What is Social Phobia?

Social phobia (also known as social anxiety disorder) is a medical condition characterized by extreme and consistent fear of meeting new people or embarrassing oneself in social situations. Social phobia is different than the occasional nervousness or shyness a person may feel before a big social event, and it may dramatically limit a person’s ability to engage in ordinary social activities.Social phobia, one of the most common anxiety disorders in adults, is thought to affect about one percent of children. It is possible that the incidence is higher than one percent because children’s symptoms may incorrectly be attributed to a shy personality rather than a treatable condition. The tendency to develop social phobia involves both genetic and environmental factors. top

What Does Social Phobia Look Like in Children and Adolescents?

Young people with social phobia are frequently preoccupied with negative views of themselves. These children are afraid they will speak or act foolishly, be rejected by peers, or publicly fail when performing school tasks. Children with social phobia may in fact be less adept in social interactions. When social phobia develops in childhood, the symptoms generally last at least six months, which distinguishes it from the temporary social awkwardness that many children briefly experience in new environments. Peer relationships, school functioning and attendance, and family functioning may all suffer as a result of a child’s social phobia.Social phobia may look different in young people than in adults. While adults recognize the excessiveness of their discomfort in social situations, children may not have that understanding. Younger children with social phobia may protest when forced to leave a parent’s side, have a tantrum when facing a social encounter, refuse to play with friends, or complain about physical illness at the time of a social event. In contrast, adolescents may simply avoid group gatherings or describe little interest in friendships. Childhood social phobia is often identified around age 12, at a time when children are expected to increase their social activities with peers and in school.Diagnosing social phobia can be challenging, and children with social phobia may have more than one anxiety disorder. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. top

 ► At Home

At home, children with social phobia may have a combination of the symptoms listed below.

• Consistent and extreme fear of situations involving new people, in contrast to the child’s ability to enjoy familiar people

• Extreme fear of social and performance situations due to the child’s worry about acting in an embarrassing way

• Anxiety attacks when anticipating or attempting social interactions (such as going to a school party, speaking in front of others, or asking someone for a pencil). Symptoms can be so severe as to resemble or include panic attacks: intense fear accompanied by heart palpitations, chest discomfort, sweating, trembling, nausea, numbness or tingling, hot/cold flashes, shortness of breath, and dizziness.

• Fearfulness with peers as well as adults. While many people become nervous around social encounters, patients with social phobia may be essentially “paralyzed,” unable to participate or engage with others.

• Avoidance of social situations. Some children may cry, complain, or tantrum to avoid social encounters. Other children may be able to tolerate these encounters only in the company of a familiar person.

• Severe distress in routine social situations such as starting or maintaining a conversation, talking to an adult, playing in a small group, or going to a party

• School refusal due to worries about school and social performance

• Reluctance to participate in ordinary outings or activities. The child may not want to go out to dinner, meet friends to play, or engage in after school programs.

• Depression or thoughts of not wanting to be alive that can arise if children believe there are no interventions to reduce their symptoms top

 ► At School

Some children or adolescents with social phobia may try to hide symptoms while at school. As a result, they may appear to have more symptoms at home than at school. With other children, the symptoms are particularly noticeable to teachers or staff because of the child’s difficulty in social or performance situations at school. At school, a child with social phobia may have a combination of the symptoms listed below.

• Difficulty transitioning from home to school. Children may have great trouble entering school in the morning. This may lead to late arrival times, long and tearful morning drop-offs, or tantrums at school. Other children try to hide their difficulty with transitions, so that only the parent or caregiver sees the child’s distress.

• Refusal or reluctance to attend school. The anxiety a child feels can be powerful and may lead the child to insist on staying at home.

• Avoidance of activities with peers. Any additional time at school or engagement with peers may be resisted.

• Low self-esteem in social situations and academic projects

• Difficulty concentrating due to persistent worry may affect a variety of school activities, from following directions and completing assignments to paying attention, particularly before stressful events such as giving a speech in class or even sitting with unfamiliar peers in a school group or event

• Other anxiety disorders, mood disorders such as depression, or behavior disorders such as attention deficit/hyperactivity disorder (ADHD). Having one mental health condition does not “inoculate” the child from having other conditions as well.

• Behavioral or cognitive side effects from medication. If a child is receiving medication treatment for symptoms, new mood changes or behaviors should be discussed with parents, as they can reflect medication side effects.

• Learning disorders and cognitive problems, which are often overlooked in this population. A child’s difficulties or frustrations in school should not be presumed to be due entirely to social phobia. If the child still has academic difficulty after symptoms are treated, an educational evaluation for learning disabilities should be considered. A child’s repeated reluctance to attend school may be an indicator of an undiagnosed learning disability. top

 ► At the Doctor’s Office

Symptoms of social phobia may be evident during an office visit when a child is reluctant to meet the clinician. This feature alone does not indicate a child has social phobia, since children routinely are nervous during office visits. Clinicians may benefit from talking with parents, school staff, and other important caregivers to evaluate a child’s functioning in each area to determine the underlying cause of the child’s symptoms.Clinicians may encounter some of the following challenges in diagnosing and treating a child or adolescent with social phobia.

