Current Trends in the Understanding and Treatment of Social Phobia in Youth (page 2)
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).
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.
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.
Reprinted with the permission of the NYU Child Study Center. © NYU Child Study Center.
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