Psychiatric Annals

CME Article 

Assessing and Treating Social Phobia in Children and Adolescents

Golda S. Ginsburg, PhD; Rachel L. Grover, PhD

Abstract

It's the first day back to school after spring break, and most kids are eager to see their friends again. Sam, an 8-year-old third grader, tells his mom he doesn't feel well and complains of having a stomachache. He spends 30 minutes in the bathroom, refusing to leave. In spite of Sam's protests, his mother manages to extricate him from the bathroom and get him out of the house and into the car. Once in front of the school, Sam begins to cry and shake, crouching into the bottom of the car to hide from his peers. With the assistance of school personnel, his mother is able to get him into the classroom, but only after all the other children have been seated.

During the day, Sam sits in the back of the room and remains silent, never raising his hand or interacting with peers. When he has to use the bathroom, he goes to the nurse or waits until he gets home. Others think of him as smart, but “shy.” Sam has social phobia.

Social phobia, also referred to as social anxiety disorder, confers significant impairment in multiple areas of a child's functioning. However, the disorder historically has been minimized as “childhood shyness” and still remains underidentified and undertreated. Currently, social phobia is among the most prevalent childhood psychiatric disorders, affecting between 5% and 15% of youth at some time through their teen years.1,2 Early estimates of prevalence, based on the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R),3 were much lower (approximately 1%) due to the overlap in diagnostic criteria between social phobia and avoidant and overanxious disorders, which were removed from the fourth edition of DSM (DSM-IV).4

Children may be afflicted with social phobia at a very young age (as young as 6), although the average age of onset is between 11 and 12.5,6 Social phobia tends to be chronic and, if left untreated, persists into adulthood.7 In light of the high prevalence of social phobia and the amount of distress that affected children experience, it is crucial that practitioners be familiar with the diagnosis and available treatments.

In this article, we describe symptoms of social phobia in youth, review appropriate screening tools for practitioners, and present recent developments in empirically supported treatments. The article concludes with practical suggestions for what practitioners can do to help alleviate the distress experienced by youth with social phobia.

Sam's behaviors and symptoms are hallmark signs of social phobia, which is characterized by a pervasive fear of negative evaluation or embarrassment in everyday social situations. A summary of DSM-IV diagnostic criteria for social phobia is provided in the Sidebar (see page 738). Children and adolescents (hereafter referred to as children) with social phobia manifest symptoms across four domains that can be assessed easily by practitioners: academic, social, familial, and personal distress. Academically, children with social phobia have difficulty participating in typical classroom and school activities. For example, they struggle with answering or asking a question in class, speaking in front of the class, using the public bathroom, and eating in the cafeteria. In the social domain, children with social phobia frequently avoid conversing with peers in person or on the phone, joining group activities (eg, sports, drama), and inviting friends to play or spend time together. For adolescents, social anxiety may prevent them from dating, attending mixed-sex social activities, and applying for jobs — all key developmental tasks.

Chronic, excessive fear of social or performance situations that the child fears will be potentially embarrassing. The anxiety must occur in peer settings, not just in interactions with adults.

Feared…

It's the first day back to school after spring break, and most kids are eager to see their friends again. Sam, an 8-year-old third grader, tells his mom he doesn't feel well and complains of having a stomachache. He spends 30 minutes in the bathroom, refusing to leave. In spite of Sam's protests, his mother manages to extricate him from the bathroom and get him out of the house and into the car. Once in front of the school, Sam begins to cry and shake, crouching into the bottom of the car to hide from his peers. With the assistance of school personnel, his mother is able to get him into the classroom, but only after all the other children have been seated.

During the day, Sam sits in the back of the room and remains silent, never raising his hand or interacting with peers. When he has to use the bathroom, he goes to the nurse or waits until he gets home. Others think of him as smart, but “shy.” Sam has social phobia.

