Familial Factors in the Development of Social Anxiety Disorder

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Familial Factors in the Development of Social Anxiety Disorder Familial Factors in the Development of Social Anxiety Disorder

Christine M. Olson

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Familial Factors in the Development of

Social Anxiety Disorder

Christine M. Olson, DNP, APRN, FNP-BC

ABSTRACT

The purpose of the current article is to explore familial factors that in uence the

development of social anxiety disorder (SAD) in children and adolescents, includ-

ing parenting, sibling relationships, and family environment. A multitude of inter-

related genetic and familial factors have been found to cause and maintain SAD in

children and adolescents. There are many challenges in diagnosing and treating

the disorder. Knowledge and awareness of familial factors provide insight on tar-

geted treatments that prevent or ameliorate SAD. [Journal of Psychosocial Nursing

and Mental Health Services, 59(7), 23-34.]

he inﬂ uence of nature and nur-

ture on human behavior has

been researched for decades. Af-

ter completion of the Human Genome

Project in 2003, one would think that

the mystery behind genetic predisposi-

tion was solved. What was discovered

is that genomes are complicated and

developmental and health factors are

inﬂ uenced by multiple genes as well

as environmental and lifestyle factors

(National Human Genome Research

Institute, 2019). Although many medi-

cal conditions have been shown to have

a genetic predisposition, there are still

unanswered questions about the inﬂ u-

ence of environment on the ultimate

development of illness.

Social anxiety disorder (SAD) is one

example of a disorder in which there is a

complex relationship between genetics

and environment. Behind only speciﬁ c

phobias, SAD is the most common anx-

iety disorder in the United States, with

approximately 13% of the population

developing the disorder during their life-

time (Kessler et al., 2012). Among ado-

lescents, the lifetime prevalence of SAD

is 8.6% (Burstein et al., 2011; Kessler et

al., 2012). Worldwide, lifetime preva-

lence of SAD is 4% (Stein et al., 2017).

SAD is a marked, intense fear of

social interactions with other people

(American Psychiatric Association

[APA], 2013). The onset of SAD is typi-

cally during childhood or adolescence

(National Institute for Health and Care

Excellence [NICE], 2013). A multitude

of interrelated variables, such as genetic

vulnerability, temperament, parental

factors, and environmental inﬂ uences

contribute to the etiology and mainte-

nance of SAD (Spence & Rapee, 2016).

For individuals who struggle with SAD,

symptoms can interfere with all areas

of life, including relationships, occupa-

tions, and educational endeavors. The

current article will explore familial fac-

Dr. Olson is Family Nurse Practitioner, CentraCare, St. Cloud, Minnesota.

Disclosure: The author has disclosed no potential con icts of interest,  nancial or otherwise.

Acknowledgment: The author acknowledges the help provided by Susan Schleper, Health Science Li-

brarian at CentraCare, for  nding research articles.

of the Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0).

This license allows users to copy and distribute, to remix, transform, and build upon the article, for any

purpose, even commercially, provided the author is attributed and is not represented as endorsing the use

made of the work.

Address correspondence to Christine M. Olson, DNP, APRN, FNP-BC, P.O. Box 0643, Alexandria, MN

56308; email: [email protected].

Received: June 30, 2020

Accepted: October 8, 2020

doi:10.3928/02793695-20210219-01

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 59, NO. 7, 2021

tors that can inﬂ uence the development

of SAD in children and adolescents.

Knowledge of familial factors provides

insight on targeted treatments that pre-

vent or minimize severity of the disorder.

DEFINITION OF SOCIAL

ANXIETY DISORDER

SAD is extreme fear and anxiety in

social situations leading to signiﬁ cant

levels of distress (APA, 2013). Social

situations may include carrying on a

conversation with another person, pub-

lic speaking, or eating a meal. A person

with SAD fears acting in a way that will

offend someone, humiliation from ex-

posing anxiety symptoms in public, and

scrutiny and negative evaluation from

others (APA, 2013). The marked level

of distress experienced by someone with

SAD is often out of proportion to the ac-

tual situation (APA, 2013). Avoidance

or anxious anticipation of the feared

situation is common (NICE, 2013). In

young children, social anxiety symptoms

may include severe and prolonged cry-

ing episodes, becoming physically im-

mobilized, shrinking away from others,

excessive clinging, or being unable to

speak in social situations (APA, 2013).

