The first symptoms of social anxiety disorder in adolescents may be excessive worrying before attending a social event or excessive preparation for a class presentation. The first symptoms in children may be tantrums, crying, freezing, clinging, or withdrawing in social situations. Avoidant behaviors (eg, refusing to go to school, not going to parties, not eating in front of others) can follow. Complaints often have a somatic focus (eg, “My stomach hurts,” “I have a headache”). Some children have a history of many medical appointments and evaluations in response to these somatic complaints.
Affected children are terrified that they will humiliate themselves in front of their peers by giving the wrong answer, saying something inappropriate, becoming embarrassed, or even vomiting. In some cases, social anxiety disorder emerges after an unfortunate and embarrassing incident. In severe cases, children may refuse to talk on the telephone or even refuse to leave the house.
For social anxiety disorder to be diagnosed, the anxiety must persist for ≥ 6 months and be consistently present in similar settings (eg, children are anxious about all classroom presentations rather than only occasional ones or ones for a specific class). The anxiety must occur in peer settings and not only during interactions with adults.
Behavioral therapy is the cornerstone of treatment for social anxiety disorder. Children should not be allowed to miss school. Absence serves only to make them even more reluctant to attend school.
If children and adolescents are not sufficiently motivated to participate in behavioral therapy or do not respond adequately to it, an anxiolytic such as a selective serotonin reuptake inhibitor (SSRI) may help (see table Drugs for Long-Term Treatment of Anxiety and Related Disorders). Treatment with an SSRI may reduce anxiety enough to facilitate children’s participation in behavioral therapy.