Social phobia, also referred to as social anxiety disorder, confers significant impairment in multiple areas of a child's functioning. However, the disorder historically has been minimized as “childhood shyness” and still remains underidentified and undertreated. Currently, social phobia is among the most prevalent childhood psychiatric disorders, affecting between 5% and 15% of youth at some time through their teen years.1,2 Early estimates of prevalence, based on the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R),3 were much lower (approximately 1%) due to the overlap in diagnostic criteria between social phobia and avoidant and overanxious disorders, which were removed from the fourth edition of DSM (DSM-IV).4

Children may be afflicted with social phobia at a very young age (as young as 6), although the average age of onset is between 11 and 12.5,6 Social phobia tends to be chronic and, if left untreated, persists into adulthood.7 In light of the high prevalence of social phobia and the amount of distress that affected children experience, it is crucial that practitioners be familiar with the diagnosis and available treatments.

In this article, we describe symptoms of social phobia in youth, review appropriate screening tools for practitioners, and present recent developments in empirically supported treatments. The article concludes with practical suggestions for what practitioners can do to help alleviate the distress experienced by youth with social phobia.

Diagnostic Criteria

Sam's behaviors and symptoms are hallmark signs of social phobia, which is characterized by a pervasive fear of negative evaluation or embarrassment in everyday social situations. A summary of DSM-IV diagnostic criteria for social phobia is provided in the Sidebar (see page 738). Children and adolescents (hereafter referred to as children) with social phobia manifest symptoms across four domains that can be assessed easily by practitioners: academic, social, familial, and personal distress. Academically, children with social phobia have difficulty participating in typical classroom and school activities. For example, they struggle with answering or asking a question in class, speaking in front of the class, using the public bathroom, and eating in the cafeteria. In the social domain, children with social phobia frequently avoid conversing with peers in person or on the phone, joining group activities (eg, sports, drama), and inviting friends to play or spend time together. For adolescents, social anxiety may prevent them from dating, attending mixed-sex social activities, and applying for jobs — all key developmental tasks.

Sidebar.

DSM-IV Diagnostic Criteria for Social Phobia in Children and Adolescents

  1. Chronic, excessive fear of social or performance situations that the child fears will be potentially embarrassing. The anxiety must occur in peer settings, not just in interactions with adults.

  2. Feared social situations almost always trigger an anxious response.

  3. Feared social situations are avoided or tolerated with great distress.

  4. Fear or avoidance must cause significant impairment in the functioning (daily routine, academic, social, familial) of the child or adolescent.

  5. Fear or avoidance is not better explained by medication, medical condition, or other mental disorder.

  6. Symptoms must be present for at least 6 months.

  7. If the social fears are focused on one, two, or even several situations, the child receives a diagnosis of SOP; however, if the child fears most social situations, the specifier “generalized” should be added to the diagnosis.

Diagnostic Criteria for Social Phobia in Children and Adolescents

One of the most destructive aspects of social phobia is the co-occurrence of social withdrawal. Social withdrawal delays and inhibits the development of appropriate social skills. The combination of social anxiety, deficient social skills, and social isolation contributes to fewer friendships and increased levels of loneliness.8–10

With respect to family and other adult relations, a common sign of social phobia is the reluctance or avoidance of participating in everyday transactions such as ordering food in a restaurant or speaking to a cashier. Children may report anxiety concerning interactions with bus drivers, asking for directions from service workers, or even asking an adult for the time. The family routines of youth with social phobia also are disrupted as parents either make several accommodations to facilitate avoidance (eg, parent ordering at a restaurant for the child or responding to questions directed to the child) or become involved in power struggles as they attempt to force children to interact. Finally, children with social phobia often report significant personal distress including a variety of somatic symptoms (eg, headaches, stomach aches, and panic attack symptoms).8

Diagnosing social phobia in children can be challenging because they often present with comorbid disorders; the most common of these are other anxiety disorders, followed by attention-deficit/hyperactivity disorder, depression, and substance-use disorders.8,11 They may also present with “oppositional” behaviors in an effort to avoid anxiety-provoking situations. Unfortunately, parents, teachers, and mental health providers tend not to consider anxiety when behavior problems present, contributing to underdiagnosis and misdiagnosis.

