Current Trends in the Understanding and Treatment of Social Phobia in Youth

Summary of article published in the Journal of Child Psychology and Psychiatry, Vol. 42, No. 1, pp. 127-140, 2001

Introduction

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:

1. 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.
2. The anxiety brought on by social situations may be evidenced in children by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
3. 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.
4. Under the age of 18 years, there must be evidence of the social fears existing for a minimum of six months.

Prevalence

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.