Social phobia in children and adolescents

Epidemiological data indicate that anxiety disorders are the most common childhood disorders. 1% of children and adolescents suffer from social phobia and it may influence further adult life. The aim of the article is to show differences of child and adolescent social phobia and its diagnostic criteria. Contrast and distinction of childhood social phobia symptoms are also shown, such as risk factors of appearance of childhood social phobia. The article presents main therapeutic methods--psychotherapy and pharmacotherapy applied to children with phobia and difficulties with estimating efficacy of the particular therapy in this group of patients. Phobic children perceive surroundings more negatively. They have reduced estimations of their own competency to cope with danger. They also show cognitive impairments of ambiguous situations. As much as 60% children with social phobia suffer from a second, concurrent disorder. Widening of information about symptoms and therapeutic methods may reduce the intensity of the disorder during adulthood.     

Cognitive-evaluative features of childhood social anxiety in a performance task

Using an experimental design, we analysed differences in the occurrence of cognitive-evaluative distortions and performance deficits across children with social anxiety disorder, with subclinical anxiety and without any anxiety symptoms.Twenty-one children with full syndrome social phobia, 18 children with partial syndrome social phobia and 20 children without any symptoms of social phobia were compared with respect to their degree of anxiety, negative thinking and task performance during two social-evaluative tasks. In addition, self-ratings of task performance, performance estimations for other children and objective behavioural ratings by two independent observers were obtained.Children with social anxiety disorder and subclinical social anxiety showed higher degrees of experienced anxiety and negative thinking than healthy control children. There was no group difference in respect to actual task performance. Findings are discussed with regard to the continuum assumption of childhood social anxiety disorder and the need of well-adapted early interventions.     

Screening for anxiety disorders in children

Anxiety disorders are highly prevalent and have negative consequences on individual and societal level. This study examined the usefulness of screening for anxiety disorders in primary school children. More specifically, the value of the screening method to discriminate between and to predict anxiety disorders was studied. Children and their parents were selected if the children had self-reported scores on the screening questionnaire Screen for Child Anxiety Related Emotional Disorders-71 (SCARED-71) within the top-15% (High-anxious) or from two points below to two points above the median (Median-anxious). Of the selected children, 183 high-anxious children and their parents, and 80 median-anxious children and their parents took part in a diagnostic interview, the Anxiety Disorder Interview Schedule (ADIS). Of the high-anxious children, 60% had an anxiety disorder versus 23% of the median-anxious children, whereas groups did not differ on rates of dysthymia/depression and attention deficit hyperactivity disorder. The diagnoses separation anxiety disorder, social phobia and specific phobia were specifically predicted by the corresponding subscales of the screening questionnaire, while the diagnosis generalised anxiety disorder was not predicted by any of the subscales. The screening method has proven its utility for discriminating between children with and without anxiety disorders when applying the top-15% cut-off. Moreover, separation anxiety disorder, social phobia, and specific phobia, all known to be prevalent and debilitating childhood anxiety disorders, can be predicted by the corresponding subscale of the screening instrument.     

Cognitive behavior therapy (CBT) in anxiety disorders

This review examines CBT as a leading evidence-based psychotherapy. It describes briefly the major components of CBT: exposure, reduction of safety behaviors, attention focus modification and cognitive restructuring. Specific CBT strategies suited for the main anxiety disorders are reported (specific phobias, panic disorder and agoraphobia, social phobia, generalized anxiety disorder, obsessive compulsive disorder and post-traumatic stress disorder). The review emphasizes the efficiency of the use of CBT as a psychotherapeutic method in anxiety disorders. Finally, it points to the lack of the use of CBT in Israel and recommends its wide use in the mental health service here.     

Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence

A large amount of research has accumulated on the efficacy and effectiveness of cognitive-behavioral therapy (CBT) for anxiety disorders including posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, social anxiety disorder, and specific phobia. The purpose of the current article is to provide an overview of two of the most commonly used CBT methods used to treat anxiety disorders (exposure and cognitive therapy) and to summarize and discuss the current empirical research regarding the usefulness of these techniques for each anxiety disorder. Additionally, we discuss the difficulties that arise when comparing active CBT treatments, and we suggest directions for future research. Overall, CBT appears to be both efficacious and effective in the treatment of anxiety disorders, but dismantling studies are needed to determine which specific treatment components lead to beneficial outcomes and which patients are most likely to benefit from these treatment components.     

Fluoxetine for the treatment of childhood anxiety disorders: open-label, long-term extension to a controlled trial

OBJECTIVE: To assess the efficacy of fluoxetine for the long-term treatment of children and adolescents with anxiety disorders, including generalized anxiety disorder, separation anxiety disorder, and/or social phobia. METHOD: Children and adolescents (7-17 years old) with anxiety disorders were studied in open treatment for 1 year after they completed a randomized, controlled trial (RCT) comparing fluoxetine and placebo. The follow-up phase assessments included clinician, parent, and child ratings with measures of global severity, global improvement, and anxiety symptoms. RESULTS: Subjects taking fluoxetine (n = 42) were compared with those taking no medication (n = 10) during follow-up on anxiety changes from the end of the RCT through the follow-up period. Statistical models included RCT assignment and follow-up psychological treatment. Excluded subjects took other medications (n = 4) or did not complete follow-up (n = 18). Compared with subjects taking no medication, subjects taking fluoxetine showed significantly superior follow-up outcomes on most measures, including clinician, parent, and child ratings. CONCLUSIONS: The results suggest that fluoxetine is clinically effective for the maintenance treatment of anxiety disorders in children and adolescents. A major limitation, however, was the lack of RCT methodology in the follow-up phase. RCTs are needed to determine the long-term risks and benefits of fluoxetine for this group.     

Qu’apportent les outils de réalité virtuelle en psychiatrie de l’enfant et l’adolescent ?

Virtual reality is a relatively new technology that enables individuals to immerse themselves in a virtual world. It offers several advantages including a more realistic, lifelike environment that may allow subjects to “forget” they are being assessed, allow a better participation and an increased generalization of learning. Moreover, the virtual reality system can provide multimodal stimuli, such as visual and auditory stimuli, and can also be used to evaluate the patient's multimodal integration and to aid rehabilitation of cognitive abilities. The use of virtual reality to treat various psychiatric disorders in adults (phobic anxiety disorders, post-traumatic stress disorder, eating disorders, addictions…) and its efficacy is supported by numerous studies. Similar research for children and adolescents is lagging behind. This may be particularly beneficial to children who often show great interest and considerable success on computer, console or videogame tasks. This article will expose the main studies that have used virtual reality with children and adolescents suffering from psychiatric disorders. The use of virtual reality to treat anxiety disorders in adults is gaining popularity and its efficacy is supported by various studies. Most of the studies attest to the significant efficacy of the virtual reality exposure therapy (or in virtuo exposure). In children, studies have covered arachnophobia social anxiety and school refusal phobia. Despite the limited number of studies, results are very encouraging for treatment in anxiety disorders. Several studies have reported the clinical use of virtual reality technology for children and adolescents with autistic spectrum disorders (ASD). Extensive research has proven the efficiency of technologies as support tools for therapy. Researches are found to be focused on communication and on learning and social imitation skills. Virtual reality is also well accepted by subjects with ASD. The virtual environment offers the opportunity to administer controlled tasks such as the typical neuropsychological tools, but in an environment much more like a standard classroom. The virtual reality classroom offers several advantages compared to classical tools such as more realistic and lifelike environment but also records various measures in standardized conditions. Most of the studies using a virtual classroom have found that children with Attention Deficit/Hyperactivity Disorder make significantly fewer correct hits and more commission errors compared with controls. The virtual classroom has proven to be a good clinical tool for evaluation of attention in ADHD. For eating disorders, cognitive behavioural therapy (CBT) program enhanced by a body image specific component using virtual reality techniques was shown to be more efficient than cognitive behavioural therapy alone. The body image-specific component using virtual reality techniques boots efficiency and accelerates the CBT change process for eating disorders. Virtual reality is a relatively new technology and its application in child and adolescent psychiatry is recent. However, this technique is still in its infancy and much work is needed including controlled trials before it can be introduced in routine clinical use. Virtual reality interventions should also investigate how newly acquired skills are transferred to the real world. At present virtual reality can be considered a useful tool in evaluation and treatment for child and adolescent disorders.     