Although children generally avoid anxiety-provoking social situations, occasionally, they will endure the feared situations with intense discomfort. As such, children that remain in feared situations may be perceived as “shy.” Therefore, a critical question is when “shyness” or social anxiety becomes a problem that needs professional intervention. Key considerations for making this determination involve assessing whether the anxiety is excessive (seems way out of proportion), is persistent (lasts too long), is developmentally inappropriate, and causes impairment in the child's life. A “yes” to these questions suggests a need for further assessment.

Assessment of Social Phobia in Children and Adolescents

Instruments for assessing anxiety disorders in children, including social phobia specifically, have proliferated in the past decade. The types of instruments now available vary widely and include structured diagnostic interviews (for determining diagnoses), paper and pencil rating scales (for screening and tracking symptoms), physiological assessments (for assessing somatic manifestations of anxiety), and observational procedures (for assessing behaviors in anxiety-provoking situations). These instruments vary along several dimensions, such as their goal or purpose (eg, diagnosis versus screening), complexity and training requirements, length of time to administer (minutes to hours), and utility or feasibility across settings.

For example, structured and semi-structured diagnostic interviews are used predominately in clinical research and are particularly useful for making diagnoses. These instruments facilitate the gathering of information on a broad range of symptoms/disorders, assisting with differential diagnosing, and determining duration and lifetime occurrences of illness. However, they are very time consuming to administer (2 to 3 hours) and require extensive training. Also used primarily in research settings are physiological assessments, such as measures of heart rate or sweat gland activity, and observational procedures, referred to as behavioral approach tasks (BATs). These tests often are conducted together when children are asked to confront the situation they fear, such as giving a 5-minute speech in front of an audience for children with social phobia. The severity of the child's anxiety (behaviorally and physiologically) is monitored throughout the task. While data on internal and external validity are scant, some studies have found that children improve on these assessments with treatment.

The most comprehensive assessment of social phobia in children includes a multi-method approach in which information about the child and his or her symptoms is obtained across multiple contexts and modalities and from a variety of informants, such as parents, teachers, peers, and the children themselves. For most psychiatrists, however, the primary goal of using standardized assessment tools is to screen for social phobia. This can be accomplished most easily by using one of several rating scales, as described in the Table.

Rating Scales for Social Phobia in Children and Adolescents

Table.

Rating Scales for Social Phobia in Children and Adolescents

Rating scales have a number of advantages. They provide information about a broad range of anxiety symptoms, may be an easier method for children to report their feelings relative to direct questioning, are generally written at a second- or third-grade reading level, and do not take long to complete (10 to 15 minutes). Thus, children or parents generally can fill out these questionnaires while waiting for their appointments. In addition, most questionnaires can be administered and quickly scored by staff with minimal training or expertise in child anxiety. Indeed, published norms are available to determine whether the child reported normative or problematic levels of anxiety. Thus, rating scales are time and cost efficient for use as screening tools or to track symptoms over time. A major drawback, however, is that they cannot be used in lieu of a diagnostic interview to determine the presence of an anxiety disorder.

We recommend that rating scales be completed by both the child and parent, as there often is variation between them. Multiple reports of symptoms enhance the ability of the physician to make informed decisions about diagnosis and treatment. The reasons for discrepancies among informants include the child's or parent's desire to answer in a socially desirable manner, the child's limited comprehension of questions, the limited contexts in which the reporter sees the child, or parents' level of psychopathology.12,13 Each of these issues should be considered when interpreting responses on rating scales.

Although there are many anxiety rating scales, two types are most relevant for social anxiety: those that assess a broad range of anxiety symptoms (eg, separation, generalized, and social), and those that assess symptoms specific only to social anxiety. The most popular and psychometrically sound of the broad-band rating scales are the Multidimensional Anxiety Scale for Children14 (MASC), the Screen for Anxiety and Related Emotional Disorders15,16 (SCARED), and the Spence Children's Anxiety Scale (SCAS).17 These instruments were developed to be sensitive and specific for assessing clinical levels of anxiety in youth.