• Symptoms vary over time and their appearance changes as a child grows. A clinician may need to see a child over time to determine the appropriate diagnosis.

• Other conditions, particularly other anxiety disorders, may look like social phobia. These conditions include specific phobias (anxiety triggered by the same object or situation, such as spiders or flying), generalized anxiety disorder (anxiety throughout the day regarding many matters), separation anxiety disorder (anxiety triggered by separation from a caregiver) and panic disorder (unpredictable panic attacks). The symptoms of mood disorders can also be similar to the symptoms of social phobia.

• Depression is also often present in these children

• Physical complaints such as stomachaches, dizziness, rapid heart beats, and tremulousness occur in children with social phobia. The clinician must determine whether these complaints warrant further medical investigation.

• Children may have difficulty talking about their fears around social situations. Phrasing questions with particular sensitivity and compassion may allow a more complete picture of symptoms to emerge. For example, asking the child, “What do you think others are thinking while you talk?” or “What do you wish would happen when you have to sit with different children?” may elicit symptoms in younger children.

• Children may be unaware, or unwilling to admit, that their behavior may indicate symptoms of a disorder

• Families may need to be coached about what they can reasonably expect from their child. Children who suffer from social phobia will benefit if their family understands that therapy and medicines may reduce, but may not cure, symptoms. top

How is Social Phobia Treated?

Social phobia is treatable through ongoing interventions provided by a child’s medical practitioners, therapists, school staff, and family. These treatments include psychological interventions (counseling), biological interventions (medicines), and accommodations at home and at school that reduce sources of stress for the child. Open, collaborative communication between a child’s family, school, and treatment professionals optimizes the care and quality of life for the child with social phobia. top

 ► Psychological Interventions (Counseling)

Counseling can help children with social phobia, and everyone around them, to understand that their symptoms are caused by a disorder with complex genetic and environmental origins–not by flawed attitude or personality. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child’s particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.

• Individual psychotherapy is generally recommended as the first line of treatment for young people with social phobia. Children with this disorder often carry a sense of failure, as if the disorder was their fault. Individual psychotherapy can help reduce symptoms, and can help young people become aware of and address their feelings of failure and self-blame.

• Cognitive Behavior Therapy (CBT) can teach young people new skills to reduce anxiety when interacting with others. In CBT, a child or adolescent is helped to become aware of, and to describe, negative thoughts, feelings or reactions surrounding social encounters. A trained clinician guides the child to think of new, more positive alternatives when having to speak or interact with others. The young person is then given a chance to practice new thoughts, feelings, or reactions beyond the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon practices that have helped many children and adolescents.

• Parent guidance sessions can help parents to manage their child’s symptoms, identify effective parenting skills, learn how to function as a family despite the disorder, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.

• Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting. A child with social phobia may resist group counseling, because of the child’s fears of meeting new people, particularly in a group setting. Group psychotherapy is still highly effective for these children, and families are encouraged to consider group interventions.

• School-based counseling can be effective in helping a child with social phobia navigate the social, behavioral, and academic demands of the school setting. top

 ► Biological Interventions (Medicines)

While psychotherapy may be sufficient to treat some children with social phobia, other children’s symptoms do not improve significantly with psychotherapy alone. These children may benefit from medications.The U.S. Food and Drug Administration (FDA) has not approved specific medications for the treatment of social phobia in children and adolescents. However, medications approved by the FDA for other uses and age groups are prescribed for young people with social phobia. The FDA allows doctors to use their best judgment to prescribe medication for conditions for which the medication has not specifically been approved.The antidepressants Celexa, Lexapro, Luvox, Paxil, Prozac (fluoxetine), and Zoloft are commonly prescribed to treat the symptoms of social phobia. These medicines belong to a group of medications called Selective Serotonin Reuptake Inhibitors, or SSRI’s. Other types of antidepressants, such as Effexor, are also prescribed.

In most cases these medicines begin to be effective in reducing symptoms after the child or adolescent has taken them for at least 2-4 weeks. Fully 12 weeks may be required in order to determine whether the medication is going to be effective for a particular individual. Medications should only be started, stopped, or adjusted under the direct supervision of a trained clinician.

There is no “best” medicine to treat social phobia, and it is important to remember that medicines usually reduce rather than eliminate symptoms. Different medicines or dosages may be needed at different times in a child’s life or to address the emergence of particular symptoms. Successful treatment requires taking medicine daily as prescribed, allowing time for the medicine to work, and monitoring for both effectiveness and side effects. The family, clinician and school should maintain frequent communication to ensure that medications are working as intended and to monitor and manage side effects.