GENETIC PREDISPOSITION

The etiology of SAD is often de-

scribed in the literature in such terms as

puzzle, delicate interplay, and complex in-

teraction. There are multiple pathways to

the development of SAD, however, the

presence of several risk factors does not

automatically lead to SAD (Spence &

Rapee, 2016). One strongly implicated

pathway is genetic transmission (Scaini

et al., 2014). A positive association has

been found between development of

SAD in children who have parents with

SAD (Halldorsson et al., 2018; Isomura

et al., 2015; Telman et al., 2018). Un-

fortunately, heritability rates vary great-

ly among studies, ranging from 13% to

76% (Moreno et al., 2016). Researchers

have postulated that individual differ-

ences in the development of SAD stem

from a multidimensional relationship

between genetic factors and environ-

mental factors, such as parenting, peer

relationships, illness, early life trauma,

and cumulative stress (Chubar et al.,

2020; Scaini et al., 2014; Schiele &

Domschke, 2018; Shimada-Sugimoto et

al., 2015). Yet even gene–environment

models contradict or inaccurately pre-

dict those who will go on to develop

SAD (Ziegler et al., 2015).

More recently, epigenetics has been

identiﬁ ed as the potential “missing link”

in the heritability of anxiety disorders

(Schiele & Domschke, 2018, p. 4).

Epigenetics is a mechanism in which

cell molecules modify gene expression,

without changing the inherited DNA

code, to promote or inhibit symptoms

or diseases, such as cancer, depression,

addiction, and anxiety (Schuebel et

al., 2016). Environmental stressors,

such as child abuse, maternal separa-

tion, or early trauma, may inﬂ uence

genetic expression of anxiety when oc-

curring at critical developmental stages

of life, including infancy or adolescence

(Bartlett et al., 2017). Subsequently, a

child or adolescent may not only inherit

genetic tendencies for SAD but also

have critical periods of vulnerability to

individual epigenetic stressors (Schiele

& Domschke, 2018). Two genetically

transmitted behavioral traits implicated

in the development of SAD are behav-

ioral inhibition and anxiety sensitivity

(Chronis-Tuscano et al., 2018; Graham

& Weems, 2015; Muris et al., 2011;

Papachristou et al., 2018; Spence &

Rapee, 2016).

Behavioral Inhibition

Behavioral inhibition, ﬁ rst coined by

Kagan et al. (1984), is described as a

cautious and fearful reaction exhibited

by some individuals to uncertain situa-

tions. Children with behavioral inhibi-

tion have demonstrated behaviors such

as being more cautious when exposed to

novel experiences, physical signs of fear,

clinging to a parent, inhibited conversa-

tion, and reticence (Kagan et al., 1984;

Ollendick & Benoit, 2012). Muris et al.

(2016) found a correlation between be-

havioral inhibition, social anxiety, and

selective mutism (i.e., when children

fail to speak in speciﬁ c public situations,

yet are comfortable speaking at home).

Longitudinal studies in children have

demonstrated that high behavioral inhi-

bition was signiﬁ cantly associated with

an increase in social anxiety symptoms

(Garcia-Lopez et al., 2020; Muris et al.,

2011). Behavioral inhibition can be

identiﬁ ed in infants and toddlers and

remains relatively persistent over time

(Fox et al., 2005; Garcia-Lopez et al.,

2020).

Anxiety Sensitivity

Anxiety sensitivity is the fear of

anxiety-related physical sensations

(McNally, 2002). Alkozei et al. (2014)

discovered that children with SAD had

higher levels of anxiety sensitivity and

were more likely to view scenarios with

unclear social threats and ambiguous

endings as anxiety provoking. Children

and adolescents with SAD believed that

physical anxiety symptoms would be

observed by others, leading to humilia-

tion, mental incapacitation, illness, or

increased anxiety levels (Alkozei et al.,

2014; Papachristou et al., 2018). Not

only do individuals with anxiety sensi-

tivity overestimate the meaning of phys-

ical anxiety symptoms, but they also

generate escalating mental scenarios in

which they feel unable to cope (Riskind

et al., 2013).

FAMILY FACTORS

Family is an essential component in

the learning, growth, and development

of children. In addition, the family is

an important source of recreation and

social interaction, especially in early

childhood years. There is a substantial

body of evidence regarding the inﬂ u-

ence of parenting and the family in the

etiology of SAD.

Parenting Factors

Parenting factors of insecure parent–

child attachment; negative parenting

styles, such as overcontrol or criticism;

and modeling social anxiety have been

implicated in the development of SAD

in children. Beyond negative parenting

styles, a further challenge for researchers

is uncertainty about whether children

with SAD wrongly perceive parental

rejection due to their SAD or if parents

adapt approaches in response to having

a child with SAD (Asbrand et al., 2017;

Levine et al., 2015; Van Zalk & Van

Zalk, 2015).

