One of my roles as a professional in the field of psychology has been to teach others who work with kids, especially medical personnel, how to recognize and treat mental health problems in their office setting. Below is one example of an article written for the American Academy of Pediatrics to help pediatricians know how to distinguish shyness from social anxiety. Read on to learn more about what doctors should know about how to help parents who are concerned about their child’s social sensitivity:
How to Identify and Help Young Patients With Social Anxiety (Or Is My Patient Just Shy?)
Susan M. VanScoyoc, Ph.D., ABPP and Edward R. Christophersen, Ph.D., ABPP
Parents of inhibited children may count on their provider’s opinion as to whether or not they should be concerned about their child’s discomfort with social interactions. In fact, over half of parents in a nationally representative study on adolescent mental health identified their teen as ‘shy.’1 Often times the answer seems straightforward, such as when a preschooler expresses initial fear at joining peers at soccer practice, or when an adolescent is nervous to give speeches in class. Yet, for many children, what seems like behavioral inhibition or age-appropriate angst is a more significant and distressing social anxiety disorder (SAD). Rates of childhood SAD range from 29% to 40% in clinical settings, making it one of the most frequently seen mood disorders in mental healthcare2. Youth with SAD have fewer friends, receive fewer positive responses from peers, and experience higher rates of comorbid depression, anxiety, and substance use disorders than children without anxiety 3. They are not simply overly shy children, but individuals with a distinct psychiatric disorder resulting in significant impairment in their daily functioning. Left untreated (and over 30% of adults report having symptoms at least 10 years before they sought help4), the course of SAD is typically chronic and unremitting. In short, children with SAD typically do not “outgrow” the disorder; poor coping skills reinforced by avoidance of social interactions perpetuate its persistence into adulthood. This article provides suggestions for assessing symptoms and impairment related to social anxiety, along with treatment recommendations for reducing distress related to social interactions.
Definition of Social Anxiety Disorder
Social anxiety disorder (SAD), also called social phobia, is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)5 as marked fear of interactional or performance situations that may involve scrutiny from others and has been present for at least 6 months. These situations must almost always elicit fear or anxiety and are typically avoided or endured with intense distress. In children, a diagnosis of SAD requires such anxiety related to peer interactions, not just those with adults. Examples of situations that children may fear are offered in Table 1. In such situations, the youngster fears negative evaluation, humiliation, or rejection based on his or her actions, with the fear being out of proportion to the actual threat. The child does not have to be aware of the excessive nature of the response. Clinical examples of how such fears may be expressed are also offered in Table 1. Many children with anxiety, including social anxiety, may present to providers with physiological complaints, especially recurring abdominal pain and headaches. They also experience behavioral avoidance and distorted cognitive evaluations that perpetuate their fears of social situations.
Table 1. Examples of Feared Social Situations and Expressions of Anxiety in Youth with SAD
Feared Social Situations
Expressions of Anxiety
Meeting unfamiliar peers or adults
Starting or maintaining a conversation with a known or unknown person
Initiating a social outing
Joining an unfamiliar group activity such as an organized sport or school club
Academic performance in front of others (reading aloud, writing on the board, speeches)
Getting up in class to turn in a paper, sharpen a pencil, or use the restroom
Recreational performance in front of others (sports, recitals)
Eating or laughing in front of others
Violating minor or serious rules
Physiological: sweating, crying, clinging, flushing, lump in the throat, tense muscles, racing heart, headaches, stomach aches, nausea
Behavioral: excessive shrinking from contact with unfamiliar people, persistent reluctance to approach unfamiliar people, overcautious, clinging, crying, defiance, anger outbursts, avoidance of feared situations
Cognitive: Negative evaluations, interpret social situations as threatening, perform a ‘social autopsy’ on past social interactions (e. g., “I won’t be able to think of enough to say”; “I will say something stupid”; “My classmates will think something is wrong with me”; “Everyone can tell how nervous I am”; “She will think I am boring”; “If I am quiet, he will think I am rude”; “We will get evicted if the neighbors think we are too loud”; “I am sure I just sounded stupid”; “Who says dumb things like that”).
