Anxiety Coach by Mayo Clinic child psychologist Stephen P. Whiteside, Ph.D, L.P, takes Mayo Clinic’s safe, rapid, effective Exposure Therapy program for children and teens suffering from anxiety disorders, OCD and phobias, and adapts it from a supervised clinical setting to the family home in an easy to follow self help guide for parents and kids. In the following excerpt from Anxiety Coach, Stephen Whiteside helps parents figure out if their child’s social challenges are actually signs of social anxiety disorder, what sets off social anxiety, why a child avoids triggering situations and finally presents a simple case study of a 16 year old girl with social anxiety disorder, who went on to be successfully treated with Exposure therapy.
What is social anxiety disorder?
The term social anxiety disorder fits when children are overly nervous about interacting with other people, particularly peers. Kids with social anxiety are afraid they will make mistakes when talking or will say or do something that could lead other people to think of them negatively. Feeling nervous leads kids to avoid situations that involve talking with or hanging out with or even being around other kids. When children with social anxiety disorder consistently avoid social situations, it means they miss out on fun activities, like sports, or don’t do things they need to do, like give a class presentation. Over time, missing out on these important activities can cause other problems. Social anxiety disorder is one of the most common reasons families come to our clinic.
How do we know it’s social anxiety disorder?
Social anxiety disorder is different from typical shyness in the degree of anxiety that kids experience and how much their fears cause problems. There is nothing wrong with being shy or introverted; I myself was pretty shy as a child. Being nervous giving presentations at school or starting a new activity is also a very normal, common experience. As I mentioned earlier, it’s important not to unnecessarily label your child’s behavior as a problem. If they are content with the way they are living their life and they are doing the school and social activities they need to, that’s a solid sign that all is well. However, when fears of embarrassment are so upsetting that they get in the way of living everyday life, that’s when we call it social anxiety disorder and recommend treatment. There are times in our clinic when kids and parents disagree on whether social anxiety is a problem. This usually happens in two scenarios. Since many social interactions for kids occur in school, without parents there to witness their child’s difficulties, parents have only the impression they get from seeing their child function in the family setting, whether that’s at home or in public. In these cases, parents may not realize how much their teens or kids are struggling socially. Other times, it’s the reverse, and kids are so upset by their social difficulties that they deny they are nervous and instead say they are simply not interested in spending time with other kids, and what is wrong with that conscious choice, if they are making it? In that and similar kinds of cases, we need to focus on the three jobs we expect from kids and teens—being successful in school, with friends, and at home—and if there are problems in those areas, we can explore how social anxiety might be getting in the way. In addition to situations and activities, for some kids social anxiety is set off by memories of awkward social situations or physical feelings of anxiety or embarrassment, like blushing or sweating, which lead to the same withdrawal and avoidance as social anxiety that relates to real-time, everyday scenarios.
What sets off my child’s social anxiety?
Social anxiety is typically set off by things in the world around us, most often situations in which kids need to talk to their peers or other people or when they may be observed by others. There are many different types of social situations and not all will give your child feelings of anxiety. Some children get more nervous in performance situations— reading aloud in class, acting in a school play, singing in a school musical, answering a question in class, competing in a basketball game, playing in a school concert, or giving a presentation in class. Others might get more nervous in unstructured social situations, like initiating conversations, meeting other kids at the start of a new school year, joining a club, finding people to sit with during lunch, or making small talk in the hallways between classes. And then there are kids whose anxiety is set off by talking to adults, especially in public situations such as the school principal, a teacher, or a sports coach. These children may also be nervous to order food at restaurants, ask questions of store clerks, or check out with you at the grocery store. Sometimes children feel nervous simply being in public where people may be watching and observing them. For many kids with social anxiety, all of the above may set off their anxiety.
