Social Anxiety Disorder in Children and Adolescents

by Jim Chandler, MD, FRCPC


Part 1.

What is Social Anxiety Disorder?
What causes it
Social Anxiety Disorder's nasty cousin - Selective Mutism
Growing up with Social Anxiety Disorder

Part 2.

What Can be Done?
Non-Medical Treatments
Medical Treatments

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What is Social Anxiety Disorder?

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This is one of the most common psychiatric illnesses. Up to 14% of adults have this. About .1% of children have this disorder or one in a thousand. (2) The official criteria for it are as follows:

What causes it?

Usually to have Social Anxiety Disorder that is severe enough to come to my attention, the cause is a combination of two things, genetics and environment.

Genetics - Anxiety disorders are inherited. Many children will have one or even two parents with an anxiety disorder, but not necessarily Social Anxiety Disorder. Many people think that this inheritance is in part expressed through something called Behavioral Inhibition.

Behavioral Inhibition is a tendency to react negatively to new situations or things. Some infants and children will be very happy and curious about new people and things. However, roughly 15% of children will be shy, withdrawn, and irritable when they are in a new situation or with new people or things. Other children are just fearful in general. Often these children and irritable as infants, shy and fearful as toddlers, and cautious, quiet, and introverted at school age. Children who are consistently this way are much more likely to have biological parents with anxiety disorders. They are also more likely to develop Social Anxiety Disorder later in childhood or in adolescence. For example, if a child is not fearful and does not avoid social situations, there is only a 4-5% chance they will get Social Anxiety Disorder as teenagers. However if a child is fearful and avoids social situations when they are little, about 20-25% will have Social Anxiety Disorder as teenagers (1). At the moment it is thought these traits of Behavioral inhibition is what is inherited. This tendency towards being fearful and socially avoidant runs in families and can lead to Social Anxiety Disorder.

Environment - By this I mean everything other than genetics. Some of the environmental causes of Social Anxiety Disorder are: a Speech or language problem, a disfiguring physical illness, abuse, neglect, being raised by very nervous people and having certain extremely embarrassing experiences - vomiting during show and tell, having diarrhea in class, tripping on a stage and falling on someone during a performance at school, etc.

In most cases it is a combination of both genetics and environment. It takes a big genetic load (both parents have multiple anxiety disorders) to cause Social Anxiety Disorder in the absence of any environmental problem. Likewise, it takes a huge environmental cause (massive abuse and neglect) to cause an anxiety disorder when there is no family history of nervousness.

What signs and symptoms do children and adolescents have?

You can see signs of Social Anxiety Disorder as early as a year old. Children with this problem are less interested in exploring new things. Rather than becoming excited by new things, they are much more likely to be scared. As pre-schoolers, they are shy around strangers and may not speak well to people outside of the family. More children with Social Anxiety Disorder than you would expect have some mild to moderate speech and/or language problem. Others are shy and also have some disfiguring medical problem which makes them more noticeable. However, most have no language or physical problem. Children with this problem almost never are thought to require assessment at this point.

Here are the "top ten" most feared social situations.

Less Common ones are

Answering questions in class, Working or playing with other kids, Asking the teacher for help, Gym Class, pictures, inviting a friend over, eating in a cafeteria with kids, walking in the hallway, answering the phone and eating in front of others. (3)

So what do children do when they are exposed to they are exposed to these situations if they have Social Anxiety Disorder?

When children are asked this, about a third have anxiety symptoms and do what they are supposed to. About 15% admit that they pretend they are sick to get out of it. Another 10% just cry. (3)

Social Anxiety Disorder can be very disabling. They are often "loners" but donít really want to be. These children have poor social skills. They are very lonely. When this is looked at, 75% of children with Social Anxiety Disorder had no or few friends. Half were not involved in any after school activities. Half said they did not like school and 10% refused to go to school. (3)

there are quite a few different other anxiety disorders which are often found with Social Anxiety Disorder. Here is a thumbnail sketch of each:

Separation Anxiety disorder - This is a fear of being separated from your parents which is far more than one would expect for the child's developmental stage. About 6% of children with Social Anxiety Disorder have this, too.

Generalized Anxiety disorder - These are people who worry all the time over nothing - themselves, others safety, their health, the world, and everything else you can imagine to a far great extent than the average. They often have many physical signs of anxiety - headache, abdominal pain, cramps diarrhea, vomiting, dizziness, and many others. About 10% of children with Social Anxiety Disorder have this, too.

