The treatment of childhood social anxiety disorder

Abstract

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.