Comorbidity of anxiety disorders with anorexia and bulimia nervosa

OBJECTIVE: A large and well-characterized sample of individuals with anorexia nervosa and bulimia nervosa from the Price Foundation collaborative genetics study was used to determine the frequency of anxiety disorders and to understand how anxiety disorders are related to state of eating disorder illness and age at onset. METHOD: Ninety-seven individuals with anorexia nervosa, 282 with bulimia nervosa, and 293 with anorexia nervosa and bulimia were given the Structured Clinical Interview for DSM-IV Axis I Disorders and standardized measures of anxiety, perfectionism, and obsessionality. Their ratings on these measures were compared with those of a nonclinical group of women in the community. RESULTS: The rates of most anxiety disorders were similar in all three subtypes of eating disorders. About two-thirds of the individuals with eating disorders had one or more lifetime anxiety disorder; the most common were obsessive-compulsive disorder (OCD) (N=277 [41%]) and social phobia (N=134 [20%]). A majority of the participants reported the onset of OCD, social phobia, specific phobia, and generalized anxiety disorder in childhood, before they developed an eating disorder. People with a history of an eating disorder who were not currently ill and never had a lifetime anxiety disorder diagnosis still tended to be anxious, perfectionistic, and harm avoidant. The presence of either an anxiety disorder or an eating disorder tended to exacerbate these symptoms. CONCLUSIONS: The prevalence of anxiety disorders in general and OCD in particular was much higher in people with anorexia nervosa and bulimia nervosa than in a nonclinical group of women in the community. Anxiety disorders commonly had their onset in childhood before the onset of an eating disorder, supporting the possibility they are a vulnerability factor for developing anorexia nervosa or bulimia nervosa.     

Maternal anxiety predicts favourable treatment outcomes in anxiety-disordered adolescents

Objective: To determine the differential impact of maternal and paternal internalizing psychopathology on cognitive‐behavioural treatment (CBT) outcome of anxiety‐disordered children and adolescents. Method: Participants consisted of 127 children and 51 adolescents with a primary anxiety diagnosis. Children were randomly assigned to a standardized group CBT or individual CBT; adolescents received individual CBT. Parents received four training sessions. Participants were evaluated at pre‐ and post‐treatment with a clinical interview and with self‐ and parent‐reported questionnaires. Lifetime anxiety and mood disorders in parents were obtained with a clinical interview. Results: For children, no associations were found between maternal and paternal anxiety or mood disorders and treatment outcome. For adolescents, however, maternal lifetime anxiety disorders were positively associated with pre‐post‐treatment improvement in clinician severity ratings and with treatment success. Conclusion: Lifetime maternal anxiety disorders were significantly associated with favourable treatment outcomes in adolescents. Paternal disorders were not associated with treatment response.     

Childhood history of anxiety disorders among adults with social phobia: rates, correlates, and comparisons with patients with panic disorder.

We examined the rates and correlates of a childhood history of anxiety disorders in 100 adults with a primary diagnosis of social phobia (social anxiety disorder). Adulthood and childhood disorders were assessed by experienced clinicians with structured clinical interviews. Rates of childhood anxiety disorders were evaluated to diagnostic comorbidity and a comparison group of patients with panic disorder. Onset of social phobia occurred before age 18 in 80% of the sample. Over half of the sample (54%) met criteria for one or more childhood anxiety disorders other than social phobia: 47% for overanxious disorder, 25% for avoidant disorder, 13% for separation anxiety disorder, and 1% for childhood agoraphobia. A history of childhood anxiety was associated with an early age of onset of social phobia, greater severity of fear and avoidance of social situations, greater fears of negative evaluation, and greater anxiety and depression morbidity. Rates of childhood social phobia, overanxious disorder, and avoidant disorder were significantly higher in patients with social phobia relative to our panic-disordered comparison group. We found approximately equal rates of a childhood history of separation anxiety disorder in patients with social phobia and panic disorder, providing further evidence against a unique relationship between separation anxiety disorder and panic disorder.     

