Social Anxiety Disorder Affects Up to 15 Percent of Children, Yet Often Goes Undiagnosed and Untreated

BUFFALO, N.Y. -- Five to 15 percent of children and adolescents in the United States suffer from a dangerous and disabling emotional disorder that poses a serious impediment to their social, educational and emotional development.

It is social anxiety disorder (SAD), a condition that, according to Todd Kashdan, a doctoral candidate in clinical psychology at the University at Buffalo, is seldom researched, recognized or treated although it is "one of the most prevalent and disabling mental disorders of childhood and adolescence."

Kashdan co-authored with James D. Herbert of M.C.P. Hahnemann University an article on the status of the condition and future directions in treatment published in Clinical Child and Family Psychology Review, Vol. 4, No. 1. The study is available online at http://www.acsu.buffalo.edu/~kashdan/.

"SAD is marked by a crippling fear of being watched or evaluated by others," Kashdan says. "Victims are prone to excessive shyness; nervousness around people; a refusal to participate in class or in group activities; difficulty making friends, and irritability, sickness, dizziness or great discomfort in certain social situations.

"The severe impairment in school, at home and in relationships that these children and adolescent suffer often lingers into adulthood, changing the trajectory of lives from an ideal path to one that is likely to be much less satisfying.

"Despite a recent surge of attention by psychologists, this still remains one of the least-recognized, least-researched and least-treated of pediatric disorders," he adds. "Ironically, one of the reasons the vast majority of individuals suffering from SAD never seek treatment is that their very concern about being negatively evaluated causes them fear of what other people might think. Also, most individuals aren't even aware that excessive social anxiety is a treatable problem.

"We don't really know what causes SAD, as there may be a genetic predisposition, the interplay of life stressors and traumatic events, and likely interactions between biological and psychological vulnerabilities," Kashdan says. He points out that several studies suggest that risk factors include a temperament characterized by shyness, social inhibition and avoidance in childhood; maladaptive, highly critical family environments; peer rejection, and victimization experiences, followed by traumatic conditioning.

"Whatever its origin in a child, SAD seems to develop and be maintained by a vicious cycle of negative thoughts, feelings and avoidance behaviors," Kashdan says.

"Children suffering from it are extremely afraid that they may say or do something to embarrass themselves or expose themselves to criticism," he says.

"They feel they don't fit in, that they'll be criticized, look stupid or no one will like them. When in a personally threatening social situation, they are very uncomfortable. They may experience physical symptoms such as dizziness, heart palpitations, upset stomach, shaky hands, blushing or muscle tension. Because of the discomfort, they tend to avoid the situations they fear. This limits their opportunity to practice and improve their social skills at a critical juncture when other children and adolescents are experimenting with parties, intimate friendships and early romances."

Unlike shyness, which children and teen-agers often outgrow, social anxiety disorder usually does not go away on its own. In fact, some children are anxiety-stricken in so many situations that they are virtually paralyzed, which can set a physical course for the disorder that can last well into adulthood, according to Kashdan.

"One of the most unfortunate aspects of this disorder," says Kashdan, "is that it strikes children at the very time in their lives when their need for 'belongingness' and peer acceptance is pronounced. We don't like to think that something this painful and even catastrophic to the well-being of a child is so seldom diagnosed or treated, but that is the case.

"These children tend to be 'invisible' and neglected in the classroom and considered 'shy' by parents. They're so concerned about how others think of them that they seldom act out, and so don't come to the attention of the adults in their lives unless their distress progresses to the point where they begin to refuse going to school."

"Undiagnosed, untreated SAD, however, doesn't go away," says Kashdan. "Not only can it produce significant stress and impairment in childhood, but studies have found that it is associated with significantly lower levels of attainment at work, education and romantic relationships, an increased rate of alcohol and drug abuse, and in the worst case, suicidal behaviors."

Some children with this disorder exhibit a very severe form of social anxiety called "selective mutism."

"They may be able to socialize with family members," Kashdan says, "but when it comes to less-familiar peers and adults, they become very uncomfortable and refuse to speak. Common signs of this may include a pervasive refusal to answer questions in class and speak to other children."

Kashdan says the diagnosis and treatment of SAD among children and adolescents is complicated by several factors, including the fact that symptoms can manifest differently in children, adolescents and adults, that it is difficult to differentiate between normal and pathological anxiety, and that SAD is marked by attention and concentration difficulties that make communication difficult.

Two approaches used successfully with adults show promise for use with children, he says. One employs medication to alleviate children's worried and depressed feelings, another teaches children ways to deal effectively with overwhelming fear and anxiety.

Kashdan says, however, that much more research needs to be done to help ascertain SAD's developmental pathways and maintenance factors; to delineate its different manifestations in children, adolescents and adults, and to look at personal and environmental factors that produce resilience.