Literature Review Paper

Social Anxiety Running head: SOCIAL ANXIETY

Social Anxiety: Who, How, and Why it effects our youth Katie Stone Indiana University Independent Project EDUC –K - 343 Professor Ochoa Last Updated: February 28, 2007

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Abstract This paper focuses specifically on the causes and effects of the disorder known as social anxiety. It also discusses a more specific form of social anxiety known as selective mutism, along with how it is caused and the implications along with it. Three types of effective clinical treatments, cognitive based, social skills training, and social effectiveness therapy, have been found to be effective with these children, and are discussed in detail. Specific modifications are very important and can be made by the school and general education teacher in order to make a big difference in the comfort and education of a child with social anxiety. The law specifies certain actions that are required to be implemented by the school for every student with an emotional or behavioral disorder, including anxiety disorders. Social anxiety is a serious disorder that, with help, can be largely decreased to allow normal social interactions and thus benefits to occur.

Social Anxiety Introduction Social anxiety is the most common form of anxiety in the population, where the person who is affected lives in fear of humiliation in any sort of social context. In order to understand social anxiety, one must first understand generalized anxiety and how they differ from one another. Generalized anxiety is defined as uncontrollable worry about a number of events or activities accompanied with physical symptoms of anxiety which unnecessarily restricts the person from interacting in normal social interactions (Kauffman, 2005; Grover, Hughes, Bergman, & Kingery, 2006). Children with generalized anxiety disorder often report worries about school, friends, family, performance of any sort, and health problems. While fears and anxiety symptoms, like distress, tension, or uneasiness, are common in all adolescence, it can reach a point where the fears become excessive. When this level is reached, the anxiety may prevent the child from engaging in social interactions, prohibit sleep, hinder school attendance, and keep them from exploring the environment. Anxiety causes the individual to monitor every situation constantly for signals of potential threats and requires constant thoughts on the surroundings (Verbeke and Bagozzi, 2000). Without intervention, these symptoms from anxiety can result in severe panic attacks which can consist of sweating, pounding of the heart, rapid breathing, tingling sensations, racing thoughts, or fear of losing control (Kauffman, 2005). For all types of anxiety, the symptoms must be present for a minimum of six months and cause significant distress or impairment in important areas of functioning (Grover et. al., 2006). This paper will focus on the causes and effects of social anxiety. It will also discuss appropriate ways to treat this disorder in clinics and in schools, as well as focus on a specific form of social anxiety, selective mutism.

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Social Anxiety Social Anxiety stems from generalized anxiety and is defined as having “a marked and persistent fear of social or performance situations in which embarrassment may occur”. The avoidance, fear, or anxious anticipation of the social or performance situation must interfere significantly with the person’s daily routine, occupational functioning or social life in order to be considered a disorder (American Psychiatric Association, 1994). Similar to general anxiety, the response is immediate and may take the form of a panic attack, however, this is not required. In feared social or performance situations, the individual will experience concerns about embarrassment and remain in a constant state of fret that others will judge them or notice that they are anxious, blushing or trembling. They fear that these actions may cause the person to incorrectly think that they are stupid or weak. Other results of social anxiety, especially in children, is to cry, throw tantrums, cling to familiar people or freeze entirely when a social situation with unfamiliar adults of peers cannot be avoided (American Psychiatric Association, 1994; Grover et al., 2006). People with social anxiety typically have a strong desire to convey a particular favorable impression of themselves to others, yet they have insecurities in doing this. This desire to portray an image initiates the fear of acting in an inept or unacceptable fashion when entering into a threatening social situation. The result of these trepidations may result in negative consequences, such as loss of self worth, status, or rejection (Verbeke and Bagozzi, 2000; Fisher, Masia-Warner, and Klein, 2004). This constant state of insecurity and lack of confidence explains the reason for avoiding such situations. The possibilities of what could happen override any rational thoughts of what would most likely happen. The routine of avoiding or fleeing a threatening situation means that the person will never actually discover whether that situation actually posed a threat, and thus will maintain the anxiety and hinder learning and