Social phobia and overanxious disorder in school-age children

Epidemiological data indicate that, based on current diagnostic criteria, anxiety disorders are the most common childhood disorders. Furthermore, the comorbidity rate among the various diagnostic categories is quite high, and relatively little attention has been given to delineating the specific and distinct parameters of these disorders. The current study examined the characteristics of overanxious disorder and social phobia by comparing children who have these disorders to matched normal controls. The results indicated that children with social phobia could be differentiated from the other groups, based on self-report inventories, daily diary data, and a psychophysiological assessment. However, there were few variables that distinguished overanxious children. The results provide strong support for the diagnostic validity of social phobia in children but lesser support for overanxious disorder as currently defined.     

Generalized anxiety disorder in children and adolescents.

Children and adolescents with GAD suffer from excessive, pervasive worries that interfere with social, academic, and family functioning. The comorbidity rate with other anxiety disorders and major depression is high. The course tends to be chronic, and evidence shows continuity between anxiety disorders in youth and adulthood. Individual and group CBT and the incorporation of family anxiety management training have demonstrated efficacy in the treatment of childhood GAD. No double-blind, placebo-controlled, pharmacotherapy trials with adequate sample sizes for children and adolescents with GAD have been published. Preliminary data support the potential efficacy of selective serotonin reuptake inhibitors, buspirone, and high-potency benzodiazepines. Adequately powered, controlled, pharmacologic treatment trials are necessary. Future research should be directed toward comparing the relative efficacy of psychotherapy, pharmacotherapy, and both in the treatment of GAD in youth.     

School-based treatment for anxious african-american adolescents: a controlled pilot study

OBJECTIVE: To evaluate the feasibility and effectiveness of a school-based group cognitive-behavioral treatment (CBT) for anxiety disorders with African-American adolescents. METHOD: Twelve adolescents (mean age = 15.6 years) with anxiety disorders were randomly assigned to CBT (n = 6) or a group attention-support control condition (AS-Control; n = 6). Both groups met for 10 sessions in the same high school. Key treatment ingredients in CBT involved exposure, relaxation, social skills, and cognitive restructuring. Key ingredients in AS-Control involved therapist and peer support. At pre- and posttreatment, diagnostic interviews were conducted, and adolescents completed self-report measures of anxiety. RESULTS: At posttreatment and among those who attended more than one treatment session, 3/4 adolescents in CBT no longer met diagnostic criteria for their primary anxiety disorder, compared with 1/5 in AS-Control. Clinician ratings of impairment and self-report levels of overall anxiety were significantly lower at posttreatment in CBT compared with AS-Control. Teenagers in both groups reported lower levels of social anxiety from pre- to posttreatment. CONCLUSIONS: Findings support the feasibility of implementing a manual-based CBT in an urban school setting. Responder rates among African-American adolescents were similar to those found in studies with white youths.     

Combined psychoeducation and treatment with selective serotonin reuptake inhibitors for youth with generalized social anxiety disorder

Treatment outcome data for childhood social anxiety are scant. Studies that do exist support the efficacy of both pharmacological and psychotherapeutic interventions. Aside from case reports, studies assessing the efficacy of combined treatment approaches are even more limited. In the current study, we present preliminary findings from a combined psychoeducational and pharmacological treatment program for children and adolescents (ages 8-17 years) with generalized social anxiety disorder. Twelve participants received 12 weeks of citalopram treatment (maximum dose 40 mg/day) and eight brief counseling sessions (15 minutes each). Counseling sessions included education about social anxiety, skills coaching, and behavioral exercises; parents were included in these sessions. Based on clinician global ratings of change, 10 of 12 (83.3%) youths reported improvement: 41.7% (n = 5) of the participants were very much improved, and 41.7% (n = 5) were much improved. Significant changes were also found on self-report ratings of social anxiety, depression, and parents' perceptions of children's social skills during the course of treatment. Findings support the need for double-blind, placebo-controlled studies of combined treatments for youth with generalized social anxiety disorder.     