Panic Disorder - Sudden onset of all sorts of physical signs which make most people think something horrible is about to happen, but it is just the brain giving you a rush of adrenaline for no good reason. About 2% of children with Social Anxiety Disorder have this, too.

Post-Traumatic Stress Disorder - After something horrible happens to a child, sometimes they will keep thinking of it over and over, avoid things that remind them of that horrible thing, and being very nervous.

Phobias- An unreasonable fear of all sorts of things. Being in crowds, the dark, dying, and heights are common ones. This is very common in Social Anxiety Disorder. In a recent study, 87% of children with Social Anxiety Disorder had at least one ver distressing phobia. The top ten were : getting shots, having blood drawn, high places, seeing blood or scrapes, darkness, insects and bees, thunder and lightening, doctors, loud noises and water. (3)

What Children with Social Anxiety Disorder rarely have

It is unusual for children with this condition to be mean, hateful, or extremely stubborn. Rarely do schools or parents see them as having a behavior problem. Sometimes this is why it takes a long time for people to realize that there is a problem as they are so nice.

Social Anxiety Disorder's nasty cousin - Selective Mutism

When children with Social Anxiety Disorder go to school, the problem is more evident. They are more likely to be embarrassed about what they say at school. Often they are embarrassed about how they look. They may be afraid of looking or doing something stupid. This leads to a person doing very little, so to as avoid making errors. One of the most common problems is speaking. I have seen many children who are so embarrassed that they will say something wrong that they do not speak at all in class, even if they have a question. There are teachers who have never seen a child speak in their class, but the minute they are at home or in their neighborhood or with friends, they have very little problem speaking. Children with Social Anxiety Disorder have a circle of people who they will speak with. Sometimes it is as small as the immediate family. More often it extends to other family members and friends. When children have this inability to talk in social settings, it is called selective mutism, a disorder that is closely related to Social Anxiety Disorder. The official criteria are:

It is important to make sure that selective mutism is not misdiagnosed. In some studies, almost half of the people who appear on the surface to have selective mutism have been abused. While anxiety is very common in children with selective mutism, frequently there are other problems. Recent studies show that there is a high frequency of learning problems, language problems, coordination problems and bed wetting in children with selective Mutism. Other disorders which are usually quite uncommon in normal children are more common in children with selective mutism such as Aspergers ( a relative of autism) and mild mental retardation. (6)

Example: Danielle

Danielle is now 8. In grade primary her teacher heard her saw "Ouch!" once when she accidentally stepped on her foot. She has never heard her speak in two years. Danielle has trouble in school besides talking. Her reading is a little behind. She refuses to do any sports. Her parents have tried everything they can to convince Danielle to talk in school. At home she talks all the time until a stranger appears at the door. When she came to see me she would not speak and would hardly do anything. Only after her selective mutism was effectively treated did I hear her speak. Then we discovered that even though she talked a lot at home, her speech was not at all clear and more like that of a 5 year old. Besides, we found out there was a reason she didnít like gym class. Her coordination was horrible. But now that she was not so anxious, she was able to work on that and her speech so that after a year she had made good progress in both areas.

Many social phobic children will have selective mutism to a significant degree. However a full diagnosis is only present in about 8%. (3) They may be reluctant to speak in class, and are deathly afraid of bringing attention to themselves by leaving or entering the class while everyone is at their desk, giving a presentation alone to the class, or doing anything which would embarrass them. While no one is keen on getting sick in school, many children with Social Anxiety Disorder will refuse to go to school at the first hint of nausea for fear they will vomit in class, something that is embarrassing for anyone, but devastating for the socially phobic child.

School Refusal

Children refuse to go to school for a couple of reasons. Some are related to anxiety, and some are related to just being stubborn and oppositional. One large study showed that half the children who refuse to go to school have no psychiatric problems. A third have ADHD, ODD (Oppositional Defiant Disorder), Conduct Disorder or all three. About 20% have an anxiety disorder. Amongst those who are anxious, About a third have Social Anxiety Disorder, a third have Separation Anxiety Disorder, and the rest have other anxiety disorders. It is the older children with School refusal and anxiety who are more likely to have Social Anxiety Disorder, while the younger ones usually have Separation Anxiety Disorder. It turns out that many of studies on treatment of School Refusal mix both these groups together.(11)

Some children will have had some experience (like vomiting in class) which will be so embarrassing that they would rather not go to school at all, no matter what the punishment. For others, their is no precipitating incident - a combination of their illness, the teachers, class and school makes the child so phobic that they refuse to go to school.

