Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder is a type of anxiety that makes children worry a lot about being rejected or judged negatively by others. The fear, anxiety, or avoidance that children with Social Anxiety Disorder feel is much more than what is normal for their age. Children with this disorder are not just shy—they are so afraid of being embarrassed that they avoid doing things they want or need to do. For example, they might refuse to go to birthday parties, speak in class, or eat at a restaurant because they are scared of what others might think. They might be afraid to go to school, eat in public, meet new people, or even just have conversations. Some kids only feel anxious in “performance” situations, like when they have to speak in class or perform in public. They avoid situations where they’ll be in the spotlight, like public speaking or trying out for a sport.

What are the symptoms of Social Anxiety Disorder?

Core symptoms

– Noticeable anxiety or fear related to one or more situations where the person might be watched by others

– Excessive anxiety or fear about being embarrassed, humiliated, or rejected by others

– Social situations consistently cause anxiety or fear

– Social situations are either avoided or faced with noticeable anxiety or fear

– The anxiety or fear is out of proportion with the social situation

Associated symptoms

– Physical symptoms, like shaking, sweating, dry mouth, and shortness of breath

– Lots of anxious questions: “What if I say something dumb?” “What if everyone thinks I’m a loser?”

– Tantrums and crying, especially in younger children

– Getting upset long before a feared situation

How is Social Anxiety Disorder diagnosed?

A child psychiatrist may diagnose Social Anxiety Disorder if a child’s or teen’s symptoms last for six months or more and cause significant distress and problems in everyday life (e.g., social, family, school, etc.).

The child-adolescent psychiatrist may interview and/or assess both the child and a caregiver to figure out the specific nature of the child’s social anxiety. Many practitioners also use questionnaires or behavior/emotion rating forms to help with the diagnosis and measure how serious the problem is. The practitioner will also try to determine that the child’s or teen’s anxiety is not related to something unexpected.

Social Anxiety Disorder facts

Worldwide prevalence of the condition:

Social Anxiety Disorder is estimated to affect approximately 2.3% of the European population, similar to other global estimates. Anxiety disorders, in general, are estimated to affect 6.5% of the global population.

Impact of the condition in Brazil

Despite limited data, the estimated prevalence of anxiety disorders in Brazil is 2.9% in children (5-9 years) and 8.6% in adolescents (10-19 years). Social anxiety is a type of anxiety disorder, and regarding it alone, there is no nationally representative data.

Gender ratio:

The diagnosis of Social Anxiety Disorder is slightly more common in girls than in boys, although different studies may show variations.

Peak age of onset:

The average age of onset of symptoms is 14.5 years, which is later than that of other anxiety disorders, which typically have an average onset of 5.5 years.

Proportion of condition that emerges before age 18:

Recent studies indicate that 79.1% of people with Social Anxiety Disorder first experience symptoms before the age of 18.

What are the associated factors for Social Anxiety Disorder?

Some common factors linked with Social Anxiety Disorder are:

– Genetic and familial factors: A tendency toward an anxiety disorder most likely comes from a combination of multiple genes interacting with environmental factors. Also, there is a greater chance that a child may develop Social Anxiety Disorder if a close relative has the disorder.

– Environmental factors: These include child maltreatment (e.g., physical or sexual abuse) and other childhood adversities, including peer victimization and rejection. On the other hand, positive peer relationships seem to protect against developing social anxiety.

– Temperament: Including behavioral inhibition early in life.

What other disorders co-occur with Social Anxiety Disorder?

Even though each child and teen is different, Social Anxiety Disorder often happens with other anxiety disorders, including Generalized Anxiety Disorder and Selective Mutism, depressive disorders, and high-functioning Autism Spectrum Disorder. Also, Social Anxiety Disorder frequently leads to Substance Use Disorder, as individuals with Social Anxiety Disorder are more likely to use substances to “self-medicate” and reduce their anxiety levels.

How is Social Anxiety Disorder treated?

Social Anxiety Disorder is usually treated with therapy or a combination of therapy and medication. Caregivers and other family members are an important part of treatment, since they can help kids and teens practice the skills they learn in therapy.