The treatment of childhood social anxiety disorder.

The concept of shyness in young children is not new; however, only recently has it been recognized that childhood SAD is a prevalent and severe disorder, with both immediate and long-term implications for academic, social, and emotional functioning. With the recognition that this disorder can result in severe lifetime impairment, both pharmacologic and psychosocial interventions for youth with social phobia are now beginning to be developed, and their efficacy, to be determined. The study of efficacious pharmacologic treatments with childhood anxiety disorders is limited at this time. There has been even less research regarding pharmacotherapy samples of children with childhood social phobia or social anxiety only. Only seven clinical trials have been conducted, and among those, only three were placebo-controlled, double-blind studies. In all of the open-labeled trials, anxious children showed improvement on both SSRIs and benzodiazepines; however, two of the three double-blind studies were unable to replicate these treatment benefits compared with placebo. The inability to find treatment effects may be a manifestation of the small sample sizes used and the comorbidity of the samples used to date. Further examination of the SSRIs and benzodiazepines with placebo-controlled studies is needed to provide more conclusive support for the efficacy of pharmacologic treatment. Similar to pharmacologic studies, research has begun to accumulate that sheds light on effective psychosocial interventions for childhood social phobia. Future research investigating the relative contribution of specific treatment components will allow for greater efficiency in the delivery of these services. Currently, which components are necessary or sufficient is unknown, although, based on meta-analyses conducted with adult outcome studies, exposure in some form seems to be the key ingredient. In addition, little attention has been given to developmental considerations regarding understanding the utility of specific psychosocial treatment components. For example, Spence et al reported that younger socially phobic children (aged 7-9 years) experienced difficulty in understanding the concept of "cognitive challenging," thus necessitating a reduction of this treatment component for this group. In addition, because differences in treatment effects across age groups was not reported, is it unclear whether the addition of a cognitive challenging component is even warranted. Similarly, Beidel et al reported significant improvement rates without the inclusion of a specific cognitive restructuring component. Thus, future research is needed to clarify the exact utility of including this intervention in treatment. Investigations have begun to accumulate that focus solely on the treatment of childhood social phobia, as opposed to general anxiety symptoms. As a result, preliminary evidence supports the use of pharmacologic and psychosocial treatments. Nonetheless, further research is needed to provide a better understanding of the efficacy of different interventions and, in the case of psychosocial treatments, different treatment components for socially phobic children across different developmental periods. Moreover, controlled treatment outcome studies that include specific measures of social anxiety and functioning, in addition to DSM diagnostic criteria, should provide a better (i.e., more thorough) evaluation of specific treatment effects for socially phobic children and adolescents.     

Temperament and character among Korean children and adolescents with anxiety disorders

The purpose of this study was to evaluate the temperament and character of children and adolescents with anxiety disorders in samples from Korean community. The study subjects were children and adolescents diagnosed with social phobia (n = 66), separation anxiety disorder (n = 47), specific phobia (n = 415), and obsessive–compulsive disorder (n = 42) with the diagnostic interview schedule for children, version IV (DISC-IV) in representative community samples. Among these, we excluded other psychiatric disorder comorbid samples, with the exception of externalizing disorders. We assessed the subjects of each anxiety group using the junior temperament and character inventory (JTCI). Social phobias were significantly associated with high harm avoidance and low self-directedness on the JTCI. The association of specific phobias with high harm avoidance, and obsessive–compulsive disorder with low self-directedness was also significant. Separation anxiety disorder was not associated with any temperament and character on the JTCI. Children and adolescents with anxiety disorders have different temperaments and character profiles in accordance with diagnostic groups, which implies the specific pathophysiological mechanism of each anxiety disorder.     