The MASC is a 39-item, four-point Likert self-report rating scale for children 7 and older. The measure has shown robust psychometric properties in clinical, epidemiological and treatment studies, in addition to discriminating youth with anxiety disorders from those with depression or no disorder.18 The MASC includes four factors: physical symptoms, social anxiety, harm avoidance, and separation/panic anxiety. Three-week test-retest reliability for the MASC is 0.79 in clinical14,19 and 0.88 in school-based samples.19 Raw scores are easily converted into standardized scores (T scores) to determine clinical relevance (T scores highter than 65 generally are considered a positive screen) using a profile sheet.20 Nine items comprise the social phobia scale.

The SCARED is a 41-item child and parent self-report instrument that assesses different types of anxiety symptoms based on criteria in DSM-IV.4 Specifically, the SCARED was developed as a screen for generalized anxiety disorder (GAD), separation anxiety disorder, panic disorder, social phobia, and school phobia. The SCARED has demonstrated good psychometric properties in two different large clinical15,16 and community samples of both Caucasian and African-American children ages 8 to 18.21,22 The total score has excellent internal consistency (0.90) and test-re-test reliability (0.86). Additionally, the SCARED showed good construct and discriminative validity and is sensitive to treatment.23 Total scores of 25 or higher are considered to be in the clinical range. Seven items are on the social phobia sub-scale, and a score of 8 or higher warrants additional assessment.

The SCAS, evaluated for children ages 8 to 12, contains 38 items, six of which are related to social anxiety specifically. Frequency is rated on a 4-point scale. Psychometric properties are adequate.17,24 The SCAS assesses symptoms consistent with DSM-IV diagnoses related to separation anxiety disorder, social phobia, obsessive-compulsive disorder, panic-agoraphobia, GAD, and fears of physical injury. Internal consistencies for the subscales ranged from 0.82 (panic) to 0.60 (fears of physical injury), and 6-month test-retest reliability for the total score was 0.60 in a community sample.17 Scores on the SCAS were highly correlated with another child self-report measure of anxiety and were significantly higher for youth with social phobia compared to their non-anxious peers.

With respect to instruments that assess social anxiety specifically, the two most commonly used rating scales are the Social Phobia and Anxiety Inventory for Children25 (SPAI-C) and the Social Anxiety Scales for Children and Adolescents (SAS).26 The SPAI-C is appropriate for children 7 and older and contains 26 items that assess the level of distress youth experience across a broad range of typically anxiety-provoking situations. The measure has adequate psychometric properties including high test-retest reliability, internal consistency, convergent validity, and it differentiates between socially anxious and nonanxious children.25,27 Studies have also shown the scores on the SPAI-C are sensitive to treatment.28 A total score of 18 or greater (total range is 0 to 52; higher scores reflect higher anxiety) suggests a possible diagnosis of social phobia.

The SAS scales were designed to assess social anxiety in the context of peer relations, ie, core constructs and key criteria for social phobia.26 There are child (ages 6 to 12) and adolescent (ages 12 to 17) versions, and each contain 18 and 22 items, respectively. The SAS yields three subscale scores: fear of negative evaluation, social avoidance and distress in new situations, and social avoidance and distress in general situations. Psychometric data (eg, test-retest, construct validity) are favorable, and norms are established for both children and adolescents.26 Studies have also shown the scores on the SAS scales are sensitive to treatment.6,29 A total score of approximately 50 suggests a possible diagnosis of social phobia.

Treatment of Social Phobia in Children and Adolescents

The past decade has seen an increase in research on the treatment of children with social phobia. From this literature, two treatments have garnered the most empirical support: cognitive-behavior therapy (CBT) and pharmacotherapy (ie, selective serotonin reuptake inhibitors or SSRIs). Each of these is discussed below.