Parent–Child Attachment. When a

child feels a trusting and secure paren-

tal bond, they are more likely to become

independent, trust other people, and

overcome difﬁ cult childhood situations

(Centre of Excellence for Early Child-

hood Development, 2012). On the

other hand, when a child has insecure

parental attachment, lower levels of so-

cial competence occur in areas of social

skills, peer interactions, and social sta-

tus (Fransson et al., 2016; Groh et al.,

2014). Ambivalent–insecure attach-

ment occurs when a child is uncertain

about parental availability, whether

due to parental inability or unwilling-

ness (Cassidy & Berlin, 1994; Kerns

& Brumariu, 2014). Through daily ex-

periences, an insecurely attached child

learns that they cannot rely on the

caregiver to be available or responsive

(Kerns & Brumariu, 2014; Ollendick

& Benoit, 2012). Behaviors associated

with insecure attachment may include

widely vacillating displays of negative

emotion, frustration with contact, cling-

ing, and preoccupation with the par-

ent (Cassidy & Berlin, 1994). Higher

rates of insecure attachment have

been discovered in infants of mothers

with social phobia (Kraft et al., 2017).

Lewis-Morrarty et al. (2015) conducted

a longitudinal study following infants to

adolescence and found that high levels

of behavioral inhibition and insecure at-

tachment signiﬁ cantly predicted social

anxiety in adolescents.

Separation of the mother, father, or

both parents during childhood due to

illness or marital discord can contribute

to social anxiety (Bishop et al., 2014).

Children who are used to daily mes-

sages that the parent is unavailable or

untrustworthy “develop a maladaptive

approach to future interpersonal situa-

tions or relationships based on the ex-

pectation that their needs will not be

met by others” (Ollendick & Benoit,

2012, p. 84).

Negative Parenting Styles. Several

negative parenting styles have been im-

plicated in the development of SAD, in-

cluding overcontrol, rejection, and criti-

cism (Akün, 2017; Knappe et al., 2012;

Lewis-Morrarty et al., 2012; Rudolph

& Zimmer-Gembeck, 2014; Xu et al.,

2017). Harsh parenting by either parent,

including physical punishment and ver-

bal aggression, such as excessive criticiz-

ing or humiliation, has correlated with

insecure attachment and risk for social

anxiety (Wang et al., 2019). Moreover,

Wang et al. (2019) noted that harsh

parenting in one parent was likely to

elicit attachment insecurity in another

parent possibly due to expectations that

the other parent will endorse the same

disciplinary tactics. Knappe et al. (2012)

found a pattern of maternal overprotec-

tion, paternal rejection, and lower emo-

tional warmth speciﬁ c to children with

social phobia. Maternal overcontrol has

been predictive of higher social anxiety

symptoms and lifetime rates of SAD

during adolescence (Bynion et al., 2017;

Lewis-Morrarty et al., 2012). Gómez-

Ortiz et al. (2019) noted that in either

parent, psychological control was the

variable that had the most signiﬁ cant

relationship with adolescent social anxi-

ety. Other negative parenting practices

(e.g., lack of affection, poor communica-

tion, limited granting of autonomy, lack

of humor) contribute to social anxiety

in adolescents by stimulating percep-

tions of low self-esteem and encouraging

ineffective emotional regulation strate-

gies (Gómez-Ortiz et al., 2019).

As early as infancy, negative parent-

ing styles may inﬂ uence the develop-

ment of social anxiety. Lawrence et al.

(2020) followed mothers with SAD,

general anxiety disorder (GAD), or

non-anxious controls and their infants

with stable behavioral inhibition from

4 months to 58 months. Children were

exposed to stressful social and non-social

tasks at ages 10 months and 58 months.

Lack of maternal encouragement and

maternal intrusiveness was noted in

mothers with SAD and predicted the

development of anxiety and SAD in

their children. The same was not true

for mothers with GAD or the control

group.

Parents with SAD may unknow-

ingly perpetuate social anxiety. Crosby

Budinger et al. (2013) evaluated inter-

actions between anxious parents with

and without SAD and their children

without an anxiety diagnosis. Children

and their parents were given speech

and drawing tasks to complete together.

Parents with SAD demonstrated sig-

niﬁ cantly less warmth, doubts of child

competency, and more criticism. Both

groups were similar in levels of overcon-

trol and granting of autonomy (Crosby

Budinger et al., 2013). In a study of mi-

grant families in China, Xu et al. (2017)

noted that both parents contribute to

social anxiety in different ways. The

authors noted that maternal overprotec-

tion can increase social anxiety in ado-

lescents, whereas social anxiety can be

reduced by paternal emotional warmth.