Expectations that make social situations scary
Once you’ve identified the situations that set off your child’s anxiety, the next thing to do is pinpoint the expectations that cause your child to feel nervous in these situations when most of their peers enjoy them or feel only somewhat uncomfortable. As we have learned, there are two main expectations that drive fear and worry—something bad will happen and I won’t be able to handle this—both apply to kids with social anxiety. A core component of social anxiety is the fear of being judged negatively. However, the type of feared judgment often differs based on the situation in which kids feel anxious. Kids who get nervous speaking in performance situations may have expectations that they will make mistakes, perform poorly, and be judged as not good enough, smart enough, or talented enough. Kids who are more nervous about talking to peers may be more afraid that they will do something embarrassing and everyone will think they’re uncool or unlikable. And when kids are nervous around authority figures they are typically concerned about getting in trouble, being a burden, or irritating others. For many children with social anxiety, expectations can occur in any combination of the above. Despite the importance of expecting negative judgment in social anxiety, it’s important to note that some kids don’t describe these specific worries. Younger kids especially are more likely to simply say that talking to others is scary and they don’t know why. Teens may add that they know it’s unlikely that people will laugh at them or be mean but that they still feel nervous. If this is the case, you might describe the child’s expectation as believing they can’t handle talking to people or they have to avoid being around people to feel okay.
Avoidance of social situations
Next, we need to identify what avoidance strategies your child uses to stay away from the situations they fear and in doing so, miss out on the opportunity to learn that these situations are not as bad as they expect them to be. The most common form of avoidance for kids with social anxiety disorder is partial physical avoidance, which is when kids can’t completely avoid a situation but try to avoid as much of it as possible when they are in the midst of it. For example, these kids can’t avoid going to class, but when in class, they are careful never to raise their hand to answer a question asked by a teacher. Or because of anxiety around playing on the school football team, a teen might arrive at practice at the last minute and rush home quickly afterward to avoid the banter and socializing among teammates in the locker room. Partial avoidance due to social anxiety can also include a child keeping their head down while walking in the hallways between classes at school, avoiding eye contact to make sure no one talks to them, or purposefully reading a book before class to put up a wall against being greeted by fellow classmates. As many parents of socially anxious children know, full avoidance of anxiety-provoking activities can also occur. Complete avoidance involves not signing up for sports, clubs, and other extracurricular activities. Or not attending school dances or sporting events. Or eating lunch in the library. It may grow to include staying home from school on days there is a presentation due or even transitioning to online school or homeschooling. Kids with social anxiety may also often rely on others to help avoid feared social interactions. As we saw earlier, parents may be asked to order food in restaurants or communicate with teachers.
Social anxiety disorder, a case study
Meet 16-year-old Maria, a smart, likable teenager and a successful figure skater. She and her parents agreed that she had always been shy, but it hadn’t been a problem because she’d maintained a core group of friends since kindergarten. In restaurants, she’d appear nervous, and her parents would order for her, but they weren’t overly concerned about it. None of this was a problem until she entered middle school. With that transition, she began to struggle. Her core friends connected with new faces and added new friends, while Maria stayed on the sidelines, feeling shy. She felt even more nervous in class when she didn’t yet know many of the other students and, with seven different classes a day, there wasn’t much of a chance to get to know her teachers. In this new environment, she came to dread presentations, yet was too nervous to ask for help. Under pressure across the board, some of her grades began to slip. When Maria began to complain that she felt too sick to go to school on days she had a class where there was always a lot of student participation, her parents brought her in to Mayo Clinic for help. During the initial assessment, Maria readily acknowledged that in social situations she was afraid she would say the wrong thing and look ridiculous in front of other kids who all seemed to be calm, outgoing, and happy to make new friends and expand their social circle. She had always felt comfortable with figure skating because so much of it involved working on her own without having to make conversation with the other skaters. However, now that they were getting older and spending more time chit chatting before and after practice, she was struggling with these interactions and feeling awkward. What she feared most was doing something foolish that would lead her peers to laugh at her and, as a result, see no value in being friends with her. Although she outright avoided some school activities and relied on her parents to order for her at restaurants, most of her avoidance strategies involved finding ways to dodge direct conversation when at school or during activities by looking busy, avoiding eye contact, or leaving early. It had reached a point where she felt left out and was considering quitting. After our clinical assessment, a diagnosis of social anxiety disorder was agreed upon and she went on to be rapidly and successfully treated with Exposure therapy.
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