Cognitive-behavior Therapy

Support for CBT in the treatment of social phobia comes from studies on social phobia specific treatment manuals as well as manuals designed for youth with a variety of anxiety disorders (ie, GAD, social phobia, and separation anxiety disorder). All CBT manuals for children with anxiety disorders share common assumptions and components. CBT assumes that anxiety is a tripartite construct consisting of physiological, cognitive, and behavioral components. As such, CBT, whether in the form of group, family, or individual modalities, typically involves teaching skills that address each of these three components along with psychoeducation and relapse prevention planning.

Treatment usually begins with psychoeducation that entails discussing anxiety as a normal emotional response and introducing the CBT model. To address the physiological manifestations of social anxiety, training in relaxation techniques frequently is used. CBT skills that target the cognitive component focus on replacing anxious thoughts (eg, “My classmates will make fun of me and think I am dumb if I make a mistake”) with more realistic thoughts (eg, “Everybody makes mistakes, and my friends haven't made fun of people in the past because of a mistake”). The cognitive component of treatment may include teaching a child to use constructive self-statements (eg, “I can handle my worries”) or to challenge anxious thoughts by examining the evidence for and against. CBT strategies that target the behavioral component focus on “exposure” techniques that consist of systematically and gradually facing feared situations, both in thought and in reality. Finally, relapse prevention focuses on creating plans to cope with future anxiety-provoking events and generalizing skills learned in treatment to additional situations.

Four treatment programs have been developed specifically for social phobia and have accumulated some empirical support over the last decade. These treatments include the core components of CBT with the addition of social skills training and social problem-solving components. These CBT treatment packages vary in terms of length, parental involvement, and organized peer interactions to facilitate exposures and practice of social skills.

Social Effectiveness Therapy for Children30 (SET-C) is a 12-week group treatment that is predominantly behavioral and consists of psychoeducation, social skills training, practice of newly acquired social skills with nonanxious peers, and individual exposure sessions tailored to the social fears of the participants. Beidel et al.30 compared SET-C to an active control condition consisting of a non-specific treatment for test anxiety. Sixty-seven pre-adolescents ranging in age from 8 to 12 were randomly assigned to one of the two treatment conditions. At the 12-week post-assessment, children in the SET-C condition (n = 36) exhibited significantly fewer self-reported symptoms of social phobia on the SPAIC and higher observer ratings of social skills in role-play tasks than children in the comparison condition. Moreover, 67% of the children who received the SET-C treatment no longer met diagnostic criteria for social phobia after 12 weeks, compared with 5% in the control group. The SET-C treatment package has also been adapted for use as a school-based intervention for adolescents with social phobia.31

Another social phobia specific treatment is Albano and Barlow's32 Cognitive Behavioral Group Treatment for Adolescents (CBGT-A). CBGT-A is a 16-week group therapy program that includes psychoeducation, exposure practice sessions, and skills training that focuses on changing distorted cognitions, social skills, and problem solving. Two small studies have garnered some preliminary empirical support for CBGT-A.33,34 In the only controlled study, Hayward and colleagues34 randomly assigned adolescent female participants (n = 35) to either a treatment or control group. Although fewer adolescents in the treatment group met diagnostic criteria for social phobia at post-treatment (55% versus 96%), there was no difference in diagnostic status between groups after 1 year. In sum, despite the short-term gains demonstrated, further investigation is needed to determine the long-term effectiveness of CBGT-A.

In an effort to assess whether parental support increased the effectiveness of CBT, Spence et al.35 examined an intervention involving 12 weeks of group treatment with two booster sessions at 3-month intervals. Fifty children diagnosed with social phobia, ranging in age from 7 to 14, were randomly assigned to one of three conditions: CBT, CBT with the addition of parent training, or wait-list control. Similar to other treatment packages, CBT included social skills training, cognitive strategies, relaxation training, and behavioral exposure. In the parental involvement condition, parents took part in weekly 30-minute sessions during which parents were encouraged to reinforce new social skills, ignore anxious behavior, and facilitate social participation outside of session.