Behavioral avoidance test for childhood obsessive-compulsive disorder: a home-based observation

Obsessive-compulsive disorder (OCD) is one of the most debilitating of the anxiety disorders. As our knowledge about this childhood condition continues to grow, there is a need for controlled treatment-outcome trials with precise assessments that are sensitive to treatment change, to guide the development of effective interventions. To evaluate the efficacy of a treatment protocol, it is necessary to have reliable and sensitive measures of OCD symptoms, including measures of obsessions, compulsions, and related levels of distress and avoidance. Whilst structured diagnostic interviews, semistructured clinical interviews, and self-report measures have been widely used in the assessment of childhood OCD, related levels of behavioral distress and avoidance have not been measured in treatment-outcome trials. This study investigated the sensitivity of a behavioral avoidance test (BAT), conducted in the home environment, in assessing treatment-outcome effects for children and adolescents with OCD following a 14-week cognitive-behavioral therapy (CBT) family intervention, in comparison to children in an 8-week "waitlist" control group. The results of the current study strongly support the sensitivity of a standardized BAT in assessing treatment-related changes in children and adolescents with OCD. Implications and future directions for research are discussed.     

Family-based treatment of early-onset obsessive-compulsive disorder

Despite a meaningful common core of symptoms observed across the life span, there are particularly unique features of early-onset (prepubertal) obsessive-compulsive disorder (OCD) that make consideration of early presentation different from adolescent or adult onset and that may have important implications for treatment. This article will first review the unique features of early-onset OCD, focusing particular attention to the developmental and familial context of these children's symptoms. The literature on behavioral family interventions for other childhood disorders, specifically anxiety, as well as that on family processes (e.g., parent-child interactions) in families of children with OCD will be reviewed. The pediatric OCD cognitive-behavioral therapy (CBT) literature (CBT alone and CBT plus medication) will also be reviewed, focusing on current evidence-based treatment guidelines. Finally, a model of family-based treatment for young children with OCD and some preliminary pilot data will be presented.     

Pharmacologic treatment of anxiety disorders in children and adolescents

This article reviews the pharmacologic treatment of anxiety disorders in children and adolescents. These disorders are quite common and can be considered a "silent epidemic" because they are more often reported by the children and adolescents than by their parents. Tricyclic antidepressants (TCAs), benzodiazepines, buspirone, and selective serotonin reuptake inhibitors (SSRIs) have been used to treat anxiety disorders in children and adolescents with varying degrees of success. Considering safety and efficacy, the SSRIs appear to be the first-line treatment for anxiety disorders in youth, but more studies are needed to confirm preliminary results. Tricyclic antidepressants and benzodiazepines may be considered when the child has not responded to SSRIs or when adverse effects have exceeded benefits. Although nonpharmacologic approaches for the treatment of anxiety in children and adolescents are beyond the scope of this article, their importance is to be underscored and they should be considered as part of the treatment plan. Over the next decade, research data will be generated regarding the treatment of anxiety disorders in youth. Ongoing research studies include the use of fluoxetine (B. Birmaher, personal communication, 1999) and fluvoxamine (J. Walkup, personal communication, 1999) for the treatment of generalized anxiety disorder, separation anxiety disorder, or social phobia; and buspirone for generalized anxiety disorder in children. Despite these efforts, there is a need for more studies to examine the safety and efficacy of different pharmacologic treatments, as well as longitudinal studies to monitor for long-term tolerability and side effects. Pharmacokinetic studies for children and adolescents will provide information on the metabolism and absorption of these medications and delineate the developmental differences between children and adolescents when compared to adults. Finally, and perhaps most importantly, studies that compare medication, psychosocial treatments, and their combination are needed.     

Genetics of pediatric anxiety disorders

This article reviews the familiality, linkage, candidate gene, and genomewide association studies of obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and other anxiety disorders (ie, generalized anxiety disorder, separation anxiety disorder, social phobia, and specific phobia). Studies involving children and adolescents are highlighted. Clinical and research implications are discussed.