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discovery. By never confronting their fears, the individual will never have the opportunity to finally relieve themselves from the constraint that fear holds on them. The cycle is further exhibited in situations where the circumstance is confronted, but the anticipatory anxiety is so strong that it leads to an actual or perceived poor performance in the feared setting which then leads to embarrassment and further anxiety about these situations. To be diagnosed as having social anxiety, especially in adolescents, is difficult because of the commonality of many of the actions shown by these individuals. To help this, guidelines state that for someone younger than age 18 years, symptoms must persist for at least six months before diagnosis (American Psychiatric Association, 1994). The majority of the individuals with social anxiety are old enough to realize that their fears are irrational and tend to speak up and ask for help. This is not the case with young adolescents who may not be developed thoroughly enough or experienced enough to know that what they are doing or feeling is not normal. If adolescents do ask for help, it is usually to their parents who may underestimate the anxiety and struggles experienced by their child and expect that it is normal fears that they will grow out of eventually. It is also hard to have a child be noticed and referred for social anxiety because many times the behaviors go unnoticed because the quiet, withdrawn, behaviors of this disorder are less bothersome then disruptive behaviors, and thus are easier to ignore or not notice at all. Finally, intervention may not be reached because many adolescence are scared to pursue services. They worry of being labeled as abnormal from the community and their peers and also worry about the stigma associated with a label and treatment (Fisher et al., 2004). After the referral and acknowledgement of a problem, there are different assessments that may be conducted to discriminate people who qualify as socially anxious from other disorders. In 1989, an instrument was constructed to assess cognitive, somatic, and behavioral dimensions

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of social phobias. This instrument, referred to as the Social Phobia and Anxiety Inventory, is a 109-item self-report instrument that has been widely used. Each item is rated on a 7-point scale (1=never, 7=always), of which the majority refers directly to social anxiety, but with some that comprise subscales for other disorders. This allows the score to be derived by subtracting the other subscales from the social anxiety subscale to get the difference and to hold discriminating factors between different disorders (Hofmann, Schulz, Meuret, Moscovitch, & Suvac, 2006; Olivares et al., 2002). The Social Anxiety Scale for Adolescents is similar but based off of a three factor structure for youngsters’ social anxiety. The first is a subscale reflecting fears or worries of negative evaluations from peers. The second two are subscales reflecting social avoidance and distress. Of the second two, one scale is specific to situations with unfamiliar peers while the other reflects generalized social inhibition. In total, it consists of 22 items on a 5-point scale with four filler items to help distinguish between different disabilities (Olivares et al., 2002). There is yet another scale that differs in that it is used more specifically to help with the treatment of social anxiety. This scale, the Liebowitz Social Anxiety Scale, is clinician-administered and consists of 24 items used to measure fear and avoidance in 24 different social settings (Hofmann et al., 2006). This scale can more precisely identify the problem areas for the patient and thus can help in the creation of an individualized treatment program for them.

Selective Mutism The results of social anxiety may take the form of other disorders in certain individuals. One more recently highlighted disorder is selective mutism, which is defined as a disorder effecting children who are extremely reluctant to speak, although they know how to converse normally. These individuals choose only to speak to certain people or groups of people in

