Social Anxiety In Children: More Than Shyness?

Social anxiety disorder (SAD), or social phobia, is one of the most common anxiety disorders, affecting millions of people worldwide. It’s characterized by an excessive fear of embarrassment and humiliation in social settings, particularly those that are unfamiliar or where you feel others will judge you. Left untreated, this may cause further avoidance of future social situations or even worsen existing anxiety symptoms.

Although we typically hear of SAD affecting adolescents and young adults, children are just as likely to be affected. The symptoms of SAD become more obvious as children progress from childhood into their teenage years, as they prioritize maintaining appearances in front of their friends and other social circles. 

Symptoms of SAD can make children feel overly self-conscious¹ about their actions, which could negatively affect² their schoolwork, social interactions, and developmental progress into adolescence.

However, SAD is more difficult to spot in children³ than in adolescents. Children are more limited in their ability to identify and express the reasons they feel anxious. Social anxiety in early childhood is often mistaken for shyness by parents and teachers. Younger children are also more likely to act out on their anxiety, such as being fussy or angry, which often gets misattributed to behavioral issues. If the severity of SAD is downplayed, it becomes harder for both parents and children to seek appropriate treatment. 

Regardless of timing and severity, effective treatments are available for SAD. Proper support can be sought by understanding what SAD is, its causes, and the symptoms to look out for.

What is social anxiety disorder?

According to the Diagnostic and Statistical Manual for Mental Health Disorders, SAD is defined as a “marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others”. The social situations may vary among individuals, but common ones include the following examples:

Performance situations 

These usually involve activities where the person may be observed (e.g., public speaking, eating in public, group participation, or performances)

Social situations

These involve interacting with other people and forming relationships (e.g., meeting new people, classmates, coworkers, and group hangouts)

It’s normal to experience some fear in new social situations; however, people with SAD may experience severe panic-like symptoms when confronted with new surroundings. This may provoke other anxiety responses in children, such as clinging onto familiar people or objects, crying, hiding, or public tantrums. 

A diagnosis of SAD for children² requires that the anxiety be disruptive to the child’s daily routine or causes the child significant distress. This diagnosis also needs to be supported with evidence that the child’s anxiety occurs in social settings with their peers and not just with adults. 

Children with SAD may show the following characteristics:

• difficulty joining other children in groups

• avoiding situations where they are the center of attention

• appearing withdrawn or reserved in groups

• physical symptoms of anxiety, such as nausea, blushing, or trembling

• a decline in performance in other areas of functioning (e.g., academic, social, or mental performance)

Causes

Scientists are not sure what the exact causes of SAD are in children; however, it’s likely due to a combination of influential factors, including the following: 

Family history

Children with a family history of anxiety disorders have an increased risk of developing SAD.⁴ However, researchers are unsure if this is genetically linked. In one study, researchers found that first-degree relatives of study participants with SAD were ten times more likely⁵ to experience SAD themselves in a family risk study.

A similar finding⁶ was also noted in children of adults diagnosed with SAD. Inherited traits can make children more susceptible to developing SAD which can be compounded by learned behaviors. Learned behaviors are ways of interacting with the world that children learn from family and caregivers. 

Some research also suggests that a particular chromosome⁷ is responsible for the development of SAD-related characteristics. 

Environmental factors

Children can also experience SAD as a result of controlling or overprotective environments. Negative parental behaviors, such as a lack of warmth, overanxious tendencies, overprotection, and rejection, have been associated with a high risk of SAD symptoms in children. 

Children may also ‘learn’ behavioral patterns of SAD through direct conditioning (i.e., being embarrassed or laughed at) or through learning cues from friends and family.

Negative social behaviors

Abuse, bullying, and teasing have been known to instigate SAD symptoms, as they may have caused the shame or humiliation a child may feel in social settings. This could arise from strangers or even their peers through “peer victimization”⁸ — an aggressive or negative act inflicted by the victim’s friends.

A research article⁹ has explored these connections and found that these negative behaviors were associated with heightened SAD symptoms. They discovered that SAD did not stop in childhood but continued into adolescence, where the rates of social phobia were significantly greater. 

This may explain the tendency to avoid similar situations or experiences associated with the event, which increases the risk of SAD onset¹⁰ and adverse effects on the health of many young adults.