In addition to experiencing the symptoms of social anxiety summarized above, a child must also be impaired by these symptoms to a clinically significant degree in order for a diagnosis of a SAD to be supported. Impairment likely exists in peer relationships but may also be present in academic functioning, employment for teens, relationships with teachers, and overall family functioning. The child with social anxiety may have few friends, lack participation in any extracurricular activities or endure them with distress, experience many absences from school due to fears or somatic symptoms, report lower grades than desired due to poor participation or attendance, and endorse feelings of loneliness and depression. Family events may be altered to accommodate the child’s fears of unfamiliar family members or large crowds. Many older children can express distress about their discomfort with social interactions and perhaps a desire to interact more similarly to their peers. Overall, parents may note a general lack of developmental-appropriateness in their child’s level of independence and social interactions. If a parent is also socially anxious, she may not be as concerned about the child’s lack of participation in social events but likely still desires that the child participate in academic endeavors with less distress.
Screening for Social Anxiety
The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders6 recommended that all children be routinely screened for anxiety. For social anxiety, parents can provide valuable information on situations that are avoided, avoidance behaviors, statements of fear, and impairment related to social functioning at and away from home. Patients may be able to self-report on such information, and may also have insight into their negative cognitions and physiological discomfort when anticipating or facing a social situation. When screening for social anxiety, the provider is likely to gain the most useful information by administering a global screen for anxiety that also specifically measures for social anxiety. Two empirically-based, self-report examples of screening measures are the Screen for Child Related Anxiety Disorders (SCARED)7 and the Revised Children’s Manifest Anxiety Scale, Second Edition (RC-MAS 2).8 The SCARED Child version may be administered to children ages 8 and older and includes 41 questions assessing for social anxiety, as well as significant somatic symptoms, general worries, separation fears, and school avoidance. A Parent version is also available. Both versions, including scoring information, are available at no cost at http://www.psychiatry.pitt.edu/research/tools-research/assessment-instruments.
The RC-MAS 28 is a 49-item measure for children ages 6 to 19 with subscale scores for physiological symptoms, general worry, and social anxiety. This tool also has a Defensiveness Scale and Inconsistent Responding Index, which can help identify children who may be answering in a socially desirable way. Children with social anxiety may have difficulty endorsing unfavorable symptoms, and thus such scales can help alert the provider to children who need more reassurance that their answers will not be viewed in a critical manner. The RC-MAS 2 is available for purchase at www.mhs.com in a hand-scored format.
The evaluation of social anxiety requires not only symptom presentation, but as noted above, information on distress and impairment as well. The child and parent should be asked about impairment related to peer relationships, family relationships, romantic relationships, school, and employment. Older children should be questioned about their level of distress related to social interactions as well. Patient questions for determining clinical significance of symptoms are offered in Table 2. Similar questions should be asked of caregivers.
Table 2. Questions for Determining Impairment and Distress in Children with Social Anxiety
Questions for Children and Adolescents
How has your anxiety affected:
How you make friends? Join kids you know/don’t know? Willingness to try new social activities? Willingness to date?
How you keep friends? How much you invite friends over/go with them places? How much time you spend with them alone? What kinds of activities you are willing to do with them?
Your relationship with your parents? Siblings? Extended family? Family outings?
How much you participate in class? Ask the teacher for help in class or privately? Ask permission to leave class? Your grades? Your relationship with your teacher?
Your ability to look for a job? Your ability to meet the interaction demands of your job?
Your mood? How you feel about yourself?
How bothered are you by your social worries? Do you tend to focus on what you did wrong in an interaction? Do you feel very different from your peers and how they interact with other kids?
How would your life be different if you weren’t so worried all the time about social situations?
What About Shyness?
In response to the typical and increasing social demands of childhood, youngsters may endorse symptoms of social anxiety related to one situation or another. Young children may become clingy, tearful, even defiant when faced with an unfamiliar peer group, and adolescents may report stomachaches and dread at the thought of giving an oral report in class. Are such children just shy? Are they experiencing developmentally-appropriate worry similar to their peers? Do they have a diagnosable SAD?