Growing up with Social Anxiety Disorder

Some children will go from having a lot of symptoms one year during elementary school to having mild symptoms at another time. Sometimes this will happen because of the environment - a particularly nasty teacher or the departure of a parent - but other times there is no precipitant. The symptoms change somewhat as people age. Teenagers will not talk on the phone with anyone outside their "circle." They can become very phobic about other people watching them write, work, or sign their name. Most will not be able to perform in public. Many will be unable to use public rest rooms. As children become teenagers, they become increasingly frustrated with the limits which this disorder places on them academically (they can not raise their hands to ask questions), socially (dating and dances can be nearly impossible) and psychologically (depression and substance abuse often begin at this age in this population). Some children and teenagers will overcome this problem, but the majority will still have the symptoms to one degree or another. On the worst end, many quit school, marry their closest neighbor, fish only with their family and never do or say much in public. Up to 34% will have thoughts of suicide as adults and about 12% will make a suicide attempt. Others will have some of the symptoms and do well as long as everything goes their way.

Many children with Social Anxiety Disorder have other psychiatric disorders, too. Many have generalized anxiety disorder, panic attacks, agoraphobia, attention deficit disorder, or depression. Not uncommonly I will see a child with two anxiety disorders, depression, and attention deficit disorder!

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What can be done?

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There are two main treatments for Social Anxiety Disorder, Behavior Modification and Medication.

Behavior Modification -

This relies on two things that most people with Social Anxiety Disorder already do. The first is Exposure.

This means that you expose yourself to the thing the makes you most anxious, but in little tiny steps so that the anxiety isn't too severe with each step. For example, if a child could not speak in a class full of children, he might start by speaking to one child he doesn't know outside at recess, and slowly move towards speaking in class.

The other element of this is response prevention. This means that somehow you are prevented from doing the thing you want to when you get nervous or scared. This is hard to do in Social Anxiety Disorder but it is possible. If one of the things a girl did with Social Anxiety Disorder was to look down and never look at someone when she was asked a question, You might have her count to three before she put her head down so she could "prevent" that response.

Along with these techniques you put in some rewards, talk to people about what thoughts are going through their mind, and change it as needed. Here is an example:

Sara can talk to her parents, brothers, and grandparents, and three friends, but no one else. She is embarrassed by the thought that she might trip or say something stupid. She will only walk slowly when anyone is around, but by herself is very athletic. She is 11 years old.

So the first thing to do is come up with the "first step". I might offer Sara a choice of trying to walk on a balancing beam in front of the three friends or say "hello" or "good-bye" to one person in class as the first step. If she did this I would say she could have some privilege like staying up later. If she managed that, I would try having her say "Hello, Ann-Marie" as the next step. The key is to make tiny steps which are easier. I would also get her to practice some relaxation exercises. Overall, you can expect children to have to work at this at least one hour daily.. They will have to make a daily diary of how things are going. This treatment would probably go on for months.

The good

A person has an incredible sense of accomplishment if they overcome Social Anxiety Disorder this way.

No medications are involved.

The Bad

Although there are lots of studies to show that this works in Adults, there are no studies which have been done on using this in children.

You need to be very motivated, patient, and not depressed.

It is very hard work.

Medical Treatments


Often the idea of taking medicines for anxiety disorders makes either one of the parents very nervous or the child. Before discussing the individual drugs, I will discuss the general approach to pediatric psychopharmacology that I use.

Why would anyone want to give drugs that affect the brain to children?

The main reason would be if the non-medical interventions are not working. No one would suggest trying medical treatments before the non-medical interventions are used. It is similar to diabetes in that way. If you have diabetes which is not severe, your doctor will first suggest you try diet control. If that doesn't work, only then will the doctor consider medical treatment. In some situations, a child is very ill, has numerous disorders or there is some urgency. For example, a child has multiple anxiety disorders and depression and is either in the hospital or unable to go to school. Then I consider medications as a first line approach along with other interventions.

If the drug works, how will my child be different?

In cases where the drugs work very well, a child will be able to speak in more public situations, do more adventuresome things without fearing embarrassment and humiliation, and have less anxiety in general. Children are usually more carefree, enthusiastic, and less depressed. Each drug works in a different way on the chemical transmitters in the brain.

What if it doesn't work?