Mak et al. (2018) examined the as-

sociation between family relationships,

social anxiety, and the effect on youth

friendships. Paternal rejection, as op-

posed to maternal rejection or family

climate, was predictive of youth social

anxiety and subsequent loneliness. Fur-

thermore, maternal rejection, paternal

rejection, and poor family climate all

contributed to loneliness and decreased

friendship quality.

Abuse. It goes without saying that

children who are exposed to abuse ex-

perience a wide array of mental health

problems. Of the major types of child

abuse studied recently, emotional abuse

was a signiﬁ cant predictor in the devel-

opment of social anxiety (Bishop et al.,

2014; Fernandes & Osório, 2015; Kuo et

al., 2011; Michail & Birchwood, 2014;

Nanda et al., 2016; Shahar et al., 2015).

Emotional abuse has been deﬁ ned as be-

ing shouted or yelled at, direct sham-

ing, put down or ridiculed, or made to

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 59, NO. 7, 2021

feel like one did not count (Bishop et

al., 2014; Shahar et al., 2015). In stud-

ies where physical abuse or sexual abuse

factored into the development of social

anxiety, depression was a signiﬁ cant co-

morbid condition (Brühl et al., 2019;

Michail & Birchwood, 2014).

Nanda et al. (2016) speculated that

emotional abuse ﬁ ts into an etiological

framework of SAD because it not only

affects a child’s attachment to parents

and contributes to feelings of being un-

loved, but also makes them fearful of

interacting with others. Moreover, chil-

dren may develop a schema in which

self-esteem and personal value is depen-

dent on the opinion of others.

Positive Parenting and Social Support.

In contrast to negative parenting styles,

higher levels of parental social sup-

port and acceptance have been associ-

ated with lower levels of social anxiety

(Akün, 2017; León-Moreno et al., 2020;

Levine et al., 2015; Xu et al., 2017). In

a large study of 2,194 adolescents, Van

Zalk and Van Zalk (2015) revealed that

adolescents who perceived a close con-

nection with mothers and fathers had

lower levels of social anxiety. Examples

of parent connectedness included en-

couragement to pursue dreams and be-

ing present when needed. Similarly,

Graham and Weems (2015) noted

that parents with high anxiety sensitiv-

ity could decrease anxiety sensitivity

in their children by encouraging open

communication, involving them in per-

sonal activities, and reinforcing good

behaviors. Oppenheimer et al. (2016)

postulated that positive parenting be-

haviors buffer negative peer events dur-

ing the transition from middle child-

hood to adolescence.

In a longitudinal observation study

of 94 families with young children,

Majdandzic et al. (2014) discovered that

certain paternal behaviors can decrease

behavioral inhibition in children and

prevent development of SAD. When

fathers challenged their 4-year-old chil-

dren with playful teasing to push limits,

encouraged them to move out of their

comfort zones, and used unconventional

ways to play with toys, a decrease in

behavioral inhibition was noted that

remained persistent 6 months later.

The same was not true for mothers’

challenging behaviors, however, as in-

creased behavioral inhibition was noted

and persisted in later measurements.

Majdandzic et al. (2014) surmised that

maternal challenging behaviors fell out-

side of expected caring and supporting

roles of mothers.

Su et al. (2016) examined the ef-

fect of positive parenting practices on

adolescent social anxiety. When parents

gave explicit instructions about how

to handle challenging peer situations

and facilitated peer social opportuni-

ties, adolescents reported lower levels

of social anxiety. Parents who designed

a wide variety of peer social interactions

provided more opportunities to practice

social skills, gain conﬁ dence, and make

friends (Su et al., 2016).

Although it would seem obvious that

warmth and expressiveness from a par-

ent would diminish social anxiety in

the child, researchers have found that

guarding children from fear-provoking,

ambiguous situations may inhibit the

development of social skills and increase

fear (Kiel & Buss, 2014; Ollendick &

Benoit, 2012; Su et al., 2016). Although

there are no perfect equations for par-

enting a child with risk factors for social

anxiety, evidence has suggested that a

balance must be struck between showing

warmth and showing excessive concern.

Modeling. Children learn social skills,

such as how to greet new people, through

parent modeling. When faced with so-

cially ambiguous situations, anxious

parents may model anxiety and extend

personal interpretive biases into their

children’s environment (Remmerswaal

et al., 2016). Bögels et al. (2011) con-

ducted a study in which children with

varying levels of anxiety observed their

parents’ reactions to ambiguous social

situations. Mothers and fathers acted ei-

ther conﬁ dent or anxious. Low socially

anxious children were inﬂ uenced more

by the mothers’ anxious behaviors com-

pared to the fathers’ behaviors. High

socially anxious children gave more

weight to anxious and conﬁ dent behav-

iors of the father.