Stress

Scientists believe that a region in the brain known as the amygdala may be involved in developing SAD symptoms. Known for its function in regulating social behavior, it has been shown that people with SAD showed greater brain activity in the amygdala¹¹ in social environments. 

This may cause overactivation¹² of the fight or flight response and lead the brain to believe a constant danger is present in social interactions, increasing the severity of SAD-related symptoms.

Risk factors

Children can develop SAD with or without the presence of risk factors. While the factors that will be responsible for the child developing SAD can’t be predicted, their presence increases the likelihood. These may include, but are not limited to, the following examples:

• Sex – girls are twice as likely¹³ to develop SAD symptoms as boys

• Presence of other mental health conditions – people with SAD are also likely to have generalized anxiety and depression

• Behavioral inhibition – a temperament style where a child may actively refrain  from engaging with unfamiliar situations and people

• Traumatic events

• History of being bullied, teased, or rejected

• School-related stress 

• Disability or disfigurement

Treatments

Given that SAD can lead to more severe symptoms later in life, it is essential to help children connect the dots between their symptoms and their emotional responses. Educating children about anxiety and its effects is a helpful first step, and this may be complemented by other techniques such as the following:  

Behavioral therapy

Behavioral therapy is an evidence-based treatment for children with SAD. It’s considered an effective treatment¹⁴ for children with anxiety disorders. Behavioral therapy involves several components, including:

• Educating children and caregivers about the nature of anxiety

• Identifying and challenging anxiety-provoking situations

• Teaching techniques to manage future anxiety-provoking situations

The therapist can work with both children and their families to replace negative behavioral patterns with more productive ones. While it won’t ‘cure’ social anxiety (because no cure exists), it can lessen the severity of its symptoms and provide children with valuable tools to respond to stressful situations. 

Before beginning behavioral therapy, therapists will work with children and their families to discuss goals and develop a personalized plan designed to gradually work through the complexities of SAD. Treatments are usually interactive and may include the following elements:

• Relaxation strategies – learning how to calm anxiety using breathing exercises, guided imagery, and muscle relaxation

• Play therapy – interactive sessions where a scenario is acted out using arts and crafts, dolls, and/or role play to help engage the child in solving problems in a no-pressure environment

• Acting – tasking the child to act out an example of desired behaviors

• Exposure – involves slowly exposing the child to situations or things that provoke their anxiety while using tools and techniques to find their calm

• Cognitive reframing – teaching children to recognize negative thoughts and how to replace them with positive ones

Studies¹⁵ that have followed up with children after they completed behavioral therapy have been promising, with one study showing that 67% of children¹⁶ no longer meet the criteria for anxiety disorders after 20–25 sessions of psychotherapy. Although this study only included 30 children, the effects in the children were long lasting. The researchers’ follow-up showed no child relapsed six months after treatment.

Medications

Evidence¹⁷ suggests that anti-anxiety and antidepressant medication are effective treatments for adults with SAD. However, in children, medications are only considered when symptoms are severe or impact the child’s participation in behavioral therapy. Whether or not your child requires medication depends on further assessment from your doctor.

Limited information is available regarding the effectiveness and safety of medication in children with SAD compared to adults. Nevertheless, these studies have supported the efficacy and safety of a particular class of drugs known as selective-serotonin reuptake inhibitors¹⁸ (SSRIs) in children. 

However, it is highly encouraged that SSRIs be combined with behavioral therapy.¹⁹ This dramatically reduces symptom severity in children and increases parents’ perceptions of their child’s social skills during treatment. 

Commonly prescribed SSRIs include the following examples:

• Sertraline (Zoloft)

• Paroxetine (Paxil)

• Fluoxetine (Prozac)

• Fluvoxamine

When to see a doctor

If SAD negatively affects your child’s ability to interact in social settings, or if you notice signs of excessive worry and/or other physical symptoms, it may be time to see your local doctor or pediatrician. The doctor may conduct an assessment to understand your child’s symptoms, how long they’ve experienced the symptoms, and the severity of symptoms. 

If appropriate, the doctor may refer you to a mental health expert, who will further assess the situation before deciding on the best course of treatment.

The lowdown

It’s normal for children to feel some level of anxiety. However, extreme levels of anxiety can disrupt a child’s ability to carry out everyday activities, interact with their peers, and may cause the children to avoid situations where they must socialize. 

SAD is treatable and, with proper support, children can learn to cope with their symptoms and develop effective strategies to help restore their confidence.