Results demonstrated that children in both active conditions improved significantly more than those on the wait list. Although there was little difference between treatment groups at post-treatment, those in the parental involvement group evidenced greater gains over the course of 1 year. At 12-month follow-up, more than half (53%) of the children no longer met diagnostic criteria for social phobia in the CBT alone group, compared with 81% of the youth in the CBT plus parental involvement group (trend toward significance).

Recent research has focused on determining the shortest effective course of CBT for children with social phobia. Gallagher et al.36 randomly assigned 23 children (ages 8 to 11) to a 3-week CBT intervention or to a wait list control group. The brief intervention consisted of three 3-hour weekly sessions during which children were educated regarding anxiety and CBT, practiced cognitive strategies, and participated in behavioral exposure. Children in the CBT group exhibited significant improvements at both post-treatment (parent- and clinician-reported symptomatology) and 3-week follow-up (child-, parent-, and clinician-reported symptomatology). Diagnostic status at post-test and follow-up also differed significantly between the two groups. By parent-report at post-test, 58% of youth in the treatment condition met criteria for social phobia, compared with 100% in the control condition.

Several outcome studies have documented promising results in using CBT to treat mixed samples of children with anxiety disorders, including those with social phobia.37,38 The majority of studies using mixed samples employed Kendall's Coping Cat treatment manual.39 The Coping Cat treatment program consists of skill development (eg, introduction of relaxation techniques, cognitive restructuring, problem solving), followed by graded behavioral exposure to fearful situations. Existing research demonstrates that the Coping Cat program is significantly more effective in both the reduction of anxiety symptoms and diagnostic recovery than wait list control and is effective in both individual and group modalities.40

One of the few studies to employ an active control comparison found mixed results. In a dismantling design, Silverman and colleagues6 randomly assigned 104 children with phobic disorders (10% met criteria for social phobia) to one of three treatments. The two active treatments were exposure plus parent training of contingency management strategies and exposure plus cognitive self-control. The comparison group involved psychoeducation about the symptoms and treatment of phobias (education support). Although the three groups did not differ on survey measures of anxious symptoms, the self-control group obtained significantly higher rates of being free of diagnosis at post-assessment (88% versus 55% and 56% for contingency management and education support, respectively).

Although the extant literature provides support for CBT as an efficacious intervention for social phobia, more research is needed to identify the most active methods in CBT, to determine the importance of parental involvement, and to ascertain the optimal dose of CBT treatment. Moreover, larger sample sizes, as well as ethnically diverse samples, are needed to ensure the generalizability of the obtained results. In addition, transportability, or the effectiveness of CBT for youth with social phobia delivered by nonexpert clinicians in settings other than specialty clinics, needs to be investigated. Finally, it is currently unclear whether CBT interventions designed specifically for social phobia are more effective than CBT treatment packages developed for youth with various anxiety disorders.

Pharmacotherapy

Pharmacologic treatments for anxiety disorders in children have improved considerably since the initial studies of the 1960s. A major reason for the improvement has been the increase in the types of medications available and recent data from large-scale clinical trials. Currently, however, only a small number of psychotropic medications have a Food and Drug Administration (FDA) indication for treatment of anxiety disorders in children, and none are specific to social phobia. These medications are all indicated for obsessive-compulsive disorder and include the tricyclic antidepressant (TCA) clomipramine and the selective serotonin reuptake inhibitors (SSRI) fluvoxamine, sertraline, and fluoxetine. To date, the SSRIs have the most empirical support and are recommended in most cases as the medications of choice for treating anxiety in children and adolescents. Data supporting the use of these medications for social phobia come from both open and controlled trials.

Three small open trials of medication have focused specifically on children with social phobia (citalopram,28 sertraline,41 and paroxotine, sertraline, and nefazodone42). Additional open trials have evaluated fluoxetine in children with anxiety disorders including social phobia.43,44 Across these studies, findings suggest the majority of children responded positively and were able to tolerate the medications with minimal side effects.