The essential feature for distinguishing shyness from a SAD is the level of distress and impairment the anxiety causes the patient and family. Children who are shy may ‘hang back’ from group situations but may eventually warm to the social demands and interact freely with one or two other peers. A child with SAD may not comfortably interact with peers or others well beyond preschool, creating impairment in functioning at and away from school. Providers should also be alert for children, especially teens, who appear to have mastered social situations from an outsider’s perspective, but report depression or distress related to how they feel about social interactions. Such teens are often high-achieving and appear confident but privately perform a ‘social autopsy’ on the smallest social interaction such as passing a peer in the hall. In short, parents of inhibited children should be made aware that being “shy” is not a disorder, but once significant impairment is noted it is likely time to intervene and improve their child’s social functioning and overall development.
Treatment for Social Anxiety Disorder
The successful management of SAD in children is typically multi-modal, often including education of immediate caregivers, consultation with school personnel, and cognitive-behavior therapy (CBT)9. CBT has strong empirical support and typically involves exposing the child to feared situations, cognitive restructuring, and social skills training. Perhaps one of the most dramatic examples of the efficacy of CBT for anxiety disorders, including SAD, is reported by Barrett, et al.10 who demonstrated that 52 clients (ages 14 – 21 years) who had completed treatment an average of over 6 years earlier, maintained their treatment gains 12 and 60 months later.
Key Components of CBT: One of the most important components of effective treatment for SAD is that of exposure to feared social situations. Graduated exposure therapy involves confronting the least anxiety provoking situation directly until it no longer triggers fear or negative self-evaluation, then advancing to the next least anxiety provoking situation, and so on. For example, a teen could be encouraged to meet a friend at a movie instead of driving together to reduce the amount of time needed to generate conversation. Such activities should be repeated until the child is relaxed before moving on to a slightly more difficult situation such as adding another peer to the same situation. A thoughtful approach to graduated exposure almost always works better than simply encouraging the child to pick up the phone and invite someone over to play. Also, most seasoned CBT therapists know that these strategies are more effective, at least initially, if the child can earn a tangible reward for practicing or participating in such exposure exercises. The child should be rewarded for participating in the exposure, and NOT for successful interaction. Older children and teens may be intrinsically rewarded by their decrease in distress and growing friendships but external rewards are also effective for these youngsters as well. In addition to exposure, children with SAD often also need to learn skills to reduce their negative thoughts, relax when they are faced with frightening social situations, and build confidence in their social skills. Patients and parents need to know that the child’s brain is sending ‘false alarms’ about the level of danger in social situations, and that avoiding or escaping fearful situations only makes the connection between distress and social interactions stronger.
Effective CBT treatment is available from mental health providers with training in this treatment modality. Given the nature of social anxiety, however, parents and children with this disorder may be reluctant to seek individual mental health help. The shortage of well-trained, mental health care providers readily available to treat anxiety is also a barrier to care in most communities. Furthermore, the provider may not be convinced that a referral for therapy is necessary given a low level of distress or impairment for the child and family. Thus, recommendations that can be discussed in the office with less impaired families or for those waiting for outside mental health care are provided in Table 3.
Medication: Many advances in the pharmacological treatment of childhood anxiety disorders have been made in the past decade, often guided by whether or not medication works as well as CBT. The AACAP Practice Guidelines5 suggested enough well-controlled research evidence was available to recommend the use of selective serotonin reuptake inhibitors (SSRI’s) as a short-term treatment option in certain cases, with no single SSRI working better than any others for childhood anxiety. Children who require acute symptom reduction, have interfering comorbid conditions, or who could benefit more fully from therapy should be further evaluated for the appropriateness of medication as an additional treatment option. Large, well-controlled studies comparing medication to CBT also offer some support for the use of SSRI’s for anxiety disorders, including SAD11. Authors from the Child/Adolescent Anxiety Multimodal (CAMS) study11 reported that CBT and sertraline both work equally well for reducing anxiety symptoms in children with SAD and other anxiety disorders, with a combination of these two therapies demonstrating superior results. Other mediation such as tricyclic antidepressants, benzodiazepines, and buspirone do not have enough evidence from well-controlled studies to be considered beneficial for treating anxiety symptoms in children.
Table 3 Office-based Strategies for Children who are Shy or with SAD
Know that your child (and you) can tolerate a little distress when it comes to social situations.
Do not punish or lecture your child for not talking or not participating in a social activity. Ask other well-meaning caregivers to avoid comments about your child’s social fears.