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particular settings and refuse to speak to all others (Kauffman, 2005). The majority of people with this disorder has no difficulties speaking in the home environment or to family members, but has the most difficulty speaking at school. In order to be diagnosed with selective mutism, all 5 of the following factors must be present. The child must show a persistent lack of speech in some social situations but not in others, the mutism must interfere with academic or occupational achievement or social communication, it must have a duration of at least one month other than the first month of school, it must be caused by something other than discomfort of, or ignorance of social language, and all other possible causes must be eliminated (Hultquist, 1995). Like children with social anxiety, children with selective mutism have a severe reaction to uncomfortable or unfamiliar situations. The difference lies, however, in that instead of just avoiding a situation or being scared, a child with selective mutism chooses to withdraw, perhaps to try to mask the fact that they exist at all. The fear of saying or doing something embarrassing is a main reason for becoming selectively mute. Under the category of selective mutism, there are four identified subtypes. The first one, symbiotic mutism, is seen as the most common of the subtypes and is observed in children who had a symbiotic relationship with their mother who was very dominant and verbal, while the father was passive or absent. The mother always met the child’s needs and was often openly jealous of other relationships in the child’s life, while the child was negative towards controlling adults and used silence as a manipulative tool. Another subtype, speech phobic, is the least common subtype and is when the child has a fear of hearing their own voice. A majority of these children had been previously warned not to disclose information about the family, are more likely to use non-verbal communication, and are more motivated to regain speech again. The third subtype of selective mutism is reactive mutism, which is when the silence is brought on by

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a single or series of traumatic events, for instance, rape, injuries, or being yelled at to never speak again. Lastly, passive-aggressive mutism is where the silence is used as a weapon that expresses hostility by refusing to speak. In all of these subtypes, the characteristics of physical tension, rigidity, fearfulness, and nervous habits are present, and in most cases the children are shy and withdrawn (Hultquist, 1995). The assessment as it is done for individuals with social anxiety is very difficult do for children with selective mutism due to the lack of expressive language. So, instead of using cognitive, emotional and behavioral, and academic performance, clinicians have to do a lot more background research of the family life and analyze the current situations in which language is or is not present. Investigations into the lives of these children should explore what meaning communication, or lack there of, holds for the child, in what ways the silence might actually be helping the child in certain situations, and if anxiety is present. By relying on outside sources and also observing the child’s interactions, a more precise and indicative diagnosis can be made.

Treatments There are three clinic-based treatments for youth that have been proven to be effective in the treatment of social anxiety. The first approach is the cognitive-based approach called the Cognitive-Behavioral Group Therapy for Adolescents (CGBT-A). This treatment has 16 group sessions and focuses on psychoeducation, cognitive restructuring, problem solving, social skills, and behavioral exposure. These exposures are intended to challenge thoughts and feelings in order to identify their negative cognitions and to teach individuals to observe the correlation between these cognitions and their anxious moods. Once the irrationality is observed and understood, feedback is then provided to present rational alternatives and coping strategies to

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help to deal with the anxiety (Hofmann et al., 2006; Fisher et al., 2004). The second treatment is Social Skills Training (SST), which was developed on the basis of social skills deficits model of social phobia. This strategy is a 12 week program which emphasizes social skills training and exposures, but provides training in other areas similar to the cognitive approach, such as problem-solving and cognitive restructuring. However different from the cognitive approach, and more similar to the treatment of generalized anxiety disorder, SST provides training which includes relaxation techniques. Individuals in this program practice learned social skills in simulated environments to prepare them for the situations they will encounter out of the clinic. The final treatment is Social Effectiveness Therapy for Children which utilizes a behavioral approach. Combining the previous approaches, this 12 week treatment program also focuses on behavior exposure and social skills training. Behavior exposures are specific to each child’s social anxieties and are repeated to ensure that the anxiety is terminated. The social skills aspect is dealt with first in group sessions and then gradually in social situations with unfamiliar peers (Fisher et al., 2004). Overall, the ultimate goal for youth who are socially anxious is to help them generate coping thoughts aimed at lowering their social performance standards set for themselves at a perfection level, and develop more positive and attainable expectations for the social interactions (Grover et al., 2006). The youth must learn to look at the benefits that could be reached as a result of the interaction as opposed to focusing on the negative possibilities of trying. Treatments for specialized social anxieties, such as selective mutism, are similar to those discussed above but must be modified. The biggest reason for this modification is that the child does not speak at the beginning of the intervention, so different steps must be taken. One modification is changing the focus from being solely on the child, to including