There are many therapies that effectively treat symptoms of Social Anxiety Disorder, but the one with the most evidence is called cognitive-behavioral therapy (CBT). CBT uses many different cognitive and behavioral techniques. One technique is called exposure. Using this technique, a therapist exposes the child to something that triggers anxiety, starting with something very small. As the child becomes upset, the therapist teaches them ways to handle their fear. They repeat this process with bigger and bigger stressors. The therapist also works with the child to change their thinking about their anxiety by identifying unhelpful thoughts or beliefs, making the child aware of them, and helping to reframe them. Group-based CBT has been shown to be especially helpful for children and teens.

Children and teens with Social Anxiety Disorder tend to respond well to certain antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine, sertraline, citalopram, escitalopram, and paroxetine. Other medications called serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, may also help reduce anxiety in children and teens. Benzodiazepines (e.g., alprazolam, lorazepam, diazepam) and tricyclic antidepressants (e.g., clomipramine, amitriptyline) are not effective in children and teens and should not be used. Medications can have side effects, but they are safe for kids to use with proper monitoring by their doctor and close supervision from their caregivers. A child or teen taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

The combination of CBT and SSRIs/SNRIs can also be considered, since some studies show evidence that the combination is better than either treatment alone in children and teens.

References

Clinical description, symptoms, and diagnostic information

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Child Mind Institute. (2021, September 7). Social Anxiety Disorder in children: A quick guide. _https://childmind.org/guide/quick-guide-to-social-anxiety-disorder/_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 6B04 Social Anxiety Disorder. _https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f2062286624_

Facts

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, Available from _http://vizhub.healthdata.org/gbd-compare_. (Accessed 11/15/2022)

– Jefferies, P., & Ungar, M. (2020). Social anxiety in young people: A prevalence study in seven countries. PLOS ONE, 15(9), e0239133. _https://doi.org/10.1371/journal.pone.0239133_

– Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345–365. _https://doi.org/10.1111/jcpp.12381_

– Sacco, R., Camilleri, N., Eberhardt, J., Umla-Runge, K., & Newbury-Birch, D. (2022). A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. European Child & Adolescent Psychiatry. _https://doi.org/10.1007/s00787-022-02131-2_

– Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. _https://doi.org/10.1038/s41380-021-01161-7_

– Somers, J. M., Goldner, E. M., Waraich, P., & Hsu, L. (2006). Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature. The Canadian Journal of Psychiatry, 51(2), 100–113. _https://doi.org/10.1177/070674370605100206_

– Tang, X., Liu, Q., Cai, F., Tian, H., Shi, X., & Tang, S. (2022). Prevalence of social anxiety disorder and symptoms among Chinese children, adolescents and young adults: A systematic review and meta-analysis. Frontiers in Psychology, 13, 792356. _https://doi.org/10.3389/fpsyg.2022.792356_

Associated factors

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Arango, C., Dragioti, E., Solmi, M., Cortese, S., Domschke, K., Murray, R. M., Jones, P. B., Uher, R., Carvalho, A. F., Reichenberg, A., Shin, J. I., Andreassen, O. A., Correll, C. U., & Fusar‐Poli, P. (2021). Risk and protective factors for mental disorders beyond genetics: An evidence‐based atlas. World Psychiatry, 20(3), 417–436. _https://doi.org/10.1002/wps.20894_

– Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2021). The risk of anxiety disorders in children of parents with severe psychiatric disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 282, 472–487. _https://doi.org/10.1016/j.jad.2020.12.134_

– Baba, A., Kloiber, S., & Zai, G. (2022). Genetics of social anxiety disorder: a systematic review. Psychiatric Genetics, 32(2), 37–66. _https://doi.org/10.1097/YPG.0000000000000310_

– Brühl, A., Kley, H., Grocholewski, A., Neuner, F., & Heinrichs, N. (2019). Child maltreatment, peer victimization, and social anxiety in adulthood: A cross-sectional study in a treatment-seeking sample. BMC Psychiatry, 19(1), 418. _https://doi.org/10.1186/s12888-019-2400-4_