According to Aktar et al. (2014), the

end of infancy is an impressionable time

for learning anxiety from parents who

have SAD. In their study of 117 toddlers

of parents with SAD and other anxiety

disorders, the authors found that tod-

dlers of parents with SAD showed more

fear and avoidance when faced with

novel situations, such as introduction

to strangers or new toys. Infants with

high behavioral inhibition learn from

the anxious signals of mothers and fa-

thers via social referencing (Aktar et al.,

2014). Social referencing cues might in-

clude nonverbal communication, such

as facial distress or body posture; verbal

expressions of anxiety; interfering with

stranger–child interactions; or control-

ling attempts to explore uncertain sur-

roundings (Aktar et al., 2014).

Verbal transmission of fear and threat

from parents to children has been impli-

cated in development of social anxiety.

Negative parental verbal threats have

been shown to lead to cognitive bias

in ambiguous situations, hypervigilance

to threats, and avoidance behaviors

(Murray et al., 2014; Remmerswaal et

al., 2016). In an experimental study of

non-anxious children, mothers were

able to inﬂ uence their children’s nega-

tive information search bias to novel

stimuli and fear levels simply by offer-

ing negative versus positive statements

about the scenarios (Remmerswaal et

al., 2016).

Beginning school is another period

in which fear is transmitted from mother

to child. Using a picture book as a mech-

anism to discuss starting school, Murray

et al. (2014) found that mothers with

SAD were less encouraging in their nar-

ratives, discussed potential threats more

often, and were more likely to ignore

their children’s expressed worry. Subse-

quently, children of mothers with SAD

were evaluated using doll-play and not-

ed to be more likely to interpret socially

ambiguous scenarios as being negative

and had higher levels of internalizing

symptoms such as anxious-depression,

withdrawal, or somatization (Murray et

al., 2014). Similarly, Pass et al. (2017)

discovered that mothers who were wor-

ried about their anxious children start-

ing school used negative information

transfer in the form of threat verbaliza-

tions, anxiety-related words, and overall

negativity in school descriptions. Pass et

al. (2012) evaluated 4-year-old children

who were beginning school through

doll-play. The researchers discovered

that children of socially anxious moth-

ers showed highly anxious, negative

doll-play responses to ambiguous sce-

narios related to beginning school.

Finally, social anxiety may be trans-

mitted from parents to children in other

ways. Castelli et al. (2015) discovered

a strong association between maternal

SAD and the development of cognitive

and language skills in their children.

Infants and young children of mothers

with SAD may lack novel social interac-

tions that promote acquisition of execu-

tive function skills, language vocabulary,

cognitive functions, and emotional reg-

ulation (Castelli et al., 2015).

Unfortunately, studies related to par-

enting and the development of social

anxiety are likely to be overly simplistic.

Study limitations exist, including false

social environments that may promote

or hinder anxiety in predisposed parents

or children, lack of clear deﬁ nitions of

what constitutes warmth or overcontrol,

reliance of self-report of parents and

children, cross-sectional studies captur-

ing only a moment in time, retrospec-

tive memory recall after the fact, and

the multitude of mediating individual,

cultural, and socioenvironmental vari-

ables that inﬂ uence study results. Fur-

thermore, although an abundance of

literature exists highlighting the inﬂ u-

ence of parenting on children at risk for

SAD, many studies measure social anxi-

ety symptoms in nonclinical samples or

are not speciﬁ c to SAD.

Adaptation of Parenting Secondary

to SAD in Children. Although there is

considerable research outlining the im-

pact of parenting on SAD in children, a

question exists of whether parents adapt

parenting practices based on social anxi-

ety in the child (Asbrand et al., 2017;

Van Zalk et al., 2018). If a child has a

fear, a natural response from the parent

would be to acknowledge the fear and

protect the vulnerable child from harm.

Overprotection, though well meaning,

might inhibit a child’s exposure to chal-

lenging and novel social situations. Kiel

and Buss (2014) found that toddlers

with high levels of fearful behavioral

inhibition elicited maternal protective

behaviors subsequently leading to social

withdrawal in kindergarten. Asbrand et

al. (2017) conducted an observational

study of mothers and their children

with and without SAD. Children ages

9 to 13 were asked to complete difﬁ -

cult puzzles in a 10-minute time frame;

mothers were allowed but not encour-

aged to assist. Mothers of children with

SAD showed more involvement in the

activity, touched the puzzle pieces more

often, and helped without being asked.