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psychoeducational training for parents to provide them with strategies to help their child with selective mutism when they refuse to speak. This parental therapy is often used in combination with individual play therapy and training. The first goal in the treatment process is to try to achieve verbal communication with the therapist. Because selective mutism is often seen in young children, cognitive analysis is often difficult, so instead simpler techniques, such as replacement of negative self-statements with positive ones, can be taught, but only after trust and vocalization is developed (Grover et al., 2006; Hultquist, 1995). Behavior modification is the most commonly used treatment for selective mutism, and is accomplished through a combination of approaches. The stimulus fading approach is very useful because it is a step-by-step process of introducing a child with selective mutism to formerly uncomfortable settings and helping them speak freely. This is completed by beginning in a comfortable setting with someone who the child is comfortable with, like a parent, and also the therapist. Next, the parent is taken away and just the therapist is present. Then they move out of the home, or comfortable setting, and then slowly introduce new people, like peers and teachers, until eventually they move into a school setting and finally into the classroom full of peers for the final sessions. Shaping is another approach where the child is tape-recorded and then the audio tape is played back to the child and analyzed, while simultaneously being played to their class. This helps to cross the barrier of fear of speaking for the first time because the peers have now heard their voice at least on tape. This is similar to self modeling in which video tapes are taken and played back daily with reinforcements every time a positive interaction, particularly verbally, is made. Other approaches include desensitization, which involves a process of taking the child through a hierarchy of steps and introducing them to each, one-by-one. Extinction and aversion is the last approach, but can be considered intense and even abusive, and thus is not often recommended (Hultquist, 1995;

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Grover et al., 2006).

School Modifications While clinical interventions are often effective, the positive results will only be sustained if modifications are also made in the general classroom. This sort of treatment is ideal because the school is a natural setting and is seen as more acceptable to the children and their families. Programs in schools and teacher training are also effective because it reduces barriers such as cost and transportation and allows for in-school opportunities to practice socializing skills (Fisher et al., 2004). As a teacher, there are certain modifications similar to those done in clinics, which can be implemented to help students who may be socially anxious. One important aspect is to help establish a good rapport with the child by making the child comfortable in the classroom setting and with the teacher. This can be done by playing structured ‘get to know you’ games or by emphasizing the child’s interests or hobbies (Grover et al., 2006). This method allows the child to try to interact while surrounded by a situation that they feel comfortable with. It is important, however, to keep in mind that treatment for social anxiety is slow, so results cannot be expected over night, but can be slowly implemented. As progress is made in clinics, progress can also be made in the classroom. The strategy should be to start with a good rapport with the teacher, and then gradually add in peers. Students, when being evaluated, should make a fear hierarchy which ranks the order of feared or avoided situations. Teachers should be aware of which situations make the student feel the most uncomfortable to help to keep the student feel comfortable until all areas of the hierarchy are reached. This also helps the teacher to identify areas of social difficulties for the student and potential classroom exposures that may cause distress. Teachers can then work with the special educators or clinicians to develop appropriate,

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gradual exposures for the student to work with (Fisher et al., 2004). Teacher feedback on the child’s progress is especially important because it represents how the student is improving in a real, non-monitored setting. As with all programs, schools struggle to provide in school treatments for social anxiety disorders because of lack of space and funding. So while treatments have proven to be very effective, treatment and identification is not always accomplished. When schools cannot provide the ideal treatment, clinical help is sought after. Teachers must be involved in all aspects of the treatment, as school is where the most social anxiety usually occurs. Making the child feel comfortable enough to eventually participate in the classroom is very important, and can be accomplished by the teacher. The teacher can also assist by constantly providing the student with positive reinforcements and setting expectations that can realistically be reached, allowing the student to raise their self esteem and in the process, confidence, that will hopefully lead to a decrease in anxiety.