– Bruijnen, C. J. W. H., Young, S. Y., Marx, M., & Seedat, S. (2019). Social anxiety disorder and childhood trauma in the context of anxiety (behavioural inhibition), impulsivity (behavioural activation) and quality of life. South African Journal of Psychiatry, 25. _https://doi.org/10.4102/sajpsychiatry.v25i0.1189_

– Caldiroli, A., Capuzzi, E., Affaticati, L. M., Surace, T., Di Forti, C. L., Dakanalis, A., Clerici, M., & Buoli, M. (2023). Candidate Biological Markers for Social Anxiety Disorder: A Systematic Review. International Journal of Molecular Sciences, 24(1), 835. _https://doi.org/10.3390/ijms24010835_

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

Co-occurring disorders

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: Diagnostic and therapeutic challenges. Drugs in Context, 8, 1–13. _https://doi.org/10.7573/dic.212573_

– Muris, P., & Ollendick, T. H. (2021). Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder. Clinical Child and Family Psychology Review, 24(2), 294–325. _https://doi.org/10.1007/s10567-020-00342-0_

– Saha, S., Lim, C. C. W., Cannon, D. L., Burton, L., Bremner, M., Cosgrove, P., Huo, Y., & McGrath, J. (2021). Co‐morbidity between mood and anxiety disorders: A systematic review and meta‐analysis. Depression and Anxiety, 38(3), 286–306. _https://doi.org/10.1002/da.23113_

– Spain, D., Sin, J., Linder, K. B., McMahon, J., & Happé, F. (2018). Social anxiety in autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders, 52, 51–68. _https://doi.org/10.1016/j.rasd.2018.04.007_

Interventions

– Correll, C. U., Cortese, S., Croatto, G., Monaco, F., Krinitski, D., Arrondo, G., Ostinelli, E. G., Zangani, C., Fornaro, M., Estradé, A., Fusar‐Poli, P., Carvalho, A. F., & Solmi, M. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. _https://doi.org/10.1002/wps.20881_

– Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. H. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15(3), 245-258. _https://doi.org/10.1002/wps.20346_

– Gosmann, N. P., Costa, M. de A., Jaeger, M. de B., et al. (2021). Selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors for anxiety, obsessive-compulsive, and stress disorders: A 3-level network meta-analysis. Patel V, ed. PLoS Med, 18(6), e1003664. _https://doi.org/10.1371/journal.pmed.1003664_

– Scaini, S., Belotti, R., Ogliari, A., & Battaglia, M. (2016). A comprehensive meta-analysis of cognitive-behavioral interventions for social anxiety disorder in children and adolescents. Journal of Anxiety Disorders, 42, 105-112. _https://doi.org/10.1016/j.janxdis.2016.05.008_

– Schopf, K., Mohr, C., Lippert, M. W., Sommer, K., Meyer, A. H., & Schneider, S. (2020). The role of exposure in the treatment of anxiety in children and adolescents: Protocol of a systematic review and meta-analysis. Systematic Reviews, 9(1), 96. _https://doi.org/10.1186/s13643-020-01337-2_

– Snir, A., Moskow, D. M., & Hofmann, S. G. (2021). When is it appropriate to treat children with social anxiety, pharmacologically? Expert Opinion on Pharmacotherapy, 22(18), 2423-2426. _https://doi.org/10.1080/14656566.2021.1948015_

– Wang, Z., Whiteside, S. P. H., Sim, L., et al. (2017). Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and meta-analysis. JAMA Pediatrics, 171(11), 1049. _https://doi.org/10.1001/jamapediatrics.2017.3036_

– Zhou, X., Zhang, Y., Furukawa, T. A., Cuijpers, P., Pu, J., Weisz, J. R., Yang, L., Hetrick, S. E., Del Giovane, C., Cohen, D., James, A. C., Yuan, S., Whittington, C., Jiang, X., Teng, T., Cipriani, A., & Xie, P. (2019). Different types and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: A network meta-analysis. JAMA Psychiatry, 76(1), 41. _https://doi.org/10.1001/jamapsychiatry.2018.3070_