In the earliest, largest, and longest trial, Birmaher and colleagues43 treated 21 children and adolescents ages 11 to 17 with separation anxiety disorder, social phobia, and overanxious disorder with open-label fluoxetine for up to 10 months. Improvement on clinician, parent and child ratings of anxiety was found in 17 out of 21 subjects, with minimal or no side effects. Less favorable outcomes were found in a study by Compton et al.,41 which examined sertraline (mean dose was 123 mg per day) for 14 children ages 10 to 17 with social phobia. After 8 weeks of treatment, 36% of children were responders, and 29% were partial responders.

The largest double-blind controlled trial to date was conducted at six sites: Johns Hopkins University, New York State Psychiatric Institute at Columbia University, New York University, Duke University, and the University of California at Los Angeles. The study was funded by the National Institute of Mental Health (NIMH), Research Units of Pediatric Psychopharmacology.23 In this study, 128 children and adolescents ages 6 to 17 with separation anxiety disorder, social phobia, GAD, or a combination of the three disorders were randomized to 8 weeks of either fluvoxamine (50 to 300 mg per day) or placebo. Children were assessed using a number of self-, parent-, and clinician reports of anxiety symptoms (including the MASC and SCARED tests). After 8 weeks of treatment, children taking fluvoxamine were significantly improved on multiple outcome measures of anxiety and impairment. More specifically, at post-treatment, 48 of 63 (76%) children taking fluvoxamine were considered improved or better, compared with 18 of 65 (29%) children taking a placebo. The medication was well tolerated, with five of 63 (8%) children taking fluvoxamine and one one of 65 (2%) on children taking a placebo discontinuing due to side effects. In addition, five of 65 (8%) taking a placebo discontinued due to lack of efficacy.

Similar results were reported more recently by Birmaher et al.45 in a 12-week controlled trial of fluoxetine in 54 children ages 7 to 17 with separation anxiety disorder, social phobia, GAD, or a combination of the three disorders. At post treatment, 61% of children taking fluoxetine, as compared with 35% of those taking a placebo, were considered responders or were significantly better. Among those treated with fluoxetine, those with social phobia and GAD responded best.

Despite these positive findings, additional studies are needed. For example, the long-term safety and efficacy of SSRIs has not been demonstrated. It is also important to identify the optimum duration of treatment. Finally, the FDA recently issued a warning noting a potential increased risk of suicidal behaviors among youth taking this class of medication. While the risk-benefit analyses of using SSRIs continue to be discussed, children prescribed these medications must be educated properly about side effects, most notably behavioral activation, and supervised closelyby the prescribing physician.

Combining Medication and Psychosocial Treatments

Practitioners often struggle with when and whether to use psychotherapy, medication, or the combination of the two. Currently, no empirical data exist to answer this question for social phobia. However, a large-scale study, the Child Anxiety Multi-modal Study, funded by the National Institute of Mental Health, is currently under way to assess the relative efficacy of medication and CBT and their combination to pill placebo for social phobia, separation anxiety disorder, and GAD. Outcomes from this study are expected to shed light on which treatments work best for which child and will provide data to inform the sequencing of treatments.

Clinically, medication and psychosocial treatments usually are combined when a child is so severely ill that two treatments appear to be needed to increase the probability of a positive outcome. Another reason for combining treatments is when a child presents with comorbid conditions that need to be treated simultaneously, such as attention-deficit/hyperactivity disorder and anxiety. Finally, a combined approach to treatment may be needed to augment an initial treatment when the child is only partially responding. For example, an SSRI can be added to CBT for social phobia to improve outcomes, particularly for the child who is reticent about engaging in exposure exercises.