Social Anxiety and the Law Being a person with social anxiety in the school system means that certain modifications are required by law to be provided by that school. The Individuals with Disabilities Education Act (IDEA) requires that all children with disabilities are entitled to identification and must be provided with special education services. Under IDEA, schools are required to maintain the continuum of alternative placements and to make the decision of proper placement based on each individuals needs. Along the basis of individual needs, IDEA also requires that every student who has a disability and desires special education services must have a written individualized education program (IEP) which will describe the appropriate education that the student will

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receive. This IEP is a written agreement in which the parents and the school collaborate to decide what the student needs are and what will be done to address those needs. The IEP team, by law, must conduct a functional behavioral assessment in order to obtain and analyze assessment data and understand the nature and causes of the problem behaviors. This analysis will allow the team to better develop an effective intervention plan. If the disability interferes with the student’s educational progress, then the IEP team must also write a behavioral intervention plan that is based off of the findings in the functional behavioral assessment (Kauffman, 2005).

Conclusion Being a child with social anxiety is very difficult. Living in constant fear of embarrassment in social situations and always trying to avoid these situations is demanding to everyday functioning. Unless an intervention plan is implemented, the child could continue the rest of their life never truly benefiting from social interactions, and thus being hindered from the highest potential they can reach. Treatments are effective, yet can be costly and usually take a long time. However, in the general classroom changes can be implemented in order to coincide with other interventions or used alone to make the child feel more comfortable, and thus more apt to put themselves in a potentially embarrassing situation. Teachers need to be made more aware of the signs and symptoms of social anxiety and trained in how to help these individuals. The severity of the anxiety could be decreased if the warning signs are spotted quickly and intervention is implemented immediately. This disorder is a matter of feeling comfortable in the situation that they are in. Anxiety occurs when fear of failure overtakes them. If failure is instead accepted, and embarrassment is no longer seen as traumatizing, then the child can learn to accept imperfection and move on past this overpowering disorder. It is the educators’ job to help the

Social Anxiety child achieve this goal and feel comfortable and confident with themselves and their surroundings.

References

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American Psychiatric Association (1994). 300.23 Social phobia (social anxiety disorder). Diagnostic and Statistical Manuel of Mental Disorders (4), 411 – 417. Washington, DC: American Psychiatric Association. Fisher, P.H., Masia-Warner, C., Klein, R.G. (2004). Skills for social and academic success: A school-based intervention for social anxiety disorder in adolescents. Clinical Child and Family Psychology Review, (7), 4, 214-249. Grover, R.L., Hughes, A.A., Bergman, R.L., Kingery, J.N. (2006). Treatment modifications based on childhood anxiety diagnosis: Demonstrating the flexibility in manualized treatment. Journal of Cognitive Psychotherapy: An International Quarterly, 20, 275- 286. Hofmann, S.G., Schultz, S.M., Meuret, A.E., Moscovitch, D.A., Suvak, M. (2006). Sudden gains during therapy of social phobia. Journal of Consulting and Clinical Psychology, (74), 4, 687 – 697. Hultquist, A.M. (1995). Selective mutism: Causes and interventions. Journal of Emotional and Behavioral Disorders, (3), 2, 100–107. Kauffman, J.M. (2005). Characteristics of emotional and behavioral disorders of children and youth (8th ed.). 370-379. New Jersey: Pearson. Olivares, O, Lopez, L.J.G., Hidalgo, M.D., La Greca, A.M., Turner, S.M., Beidel, D.C. (2002). A pilot study on normative data for two social anxiety measures: the social phobia and anxiety inventory and the social anxiety scale for adolescents. International Journal of Clinical and Health Psychology, (2), 3, 467- 476. Verbeke, W., Bagozzi, R.P. (2000). Sales call anxiety: exploring what it means when fear rules a sales encounter. Journal of Marketing, (64), 3, 88-101.