The following cautions should be observed when any child or adolescent is treated with antidepressants.

• Benefits and risks should be evaluated. Questions have arisen about whether antidepressants can cause some children or adolescents to have suicidal thoughts. The evidence to date shows that antidepressants, when carefully monitored, have safely helped many children and adolescents. The latest reports on this issue from the U.S. Food and Drug Administration can be found on its web site at www.fda.gov. Consideration of any medicine deserves a discussion with the prescribing clinician about its risks and benefits.

• Careful monitoring is recommended for any child receiving medication. Though most side effects occur soon after starting a medicine, adverse reactions can occur months after medicines are introduced. Agitation, restlessness, increased irritability, or comments about self-harm should be addressed immediately with the clinician if any of these symptoms emerge after the child starts an antidepressant. Frequent follow-up (weekly for the first month) is now advocated by the FDA for children starting an antidepressant.

• Some children who have social phobia may also have bipolar disorder. In some individuals with bipolar disorder, antidepressants may initially improve depressive symptoms but can sometimes worsen manic symptoms. While antidepressants do not “cause” bipolar disorder, they can unmask or worsen manic symptoms.

Helpful information about specific medications can be found at www.medlineplus.gov (click on “Drug Information”) and in the book Straight Talk About Psychiatric Medications for Kids (Revised Edition) by Timothy E. Wilens, MD. top

 ► Interventions at Home

At home, as well as at school, providing a sympathetic and tolerant environment and making some adaptations may be helpful to aid a child or adolescent with social phobia.

• Understand the disorder. Understanding the nature of social phobia and how it is experienced by the child will help parents sympathize with a child’s struggles.

• Listen to the child’s feelings. Isolation can foster low self-esteem and depression in youth with social phobia. The simple experience of being listened to empathically, without receiving advice, may have a powerful and helpful effect.

• Keep calm when a child is upset about a social encounter. If a child sees a parent is able to remain calm, the child can model the parent’s attitude.

• Help the child remember that he or she survived the last social encounter. This may assist the child in reducing anxiety.

• Anticipate transition points that can cause apprehension, such as going to school or meeting friends for play

• Teach relaxation techniques. Relaxation techniques include deep breathing, counting to 10, or visualizing a soothing place. Teaching children how to relax will empower them to develop mastery over symptoms and improve a sense of control over their body.

• Support the child’s quick return to school, particularly in the case of school refusal. Even if a shorter school day is necessary initially, children’s symptoms are more likely to decrease when they discover that they can survive the anxiety.

• Support the child’s participation in activities. Helping the child or adolescent to get through social fears and engage in activities will encourage continued participation in healthy activities.

• Suggest moving forward in small steps that allow the child to build upon successful social encounters. Successfully navigating a playdate with one or two preferred friends may be a good goal to work toward before attempting to attend a large birthday party. Similarly, speaking in front of a small number of friendly peers may be a helpful step before the child attempts reading aloud or speaking in front of others at a family function.

• Encourage the child to help develop interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child’s ability to problem-solve.

• Praise the child’s efforts to address symptoms. Young people often feel like they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised. top

 ► Interventions at School

There are many ways that schools can help a child with social phobia succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifications, and school strategies include the following:

• Establish check-ins on arrival to reduce the child’s initial anxiety and facilitate transition into school

• Accommodate late arrival due to difficulty separating

• Identify a safe place where the child may go to reduce anxiety during stressful periods. Developing guidelines for appropriate use of the safe place will help both the student and staff.

• Develop relaxation techniques to help reduce anxiety at school. Employing techniques developed at home can be useful.

• Modify stressful social situations. For example, develop a small lunch group for the child or speak to the child individually rather than in a large group.

• Encourage small group interactions that allow the child to develop increased areas of competency and become more comfortable performing in front of others

• Avoid singling out the child in front of peers

• Encourage the child to help develop interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child’s ability to problem-solve.

• If the child or adolescent is avoiding school, address the cause and initiate an immediate plan for returning to school. Students may require gradual reintroduction in some cases, by attending for less than a full day.

• Provide assistance with peer interactions. An adult’s help may be very beneficial for both the child and peers.

• Be aware that transitions may be difficult for the child. When a child with social phobia refuses to follow directions, for example, the reason may be symptoms of anxiety rather than intentional oppositionality.

• Reward a child’s efforts. Every good effort deserves to be praised.

• Please click on School-Based Interventions for a more complete list of school accommodations for children with social phobia

Flexibility and a supportive environment are essential for a student with social phobia to achieve success in school. School faculty and parents together may be able to develop remedies to reduce a child’s challenges.