In children without SAD, maternal

involvement occurred in the context

of the children asking for more help.

Neither group demonstrated negativ-

ity during interactions. Asbrand et al.

(2017) speculated that mothers of chil-

dren with SAD may limit their abil-

ity to learn autonomy and self-efﬁ cacy.

Similarly, Morris and Oosterhoff (2016)

noted that mothers’ unsolicited physical

takeover of an origami task was associ-

ated with higher reported social anxiety

in their children.

Sibling Relationships

Siblings play an important role in so-

cialization, understanding emotions, and

developing empathy (Howe & Recchia,

2014; Jambon et al., 2019). During in-

fancy, children spend more time with

siblings than with parents and friends

(Serra Poirier et al., 2016). Although

there are few studies related to sibling

relationships and development of SAD,

several studies have demonstrated a re-

lationship between siblings and mental

health. Serra Poirier et al. (2016) found

that adolescents who had a same-sex

twin with high levels of anxiety symp-

toms were more likely to have increased

anxiety themselves 1 year later. Anxiety

was contagious among twin same-sex

siblings in situations where the relation-

ship was perceived as highly negative

as well as highly positive. Keeton et al.

(2015) noted a protective role among

siblings who had a parent with a clini-

cal anxiety disorder. In settings where

children had low sibling companionship

or high conﬂ ict, children of anxious

parents reported more psychological

symptoms (Keeton et al., 2015). Fur-

thermore, strong sibling relationships

characterized by warmth and closeness

buffered the negative effects of interpa-

rental conﬂ ict and subsequent emotion-

al insecurity (Davies et al., 2019).

Recent research has highlighted the

detrimental impact sibling bullying has

on development of depression, anxiety,

social stress, and self-harm (Bowes et

al., 2014; Coyle et al., 2017; Liu et al.,

2020). Furthermore, the amount and

types of sibling bullying (e.g., physical,

verbal, relational) had a dose dependent

effect on the amount of mental distress

experienced (Liu et al., 2020). Bullying

has been an underrecognized problem

across all settings, particularly as youth

do not report bullying to adults (Coyle

et al., 2017). Alternatively, high social

support from siblings has been shown

to be a protective factor against bully-

ing from peers in school (Coyle et al.,

2017).

Family Environment

A discussion of family factors inﬂ u-

encing the development of SAD would

not be complete without exploring the

family environment. Stressful life events

in childhood with a strong social com-

ponent, such as interpersonal conﬂ ict

within the family, can contribute to the

development of social anxiety symp-

toms (Levine et al., 2015; Weymouth &

Buehler, 2018; Wong & Rapee, 2016).

Furthermore, interparental conﬂ ict has

been shown to increase threat percep-

tions and social anxiety symptoms,

potentially inﬂ uencing interpersonal

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 59, NO. 7, 2021

relationships with peers (Weymouth et

al., 2019). Other family-related stressful

events found to inﬂ uence the develop-

ment of SAD included witnessing vio-

lence, family mental illness, serious inju-

ry or illness of parent, parental divorce,

moving to a different school, and separa-

tion from one or both parents (Bishop et

al., 2014; Grills-Taquechel et al., 2010;

Wu et al., 2016). Draisey et al. (2020)

noted that a mother taking a new job

was a signiﬁ cant factor associated with

SAD in children. Individuals who ex-

perience multiple stressful life events

or a direct, severe single event are par-

ticularly predisposed to SAD (Wong &

Rapee, 2016).

A complicated relationship has been

uncovered between peer victimization

and family cohesion in adolescents with

SAD. Speciﬁ cally, adolescents who lack

a cohesive family environment or who

experience poor parental relationships

may be more prone to compliant behav-

iors with peers, leading to victimization,

rejection, and increased social anxiety

(Kapoor et al., 2020; León-Moreno et

al., 2020; Su et al., 2016; Weymouth

& Buehler, 2018). Peer-related trauma

or victimization is believed to be an ex-

ceedingly inﬂ uential factor in the etiol-

ogy of SAD (Norton & Abbott, 2017;

Pontillo et al., 2019; Wong & Rapee,

2016). Unfortunately, adolescents with

SAD have cognitive distortions that

may interfere with family cohesiveness

or misinterpret well-meaning parent be-

haviors (Levine et al., 2015; Rapp et al.,

2017; Van Zalk & Van Zalk, 2015).