In addition to these clinically driven decisions, a critical review of pharmacotherapy studies for child anxiety revealed that efficacy rates for pharmocotherapy were higher when accompanied with a behavioral therapy component.46 More recently, Chavira and Stein28 conducted an open trial evaluating the combination of CBT-based psychoeducation and citalopram for children with social phobia (n = 12; ages 8–17) and found higher rates of improvement (83%) than those in studies evaluating medications alone. Finally, recent data from the Treatment of Adolescent Depression study (TADS) also suggest that the combination of CBT and medication may lead to the most beneficial outcomes.47 In sum, children with social phobia and their families have a number of excellent treatment choices. Efforts to disseminate these findings are critical to maximize the benefit children with anxiety can achieve.

What Psychiatrists Can Do

A plethora of information now exists to inform and enlighten psychiatrists about social phobia in youth. As such, there are several practical strategies that can be implemented to help these youth get the services they need. First, know what to look for and be familiar with the common symptoms of social phobia. Second, when signs of anxiety are present, use a screen to help determine if symptoms are “normal” or pathological (eg, whether the anxiety is impairing the child's functioning). Remember, screening tools do not determine a diagnosis but can be helpful in identifying when anxiety is a problem that needs further assessment. If anxiety levels are in a clinical or subclinical range, conduct a thorough assessment of anxiety and consider treating with an SSRI, CBT, or a combination of the two. Encourage gradual exposure (ie, having the child face his or her fears in small steps), and encourage parents to model “brave” behavior.

Parents should also be encouraged to support and reward exposures. Educating families that anxiety tends to wax and wane may be helpful to prepare for recurrences. At the same time, it is critical for families to be vigilant for the return of symptoms and not to allow children to engage in avoidance. Practitioners may also find it useful to recommend books to parents on anxiety management such as Keys to Parenting Your Anxious Child48 and Helping Your Anxious Child: A Step by Step Guide for Parents.49

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Rating Scales for Social Phobia in Children and Adolescents

Scale# of itemsSample ItemsScoring Format
MASC39I worry about other people laughing at me.Likert-type scale
I'm afraid other kids will make fun of me.0–3

SCARED41I worry about other people liking me.Likert-type scale
I feel shy with people I don't know well.0–2

SCAS38I feel afraid that I will make a fool of myself in front of other people.Never, Sometimes, Often, Always
I worry what other people will think of me.
SPAI-C26When with others, I think scary thoughts.Likert-type scale
Before going somewhere, I worry what might go wrong.0–2

SAS18I worry about what others think of me.Likert-type scale
I get nervous when I meet new kids.1–5

Educational Objectives

  1. Identify key diagnostic criteria for social phobia in children and adolescents.

  2. Describe rating scales to screen for social phobia in children and adolescents.

  3. Discuss empirically supported treatment approaches for social phobia in children.

Sidebar.

DSM-IV Diagnostic Criteria for Social Phobia in Children and Adolescents

  1. Chronic, excessive fear of social or performance situations that the child fears will be potentially embarrassing. The anxiety must occur in peer settings, not just in interactions with adults.

  2. Feared social situations almost always trigger an anxious response.

  3. Feared social situations are avoided or tolerated with great distress.

  4. Fear or avoidance must cause significant impairment in the functioning (daily routine, academic, social, familial) of the child or adolescent.

  5. Fear or avoidance is not better explained by medication, medical condition, or other mental disorder.

  6. Symptoms must be present for at least 6 months.

  7. If the social fears are focused on one, two, or even several situations, the child receives a diagnosis of SOP; however, if the child fears most social situations, the specifier “generalized” should be added to the diagnosis.

Diagnostic Criteria for Social Phobia in Children and Adolescents

Authors

Dr. Ginsburg is an associate professor and Dr. Grover is a postdoctorate fellow, Johns Hopkins University School of Medicine, Baltimore, MD.

Address reprint requests to: Golda S. Ginsburg, PhD, Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, 600 North Wolfe Street/CMSC 312, Baltimore, MD 21287-3325.

Preparation of this article was supported by a grant from the National Institute of Mental Health (K23 MH63427-02) and an unrestricted research grant from Pfizer, both awarded to Dr. Ginsburg. The authors have no other industry relationships to disclose.

10.3928/00485713-20050901-06

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