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Joseph Gonzalez-Heydrich, MD, chief of Children's Hospital Boston's Psychopharmacology Program, specializes in mood disorders, problems with impulse control, developmental disorders and psychosis. Here, he discusses diagnosis and management of social anxiety disorder (social phobia).
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Joseph Gonzalez-Heydrich, MD |
What are the typical features of social anxiety disorder?
Those with social anxiety disorders have an intense and persistent fear of situations in which they're exposed to unfamiliar people or scrutiny. In social situations, they're afraid that people are looking at them, and overestimate the chances that people are going to reject them or that they're going to be embarrassed. Exposure to these situations provokes anxiety responses like panic, freezing, blushing, tantrums, crying and clinging. People with social anxiety disorder tend to avoid these situations for obvious reasons. Over time, this gets in the way of social development and can become a real cost to them in terms of education, family functioning, employment and overall happiness.
How are children affected by social anxiety disorder?
The rate in children is thought to be 0.5 percent to 4 percent. In adolescents, it may be as high as 7 percent. It's not known why certain children are affected, but it's thought that it may be hereditary. Parents with panic disorder, for example, have a higher rate of children who have social anxiety disorder.
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Does ____ avoid going to parties or joining clubs? Does ____ avoid talking to classmates or others on the phone? Does ____ avoid talking to people he or she doesn't know well? Is ____ bothered by blushing? Does ____ avoid being the center of attention? Is ____ scared of being criticized? Does fear of embarrassment cause him/her to avoid doing things or talking to people? Is ____ afraid of doing things if people are watching? Does ____ avoid speaking to people in authority? Does ____ tremble or shake in front of others? Do heart palpitations bother him or her? Does ____ cling excessively to his/her parents in social situations? Is ____ excessively shy?
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Is it more common in boys or girls?
It seems like it's more common in girls, but if you look in treatment settings, there are more boys than girls. It's not known why that is, but it's probably because being more socially inhibited and shy, even extremely shy, is more acceptable in girls. So boys are more likely to be identified and get referred for treatment.
How early can it be diagnosed?
Most diagnoses are made in adolescence when it's obvious that children are not doing the things developmentally that they should be doing—they're not going out with peers, they're avoiding talking with classmates and with people in authority, they're not
joining teams or clubs. However, social anxiety can be detected in children as young as 8. In fact, if a child presents with clear social anxiety disorder before age 11, it is likely to persist into adulthood and referral for treatment is recommended. If it presents in
adolescence, there's a greater chance that it will remit with experience over time.
How does social anxiety disorder differ in children vs. adolescents?
In children, it manifests itself with freezing, selective mutism (refusing to speak in public), tantrums or never leaving the mother's side at a birthday party. Adolescents exhibit symptoms like not participating in after-school activities, never talking in class or they'll never return something in a store or talk to a person of authority for fear of being embarrassed. Seventy-five percent of adolescents with social anxiety disorder report no or few friends, 50 percent have no extracurricular activities and 10 percent refuse to attend school regularly.
What symptoms should pediatricians look for during an office visit?
Children and teens often deny their symptoms, so it's important to ask the parents. Basically, you look for extreme shyness that's causing
significant interference with a child's normal development and quality of life. Questions should include: Does Johnny avoid going to parties or joining clubs? Does Johnny avoid talking to classmates or to people he doesn't know well? Is he bothered by blushing? Does he avoid being the center of attention? If the answers are positive and the child is not doing things that are developmentally appropriate for his or her age, then it's worth referring to a psychotherapist for formal evaluation.
How is social anxiety disorder treated?
The first line of treatment for mild and moderate social anxiety disorder is psychotherapy to give the child tools to deal with the anxiety. The therapist will look at the child's distortions—people are looking at me all the time, they think what I say is stupid—and will help the child develop automatic ways of dealing with these thoughts, and help him understand that maybe there's another way of thinking about his distortions. Exposure is also a part of treatment. For a child whose anxiety is so strong that you can't get him to fully engage in psychotherapy, then selective serotonin reuptake inhibitors (SSRIs) are the first line.
What are the best medications?
So far, SSRIs have proven to be the most effective and may be used as long-term treatment to reduce anxiety. Other medications are effective as short-term solutions. For example, a child with school-refusal may benefit from a Benzodiazepine, which can help lower the anxiety and allow the parent to at least get the child out the door. It's important to note, however, that Benzodiazepine should only be used as a bridge. Also, the use of any medication should be part of a comprehensive program where there's another person handling the psychosocial treatment and can see whether the medication is helping or not and at what point the child can start coming off the medication.
Are there other treatment options?
Medication and psychotherapy can help lower anxiety, but if you don't have a plan for getting a child back into the world, then you just have a child who's less anxious and sitting at home. You need to expose him by having him go to a party, join a club, make new friends and have a good time. Those experiences weaken the social anxiety and help treat the disorder itself.
More information: childrenshospital.org/psychopharmacology
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