Many advocating for more attention to psychosocial issues by primary care pediatricians focus on serious conditions and the value of early recognition. For example, early recognition of autism spectrum disorder could lead to earlier intensive treatment that might impact the long-term course. Early diagnosis and appropriate treatment of attention-deficit/hyperactivity disorder very likely will lessen symptoms and also maintain self-esteem under the withering ordeal – often punctuated by teacher comments – of trying to pay attention hour after hour in school.
Are there seemingly less serious conditions very likely worthy of early diagnosis, even those on the edge of normal developmental hurdles? One of the essential tasks of childhood is mastering the anxiety that emerges as children face the new challenges of each developmental stage, so parents, teachers, and clinicians are (or need to be) used to bearing anxiety in the children with whom they work. Intense shyness and anxiety around separation from parents are routine and healthy in infants and toddlers from 6-18 months. Anxiety in new social situations, such as the first day of preschool, is the rule, not the exception. School-age children commonly experience a surge of anxiety around performance and independence, as they are managing and mastering new skills in these domains every day. This anxiety can cause distress, but it should get better every time a child faces it, as they become better at managing the situation. When a child has an anxious temperament, poor coping skills, or parents who struggle to manage their own anxiety, children may have a harder time mastering new, anxiety-provoking challenges across settings. But, with time, and even just one adult who patiently models good coping, they will face and manage challenges. Social anxiety disorder is present when specific social or performance situations provoke the same intense anxiety and avoidance over and over, and for more than 6 months.
Most infants and young children who are more timid and fearful seem to grow into a normal range of social behavior, although few become extroverts. Some of these shy children are cautious in new situations for a period of time measured in minutes, but once the situations are familiar, these children are indistinguishable from their peers. However, some of these temperamentally timid children emerge consistently more anxious with greater likelihood to have phobias and to have social anxiety that can seriously impact long term happiness, achievement, and increase risk taking behaviors. A pediatrician should watch and note the emerging pattern of a timid toddler to see if the shyness eases or impacts social functioning; by bending the course of social interactions, social anxiety disorder critically affects developing social skills, self-regulation, affect tolerance, emerging identity, and confidence. Recognition and effective treatment of social anxiety will keep a child on the optimal developmental trajectory.
Anxiety disorders are the most common psychiatric illnesses in the United States, and social anxiety disorder (previously labeled as social phobia) is the third most common psychiatric disorder in U.S. adults (after depression and alcohol dependence). Most persistent anxiety disorders begin in childhood, and social anxiety is no exception. The mean age of onset for social anxiety is 13 years old, and it rarely begins after the age of 25, with an annual prevalence around 7% in childhood and adolescence ( Psychiatr. Clin. North Am. 2009;32;483-524 ).The DSM-5 criteria for social anxiety disorder include, “a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others,” and exposure to those situations provokes intense anxiety, which in children can be marked by severe or prolonged crying, freezing, tantrums, shrinking from social situations, refusing to speak, or clinging to parents. In adolescents, it may trigger panic attacks. The avoidance and distress interfere with the child’s function in school, social activities, or relationships, and must have lasted for at least 6 months. To ensure that there is not another problem of social relatedness, the child should have shown some capacity to have normal peer relationships.
Will social anxiety disorder be vividly apparent to teachers, parents, and clinicians? No. The feeling of anxiety is an internal experience, not easily observed, and anxious children and teens are rarely eager or comfortable communicators about their own anxiety. Indeed, in a 2007 survey of patients in treatment for anxiety, 36% of people with social anxiety disorder reported experiencing symptoms for 10 or more years before seeking help. It’s true that the distress children experience when feeling intensely anxious will probably be observable, but all of those behaviors (clinging, crying, tantrums) are common and normal expressions of distress in childhood. Even in adolescence, while having a panic attack may prompt the teenager to seek care, she may not connect it with the anxiety she was feeling about being called on in class or talking to peers, especially if that is an anxiety she has experienced for a long time as a daily part of her lives and routines.
Social anxiety disorder is treatable. The first-line treatment in mild to moderate cases, particularly with younger children, is cognitive-behavioral therapy. This is a practical variant of psychotherapy in which children develop and practice skills at recognizing and labeling their own feelings of anxiety, identifying the situations that trigger them, and practicing relaxation strategies that help them to face and manage the anxiety-provoking situations rather than avoiding them.
When symptoms or the degree of impairment are more severe, medications can become an important part of treatment. SSRIs are the first-line medications used to treat social anxiety disorder, and the effective doses are often higher than effective antidepressant doses, although we often titrate toward those doses more slowly with anxious patients to avoid side effects that might increase or exacerbate their anxiety.
Even with effective medication treatment, though, psychotherapy will be an essential part of treatment. These young patients need to build the essential skills of anxiety management, although it is in the nature of anxiety that such patients often wish to dissolve their anxiety by simply using a pill.
Anxiety disorders are typically chronic and will persist without effective treatment. Failure to recognize and treat social anxiety disorder can distort or even derail healthy development and may result in major psychiatric complications. As a pediatrician, you are trying to stop or modify a chain of potential events. Imagine a socially anxious young woman who enters puberty in high school. Will she withdraw from social activities? Will she avoid new opportunities or interests? Will alcohol become a necessary social lubricant? Will she be at increased risk for sexual assault at a party or poor grades in school? Will social anxiety affect her choice of college, fearful of leaving home? The incidence of secondary depression and substance abuse disorders is substantially higher in adolescents with untreated anxiety disorders. Although a depressed, alcohol-dependent teenager is more likely to be recognized as needing treatment, once they have developed those complications, effective treatment of the underlying anxiety will be much more complicated and slow to treat. Prevention starting before puberty is a much more desirable approach.
Pediatricians truly do have the opportunity to improve outcomes for these patients, by learning to recognize this sometimes-invisible disorder. Children suffering from anxiety disorders are more likely to identify a physical concern than a psychological one. (They have a lot of headaches and tummy aches!) When you are seeing a “shy” school-age child who has persistent crying spells around attending school on test days or before each sporting event despite loving practice, it is useful to gather more history. Is there a family history of anxiety or depression? What are the circumstances of their crying jags or persistent tantrums? Ask teenagers about episodes of shortness of breath, tachycardia, dizziness or sweating that leave them feeling like they are going to die (panic attacks). See if they can rank their anxiety on a scale from 1-10, and find out of there are consistent situations where their anxiety seems disproportionate. Children or teens may recognize that their anxiety is not merited, or they may not. If their parent also suffers from anxiety, they are less likely to recognize that this intense, persistent “shyness” in their child represents a treatable symptom. When you simply have a high index of suspicion, it is worth a referral to a mental health expert to evaluate their anxiety.
Reassuring parents and children that this is a common, treatable problem in childhood will go a long way to diminishing the secrecy and shame that can accompany paralyzing anxiety, and help your patients toward a track that optimizes their psychosocial development.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at firstname.lastname@example.org. Scan this QR code to read similar articles or go to pediatricnews.com.