Alternatively, certain environmen-

tal factors seem to be protective. Emo-

tional closeness and frequent contact

with family, including immediate family

members, grandparents, and other rela-

tives, has been protective against SAD

(Levine et al., 2015). Support and ac-

ceptance of peers has been shown to

lower social anxiety (Cavanaugh &

Buehler, 2016; Grills-Taquechal et al.,

2010; Levine et al., 2015; Van Zalk &

Van Zalk, 2015). Proactive approaches

to preserve friendships may be help-

ful to decrease social anxiety if parents

anticipate a move, divorce, or major

life event. The support of teachers has

been proposed as another mechanism to

prevent social anxiety symptoms. Low-

er teacher support in adolescence has

been associated with social anxiety and

greater compliance to peers (Weymouth

& Buehler, 2018). Finally, cumulative

emotional support given across multiple

contexts of family, peers, and school has

been proposed as a mechanism to de-

crease loneliness and social anxiety in

children and adolescents (Cavanaugh

& Buehler, 2016).

CLINICAL IMPLICATIONS

IN TREATING SOCIAL

ANXIETY DISORDER

Many interrelated factors, including

genetics, family, and environment, po-

tentially lead to SAD in children and

adolescents. Left untreated, SAD causes

pervasive problems with academic per-

formance, romantic and personal re-

lationships, victimization, loneliness,

future college endeavors, and profes-

sional goals (de Lijster et al., 2018). Un-

fortunately, challenges exist for mental

health practitioners in diagnosing and

treating the disorder.

SAD is often underrecognized, with

long delays between onset of symptoms

and initiation of treatment (Nagata et

al., 2015; Zarger & Rich, 2016). Zarger

and Rich (2016) found that only 13%

of adolescents with SAD had ever dis-

closed their social fears to a professional.

There are several reasons postulated for

the poor detection rates of SAD in chil-

dren and adolescents. First, the nature of

SAD is to fear negative evaluation and

avoid social encounters. As such, indi-

viduals with SAD usually hide or refrain

from seeking help (Neufeld et al., 2020).

Second, there is a high comorbidity

with other mental health disorders, in-

cluding depression, GAD, agorapho-

bia, panic disorder, and speciﬁ c phobia

(Adams et al., 2016; Chapdelaine et

al., 2018; Creswell et al., 2014; Garcia-

Lopez et al., 2016; Halldorsson et al.,

2019). SAD shares some of the same

characteristics of personal failure be-

liefs, social communication difﬁ culties,

fears, worry, intolerance of uncertainty,

somatic complaints, and internalized

distress (Counsell et al., 2017; Crome &

Baillie, 2015; Halls et al., 2015; Hearn et

al., 2017; Mobach et al., 2020; Pearcey

et al., 2018; Sackl-Pammer et al., 2018).

Subsequently, subtle symptoms of SAD

may be difﬁ cult to detect when a youth

presents with more disabling symptoms

of depression or panic disorder. One

hallmark feature that distinguishes SAD

from other disorders is dysfunctional

social beliefs (Mobach et al., 2020). A

child or adolescent with SAD expects

negative evaluation or rejection from

others and subsequently becomes hyper-

vigilant to threats in the social environ-

ment (Weymouth et al., 2019). Addi-

tional features speciﬁ c to SAD include

rumination after a social encounter, fear

of visually displaying anxiety symptoms,

and avoiding feared social situations

(APA, 2013; Halldorsson et al., 2019;

Kodal et al., 2017; Norton & Abbott,

2016; Weymouth et al., 2019). Third,

many individuals with SAD believe that

symptoms are a part of their personality,

attributable to shyness, or not severe

enough to warrant treatment (Hyett

& McEvoy, 2018; Nagata et al., 2015;

Zarger & Rich, 2016). Fourth, although

children with anxiety disorders rely on

parents to recognize problems and seek

help, parents may not ﬁ nd the behaviors

to be a difﬁ culty or perceive the need for

professional support (Reardon, Harvey,

et al., 2018). Finally, the presentation

of SAD encompasses a wide range of

symptoms, internalized fears, and lev-

els of severity leading to diagnostic er-

rors (Crome & Baillie, 2015; Hyett &

McEvoy, 2018).

Several cues can aid mental health

practitioners and teachers in early

identiﬁ cation of SAD. Children and

adolescents with a primary diagnosis

of SAD have endorsed a greater sever-

ity and number of somatic complaints,

including stomach pain, fatigue, sud-

den heart complaints, and dizziness

(Sackl-Pammer et al., 2018). Further-

more, school refusal behaviors and

dropout have correlated with social

anxiety (Gonzálvez et al., 2019; Ranta

et al., 2016; Waite & Creswell, 2014).

