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Social Phobia in Children

Social Phobia (or Social Anxiety Disorder) is an extreme fear of being judged or criticized by others. This often leads to the child avoiding situations where he or she may be exposed to new people, or to large groups of people. Children and adolescents with social phobia may experience excessive fear in social situations (e.g., meeting or talking to people) which causes significant distress and interferes with functioning. The disorder can be selective in that some children have significant difficulty in particular social situations but may be perfectly fine in other, seemingly similar, situations.

It is important to note that this is not “shyness,” which is a normal developmental challenge for all kids, and which typically resolves itself by the age of two. Social Phobia has a typical age of onset at 13 years old. However, early symptoms such as excessive clinginess and selective mutism (i.e., the failure to speak in certain situations, despite speaking in other situations) may initially appear in younger children.

Some of the most common things that the socially anxious child avoids include:

• Reading aloud in front of class
• Musical or athletic performances
• Starting or joining in on a conversation
• Speaking to Adults
• Writing on the blackboard
• Ordering food in a restaurant
• Attending dances or birthday parties

Social phobia is a severe, disabling form of shyness and can cause problems in people’s lives. Sometimes the problems are minor, such as not being able to speak up in class. Sometimes, however, the problems can be very serious. Children and adolescents with severe social phobia often have very few friends, feel lonely and have trouble reaching their personal and academic goals.

Social phobia is very common in that it affects one out of eight people at some point in their lives, and it is twice as common for girls as for boys. However, males are more likely to seek help for the problem. Social phobia usually starts when people are in their early teens, but it can begin much earlier. If people do not get help, the problem can last for years.

Appropriate intervention for anxiety disorders includes:

• Individual Therapy: Individual work focuses on developing specific skills for managing anxiety, while also addressing the struggles with daily stressors and low self-esteem that often accompany a diagnosis of anxiety.
• Biofeedback: Like individual therapy, Biofeedback works by teaching specific anxiety management skills to the client. Biofeedback employs the use of technology to make the client more aware of the internal processes that contribute to anxiety, and in doing so, teaches the client to better control these processes.
• Family Therapy: Family work is important in the treatment of anxiety in that it focuses on developing open communication and expression of emotion, while teaching parents techniques to utilize at home with the anxious child.
• Group Therapy: Groups provide safe and appropriate social training where the child can get feedback from peers and adults about how to regulate their behavior.

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Tourette's Syndrome and Other Tic Disorders

Tic Disorders refer to disorders where the child (or adult) has involuntary, rapid, and repetitive movements of individual muscle groups. These movements, known as “Tics,” can be either motor (movements) or vocal (noises). The most common motor tics are: eye blinking, grimacing, nose twitching, eye brow raise, and squinting. Many common vocal tics include: clearing the throat, coughing, humming, sniffing, or snorting.

Tics are a way of responding to a build up of tension in the body. The person often feels an urge just before they tic, similar to when you feel an itch just before you scratch. While the patient can often suppress these tics for a short while, the build up can become unbearable after too much time. One common misunderstanding is that these tics are voluntary, and that the child is doing them on purpose. This misperception can lead to disciplinary problems at home and at school, as the adult may see the behavior as defiance, rather than as a neurobiological disorder. The good news is that tics often decrease in adolescence and may stop completely by adulthood. But early diagnosis and intervention has led to the most favorable outcomes in our experience.

Diagnosis of Tic Disorders can be tricky because Tic Disorders exist on a spectrum of severity; some are mild with infrequent flare-ups, and others are more severe and involve several complex symptoms. Patients with Tourette Disorders often also have Attention Deficit/Hyperactivity Disorder (ADHD) and Obsessive Compulsive Disorder (OCD) . The most troubling symptoms of this disorder are the impulsivity, emotional lability, and aggression. Tourette Syndrome is also associated with Learning Disorders, which include impairments to visual-perceptual and visual motor skills, and Language Learning Disorders. These co-occurring difficulties can cloud the picture and may mask each other. An expert in Tourette Syndrome and other Tic Disorders is usually needed to make accurate diagnosis because they know the questions to ask to bring out all the relevant information.

The Tarnow Center’s clinicians have the expertise to diagnose and treat Tic Disorders. Our interdisciplinary approach to the diagnosis of these disorders understands the complexities and the struggle as each individual (and family) struggles to cope with symptoms that can be ever changing. Here is the example where the whole is greater than its parts.

• Neuropsychological Evaluation: Every child with a Tic Disorder should have an assessment of their learning. Not just their academic achievement scores, but also their learning style. This assessment insures that there are no learning disorders, and more importantly, informs parents and teachers in how to help the child cope.
• Individual therapy: The goal of individual treatment is not to stop the tics, but rather teach the client tools to help reduce frequency and severity of tics. Treatments include biofeedback, relaxation training, and cognitive behavioral approaches. Supportive therapy is also valuable in that it gives the client a place to process any secondary social and emotional problems that can occur with Tic Disorders.
• Group therapy: Many children with Tic Disorders experience social difficulties such as peer rejection or isolation resulting from their tics. Group therapy provides the client with a safe social environment to get support from peers, while also learning and practicing interpersonal skills.
• Family therapy: Tic Disorders affect the entire family. Parents can feel powerless to help the child, and even the most patient siblings can become aggravated with the symptoms. The child with a Tic Disorder benefits the most when family members learn to develop a therapeutic and supportive environment that helps the child grow and mature.
• Medication Evaluation: Medication is not always necessary in the treatment of Tic Disorders, and there is no medication specifically designed to treat Tic Disorders. But there are medications that can be helpful in helping one control tics. Medication may also be helpful in treating any co-occurring difficulties with ADHD, OCD or mood.

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Substance Use Disorder

Substance use disorders are classified into two categories: Substance Abuse and Substance Dependence. The substances can include alcohol, illegal drugs, and prescription drugs. Use of illegal drugs is concerning, to be sure, as is alcohol use in minors under the age of 21. But use alone is not necessarily a diagnosable disorder.

Substance Abuse describes a pattern of use that leads to significant problems such as:

• Failure to attend work or school
• Risky behaviors while intoxicated, such as driving a car
• Legal-problems resulting from substance use (arrest, traffic violations, etc.)
• Use interferes with friendships and/or family relationships

Substance Dependence is the term used when someone continues to use drugs or alcohol, even when significant problems related to their use have developed. Signs of substance dependence include:

• Needs greater amounts of the substance in order to attain the desired effect
• Suffers physical and/or psychological symptoms when not under the influence
• Has tried to quit or cut down, but hasn’t been successful
• Spends increasing amounts of time trying to obtain the substance
• Spending less time in social or recreational activities
• Continues to use the substance even though aware that use causes physical or psychological problems

Some warning signs of substance abuse or dependence may be that someone is:

• Getting high or drunk on a regular basis
• Lying, especially about how much they are using or drinking
• No longer spending time with non-using friends
• Talking a lot about using drugs or alcohol
• Believing they need to use or drink in order to have fun
• Pressuring others to use or drink
• Having legal problems, particularly related to substance use
• Driving under the influence of a substance
• Missing work or school, or performance suffers due to substance use
• Feeling depressed, hopeless, or having suicidal feelings

If you recognize any of these symptoms in yourself, a friend, or a loved one, a psychological evaluation is recommended. A variety of treatment programs for substance abuse are available on an inpatient or outpatient basis depending upon the extent of the problem. In more serious cases, detoxification may be needed.

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