Try not to rescue your child by telling others ‘he is just shy.’ Wait a few seconds for him to respond. If he doesn’t, simply state something like, ‘he is working on being brave around other people.’
Keep exposing your child to new experiences. Some children do better when they can participate in a group activity like soccer vs. t-ball, which has increased individual attention. Private lessons provide your child the opportunity to gain comfort and skill level with one adult and may be preferable for some children.
Try to keep your child in a committed activity for as long as possible, but within reason. If your child is 3 and refusing to attend basketball practice, you can probably let her off the hook and try again in a few years. If your child is 7, ask her to meet at least some of her commitment. For example, ask that she attend practices and games and cheers on her team if she does not want to actually participate in the game.
If your child must leave a social situation due to high anxiety, try to him calm down even slightly before leaving. Encourage him to get a drink, take deep breaths, watch a funny video, or walk around until he feels calmer. This will help break the association between high anxiety and escape behaviors.
Consider teaching your child relaxation strategies such as deep breathing, guided imagery, and progressive muscle relaxation. Many media resources such as CD’s and apps for smart phones are available (see additional resources).
Problem solve with your older child about situations that he struggles with now but would like to master. Rate them 1-10 depending on how scary they sound to your child. Start with activities on the ‘1’ end of the scale and practice them until the rating drops to a 1 or 2. For example, if your child is afraid of raising her hand in class because her classmates will think she is dumb, have her practice raising her hand at home while you play school. Or ask the teacher to practice with her during 1:1 time. The teacher and your child could also pick a question she would like to answer and arrange for the teacher to call on her in class for that question only.
Involve school personnel when appropriate to modify their demands for social interaction. A preschool teacher could simply say, ‘you are here today in your green dress’ versus questioning your child about her weekend when she arrives at school. Teachers of older children can be asked to not call on them in class unless they raise their hand, to allow all children to ‘pass’ on reading out loud, and modifying participation requirements for more significant anxiety. These modifications may take a request from the provider to be pursued.
1. Anxiety and Depression Association of America at www.adaa.org (includes podcasts for teens; CEU workshops are offered at their annual meetings)
2. Social Anxiety Institute at www.socialanxietyinstitute.org (includes fee-based, online CBT course-appropriate for motivated teen or adult)
3. Child Mind Institute at www.childmind.org (includes educational videos on selective mutism)
4. Kids Health at www.kidshealth.org (also provides information in Spanish)
5. Relaxation Apps for ioS such as MindShift, Smiling Mind, Mind Jar, and Super Stretch Yoga
6. Websites with relaxation information and an ioS app such as stopbreaththink.org and kidshappyapps.com
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2. Hammerness P, Harpold T, Petty C, Menard, C, Zar-Kessler C, Biederman, J. Characterizing non-OCD anxiety disorders in psychiatrically referred children and adolescents. J Affective Disord. 2008; 105: 213-219.
3. Spence SH, Donovan C, Brechman-Toussaint MB. Social Skills, social outcomes, and cognitive features of childhood social phobia. J Abnorm Psychol. 1000; 108: 211-221.
4. Wang, PS, Lane, M, Olfson, M, Pincus, HA, Wells, KB, Kessler, RC. Twelve month use of mental health resources in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62: 629-640.
5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). 2013. Washington, DC: Author.
6. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007; 46: 267-283.
7. Birmaher B, Ehmann M, Alexson DA, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale construction and psychometric characteristics. J Amer Acad Child Adolesc Psychiatry. 1997; 36: 545-553.
8. Reynolds CR, Richmond BO. Revised Children’s Manifest Anxiety Scale (2nd ed). 2008. Torrence, CA: Western Psychological Association.
9. Christophersen ER, VanScoyoc SM. Treatments that work with children: Empirically supported strategies for managing childhood problems (2nd ed.). 2013. Washington, DC: American Psychological Association.
10. Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6 – year) follow-up. J Consult Clinic Psychol. 2001; 69: 135-141.
11. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New Eng J Med. 2008; 359: 2753-2766.
© 2014 reprinted from AAP Section on Developmental and Behavioral Pediatrics, Developmental and Behavioral News, www.dbpeds.org