Peer victimization, substance use, aca-

demic delays, and fewer or lower qual-

ity friendships are other cues to identi-

fying SAD in children or adolescents

(APA, 2013; Early et al., 2017; Mekuria

et al., 2017; Pickard et al., 2018; Ranta

et al., 2016). Unfortunately, designa-

tions by school counselors or teachers

are not consistently accurate (Ecklund

& Dowdy, 2013; Sweeney et al., 2015).

Several brief screening tools have been

helpful in identifying social anxiety in

low resource mental health settings and

schools (Beale et al., 2018; Garcia-Lopez

et al., 2015; O’Connor & Fitzgerald,

2020; Reardon, Spence, et al., 2018;

Sweeney et al., 2015). Due to the high

likelihood of comorbidity, researchers

recommend screening for SAD when

a child or adolescent presents with an-

other mental health disorder, such as

depression or GAD (Adams et al., 2016;

Garcia-Lopez et al., 2016). Universal

screening in schools or pediatrician of-

ﬁ ces has been suggested (Ecklund &

Dowdy, 2013; Zarger & Rich, 2016).

Focusing on children and adolescents in

families experiencing signiﬁ cant stress-

ors, such as interparental conﬂ ict, pa-

rental mental illness, or serious illness,

may be another option. Finally, beneﬁ ts

have been noted with multi-informant

approaches, keeping in mind that parent

reports should be prioritized for children

and adolescent self-reports contribute

essential data about their own peer-

related impairments (Beale et al., 2018;

Reardon, Spence, et al., 2018).

A multitude of options exist for treat-

ing SAD in children and adolescents.

The gold standard is individual treat-

ment with cognitive-behavioral therapy

(CBT) incorporating social skills train-

ing, modiﬁ cation of cognitive biases, ex-

posure to situations, and education (As-

brand et al., 2020; NICE, 2013; Nordh et

al., 2017; Scaini et al., 2016; Spence et

al., 2017). Treatment techniques are rec-

ommended that encourage the individual

to discover how social anxiety is main-

tained and target cognitive distortions

(Leigh & Clark, 2018; Lisk et al., 2018;

Neufeld et al., 2020). Unfortunately, in-

dividuals with SAD treated with CBT

have demonstrated poorer outcomes

and lower likelihood of remission than

other anxiety disorders (Hudson, Rapee,

et al., 2015; Kodal et al., 2018; Leigh &

Clark, 2018; Lundkvist-Houndoumadi

& Thastum, 2017). Possible reasons

cited include parental psychopathology,

difﬁ culties establishing a therapeutic re-

lationship with the practitioner, longer

time to SAD diagnosis leading to more

resistant behaviors, generic manualized

CBT programs, and comorbid mood

disorders (Adams et al., 2016; Hudson,

Keers, et al., 2015; Hudson, Rapee, et

al., 2015; Kodal et al., 2018). Parental

involvement in treatment is essential, as

problematic parenting behaviors, psycho-

pathology, and stress may perpetuate the

child’s social anxiety (Garcia-Lopez et al.,

2014; Leigh & Clark, 2016; Manassis et

al., 2014; Schleider et al., 2015; Weijers

et al., 2018; Yang et al., 2019). Involving

the parents is particularly essential when

working with young children (NICE,

2013). Parent treatment approaches

should encompass education on how to

manage personal anxiety and negative

cognitive biases as well as how to fa-

cilitate exposures to anxious situations,

model healthy coping, reward brave be-

havior, and assist in preventing relapse

(Chronis-Tuscano et al., 2018; Leigh

& Clark, 2016, 2018; Manassis et al.,

2014). Advantages may exist for parent-

only treatments (Luke et al., 2017;

NICE, 2013; Reuland & Teachman,

2014). In situations where CBT is inef-

fective, other options should be consid-

ered, such as family psychoeducation,

modeling by practitioner, assertiveness

training group therapy, relaxation, and

possibly CBT plus medication (Higa-

McMillan et al., 2016; NICE, 2013).

Although signiﬁ cant strides have been

made in the literature regarding SAD

in children and adolescents, future re-

search is still needed to identify best

practices for preventing, diagnosing, and

treating the disorder.

CONCLUSION

Family represents the most impor-

tant social group from infancy to early

adolescence. For children with a genetic

vulnerability for SAD, it is essential to

recognize familial factors that contrib-

ute to the development of SAD. SAD

is a pervasive disorder that impacts all

aspects of life including personal and

professional relationships. Knowledge of

familial factors helps in recognition and

treatment for children and adolescents

thereby preventing or minimizing the

disorder.

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