Sometimes a medication won't work because the dose is too high or too low. Some people will not respond to one medication for the treatment of this problem but they will respond to another. If the drug doesn't work, of course, it is discontinued, and then you and I decide what do next. Try something else? Abandon medical treatment? Both are sometimes reasonable options.

I have heard that these drugs can do a lot of bad things. Is this true?

Yes, it is. Like all medical treatments, there are side effects and sometimes people can have pretty bad side effects. There are two types of side effects. One type are the kind that disappear when you stop the drug. The other kind can last long after the drug is discontinued. I do not use any of the drugs that can cause permanent side effects after the drug is stopped.

Are they that dangerous??

Yes, when used improperly they can be quite dangerous. However, when used carefully they can be very safe.

How can that be?

Each drug has certain problems that need to be watched for. The current medical literature suggests three basic principles when using psychiatric drugs in children. 1) Start low, 2) Go slow, and 3) Monitor carefully

What do you mean by Start low?

This means that you do not start any of these drugs at the usual dose, or the maximum dose. When you have pneumonia, it can be a real emergency. You want to give people plenty of medicine right away, and if there is problems, then you reduce it. Unfortunately, many people use this same strategy in the medical treatment of anxiety. The problem is that big doses can cause big problems, and when the problems affect your mind and personality, this usually means trouble for the person taking the medicines. So I start with the lowest dose possible. For example, if I use a drug called rivotril, for a boy about 60 lb., I know that the dose that will probably work for most boys that size is 2-3mg a day. If I gave him that to start out with, I might win and it would work. But if he happens to be sensitive to that drug, he could have big problems. Although they would be reversible problems, it would probably make most kids and or parents never want to take the drug again. So what do I do? I start with .5 mg a day, about 25% of the usual dose. That way if the child is sensitive to the drug, it causes little problems. I also find that some children respond to drugs at very low doses, far below the usual recommendations.

What do you mean, go slow?

Anxiety disorders are usually not acute illnesses. Less than 10% of the people I see with this need to be treated very quickly. Most people who I see with this problem have had it for months to years. As a result, there is no need to increase the dose quickly. By going slowly, it is a lot easier to manage any side effects because things don't happen suddenly. Also, it is easier to find the lowest effective dose.

What do you mean, monitor?

For each of the medical treatments for anxiety, there are specific side effects which need to be checked regularly. Some common ones (see individual drugs below) are monitoring weight so that people are gaining weight, watch for tics, watch for depression, checking blood pressure and pulse, checking blood tests and EKGs, and making sure parents know what the side effects are of the different medications. In this way, if there is a problem, we can pick it up early and avoid the horror stories, some of which are true, about the medical treatment of this problem.

Here are the specific drugs.

Serotonin Reuptake inhibitors (SRIs) - There have been a few studies in children using this class of medications, but only two which have used placebos. The best test to see if a drug really works is to compare it to a placebo. Two drugs have been found to be more effective than placebo when tested in this way for Social Anxiety Disorder: Luvox (fluvoxamine) and Prozac (fluoxetine) (7, 12). Another two drugs have been tested but no placebo was used. That is the second best level of evidence that a drug work. These are Zoloft (Sertraline) (8) and Celexa (Citalopram) (9)

These drugs can cause restlessness, insomnia, and sometimes stomach upset, nausea vomiting, or diarrhea. They can also cause behavioral disinhibition. This can be things like acting silly, saying things that should not be said, increased aggressiveness and irritability, and other features which are exactly the opposite of Social Anxiety Disorder. This is always reversible upon discontinuing the medicine. The effect can take 6-8 weeks to become apparent, and sometimes up to three months before the full effect is seen. It is impossible to tell which drug a child might tolerate best. It is also impossible to know which drug will work.

What about Paxil?

Although is indicated for Social Anxiety Disorder in Adults, there is no data to suggest that it works in children. It is always best to start with medications that have been tested.

Drug Interactions

The drugs in this family can change how much of other medicines get into your blood stream. Other drugs can also change the amount of these SRI medications in your blood stream. What can happen? Here are the possibilities:

If you start taking a drug that interacts with the SRI, the amount of the SRI in your blood could go up enough to give you more severe side effects.

If you start taking a drug that interacts with the SRI, the amount of the SRI in your blood could go down and you could become more psychiatrically ill again.

The SRI can result in another medication going up in your system, too. If you were taking other drugs while you were on an SRI, those other drugs might give you more side effects.

