment from the cognitive-behavioral perspective assumes that social anxiety is a normal and expected emotion. Social anxiety becomes problematic when it exceeds expected developmental levels and results in significant distress and impairment at home, school, and in social contexts. Anxiety is assumed to comprised of physiological, cognitive, and behavioral components. Cognitive behavioral treatment (CBT) involves specific psychoeducation, skills training, exposure methods, and relapse prevention plans for addressing the nature of anxiety and its components. Psychoeducation provides corrective information about anxiety and feared stimuli; somatic management techniques target autonomic arousal and related physiological responses; developmentally appropriate cognitive restructuring skills are focused on identifying maladaptive thoughts and teaching realistic, coping-focused thinking; exposure techniques involve graduated, systematic, and controlled exposure to feared situations and stimuli; and, relapse prevention methods focus on consolidating and generalizing treatment gains over the long term.
In addition to general CBT programs for anxiety, two promising and developmentally appropriate programs have been developed specifically to treat social phobia in children and adolescents. Social Effectiveness Therapy for Children (SET-C)1 is appropriate for youth ages 8 through 12 and involves 24 treatment sessions held over a 12-week period. Each child participates in one group social skills training session and one individual exposure session each week, with structured homework assignments serving to promote generalization of the within session experience to the child's real life. Based upon the success of Cognitive Behavioral Group Treatment for adult social phobia, Albano and colleagues adapted the protocol (CBGT-A) for adolescents ages 13 through 17.2 CBGT-A involves 16 group sessions incorporating psychoeducation, skills training (cognitive, social, and problem solving), and behavioral exposures.
Pharmacotherapy Attention is just turning to the evaluation of pharmacologic agents for the treatment of social phobia in youth. Selective serotonin reuptake inhibitors (SSRIs) are demonstrating the most promise in treating anxiety in youth. Only two studies directly addressed social phobia or its variant, selective mutism.
In response to the dearth of controlled pharmacologic trials, the National Institute of Mental Health has established the Research Units in Pediatric Pharmacology (R.U.P.P.), a division focused on the controlled evaluation of psychotropic medications for use in children younger than 18 years of age. R.U.P.P. investigations focus on testing the efficacy of specific compounds for the range of emotional and behavioral disorders in youth. At present, the R.U.P.P. is evaluating the efficacy and safety of medications such as the SSRIs for the treatment of social phobia and related anxiety disorders in youth. Results of these trials are forthcoming.
In general, most pediatric psychiatrists will agree that treatment of anxious youth should begin with cognitive behavioral therapy or that CBT should be included in the treatment plan. It is unusual and not recommended for medication to be considered as the sole treatment for anxious youth.
Social phobia, once called the "the neglected anxiety disorder," is a chronic and debilitating condition that onsets early and can extend into adulthood. Exciting and essential research efforts are under way, bringing together researchers from different yet interrelated disciplines to understand the psychological and physiological contributants to social phobia. Through such research we are developing a better understanding of the risk and protective factors of social phobia in children and adolescents, which will ultimately lead to improvements in primary prevention and intervention efforts for children at serious risk for long-term problems with education, employment, social relationships and independent adult functioning.
About the Authors
Olivia N. Velting, Ph.D. is an Associate Research Scientist at the NYU School of Medicine.
Anne Marie Albano, Ph.D., is the Recanati Assistant Professor of Child and Adolescent Psychiatry, NYU School of Medicine. www.AboutOurKids.org.
Complete references may be found in the original journal article cited above. References for the specific treatment programs mentioned in this summary are:
1. Beidel DC & Turner SM (1988) Shy Children, Phobic Adults: Nature and Treatment of Social Phobia. Washington, DC: American Psychological Association.
2. Albano AM, Marten P, Holt C, Heimberg R, & Barlow,D (1995) Cognitive-behavioral group treatment for social phobia in adolescents: A preliminary study. The Journal of Nervous and Mental Disease, 183, 649-656.