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.