Example: Tina has a cough

Tina is 11. She has been taking Prozac now for about a month and she is a lot better. But she has the flu which is going around and so her mom went to the drug store and got some cough syrup. Tina took the cough syrup and got very, very confused. Her mom (already nervous) was worried that Tina was getting meningitis. She took her to the hospital and was glad to find out that it was a drug interaction between dextromethopham, the main ingredient in cough syrup, and Prozac. Still, it took Tina about a week to get over this. (5)

This does not mean that these drugs are dangerous. It does mean that if you are taking an SRI, a doctor should make sure that it will not interact badly with other drugs you might be prescribed. It also means you should check with the pharmacist before you take anything. (4)

The chart below gives some guidelines in this regard.

Green Font - best evidence -

Yellow Font - some evidence

Red Font - no evidence

 

Drug

Brand Name

Usual Dosage

Sizes

comments

Fluoxetine

Prozac

About 1mg/kg

10, 20, liquid

Long acting

Paroxetine

Paxil

20-60mg a day

10, 20, 30

Worse withdrawal symptoms

Citalopram

Celexa

20-60mg a day

20, 40

Capsules you can dissolve in water

Sertraline

Zoloft

3mg/kg max

25, 50

Capsules you can dissolve in water

Fluvoxamine

Luvox

3mg/kg max

50, 100

Pills are scored


The good
The Bad

Benzodiazepines

How good is the data to support using these drugs in children?

Not very good. There are no first class studies (using placebo) supporting the use of these drugs for Social Anxiety Disorder.(10)

I have heard that these are addictive. Will my son become addicted to these?

It depends on which one was used and the dose. There are two things that determine whether one of these drugs will be addictive and produce withdrawal. The first is how fast it gets into the bloodstream. The second is how fast it goes out. The faster it gets in and the faster it gets out of your system, the more addictive it will be. Valium, for example, goes into your system very fast. It goes out slowly. It has moderate addiction potential. Librium goes in you system slowly and goes out slowly, too. It is not at all addictive. Cocaine goes in and out very fast. It is very addictive. There are two drugs that are commonly used in children with anxiety in this group. These are Rivotril (Clonazepam) and Ativan (Lorazepam).

Rivotril (clonazepam) - This drug was first used to control seizures in children and still is. Along the way people started using it in anxiety disorders. It lasts a long time in your body after a dose, so it only needs to be given once or twice a day. It is very unlikely to produce withdrawal, and since it goes into your system slowly, it does not make people high nor is it very addictive. It is very safe in children. The dosage is usually .5 mg to 2.5 mg a day. I start with the lowest dose first and slowly increase it up to about 2 mg a day and then watch for a week or two. If it works, which is about 50% of the time in the research studies, but higher in my experience, people are able to do things that they could not before with minimal anxiety. Rarely do all the symptoms disappear, but it can make a big difference in a hurry. The side effects that have been reported are sleepiness, slurred speech, bad balance, and sometimes aggression or agitation. Most people will have one or two side effects to a mild degree, but only at the beginning. However, some people can not tolerate this, as is true with all medications.

Ativan (Lorazepam) - This drug is similar to rivotril except it does not last as long. It usually is given two or three times a day as a result. It does have the potential to produce some withdrawal symptoms if it is stopped suddenly. Because of this it is my second choice amongst these drugs. However it is very safe and has been used in children for years.

The Good
The Bad

You could be unlucky and have a lot of side effects. That is why I start low and slowly increase the dose. All the side effects are reversible within a few days of stopping the medicine

Some children will stop taking responsibility for their lives and just wait for the medicine to work without pushing themselves at all.

Tricyclics-

These drugs have been used in School Refusal, but mostly when the child has Separation Anxiety Disorder rather than Social Anxiety Disorder. See the Separation anxiety Disorder Handout.

How long will my child take one of these medications for?

For all of these drugs, I would have people take it about six months and then taper it off. If they relapsed, I would have them take it another 6-12 months and then try to taper it again. Usually if the medications work, people can do the behavior modification steps without even thinking. there are other drugs which have been used in adults with Social Anxiety Disorder which might be effective in children. I have never had to use them. All the children I have seen with Social Anxiety Disorder improved with either one of these two drugs, both of the above two drugs, or with Behavior Modification or all three.

In summary,

Social Anxiety Disorder is a common and disabling condition that can often cause significant problems in childhood. A more severe form, selective Mutism, is also common in children. The first step is to find out what Social Anxiety Disorder is and to make sure there are not other psychiatric problems, too. The next step is to fit the treatment to the child. The treatment depends on the child's personality, family, and what other psychiatric problems are also present.

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