J. Child Psychol. Psychiat. Vol. 42, No. 1, pp.

127–140, 2001
Cambridge University Press
' 2001 Association for Child Psychology and Psychiatry
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0021–9630\01 $15n00j0n00

Current Trends in the Understanding and Treatment of Social Phobia in

Youth
Olivia N. Velting and Anne Marie Albano
NYU School of Medicine, New York, U.S.A.

Social phobia is a common psychiatric problem in children and adolescents that has recently
gained serious attention in clinical practice and research. This article describes the clinical
presentation of social phobia and reviews several emergent areas of related research to social
phobia in children and adolescents. We begin with a summary of research regarding the
developmental pathways of childhood social anxiety into social phobia, highlighting
normative developmental factors, behavioral inhibition, pathophysiology, genetics, and
parenting\environmental factors. This is followed by a critical review of findings from
studies providing evidence for and against the existence of subtypes of social phobia.
Common comorbid disorders and sequelae of social phobia in children and adolescents are
discussed, bringing to attention the critical need for effective treatments, the current status
of which is reviewed in the final section. In sum, this review demonstrates that through
research in multiple disciplines, scientists are now developing a better understanding of the
risk and protective factors of social phobia in children and adolescents, ultimately leading to
improvements in primary prevention and intervention efforts for children at serious risk for
long-term problems with education, employment, social relationships, and independent
adult functioning.

Keywords : Adolescence, anxiety, diagnosis, intervention, social phobia, review.

Abbreviations : ANS : autonomic nervous system ; BI : behavioral inhibition ; CBGT-

A : Cognitive Behavioural Group Treatment for Adolescents ; CBT : cognitive behavioral
treatment ; SET-C : Social Effectiveness Therapy for Children.

Introduction Regarding the diagnosis of social phobia in children,

The Diagnostic and statistical manual of mental dis-
orders – 4th ed. defines the essential feature of social
phobia as ‘‘ a marked and persistent fear of social or
performance situations in which embarrassment may
occur ’’ (DSM-IV ; American Psychiatric Association,
1994, p. 411). Additionally, a diagnosis of social phobia
requires that, when exposed to the feared social situation,
an individual must invariably experience anxiety, possibly
in the form of a situationally bound or situationally
predisposed panic attack, and must recognize that this
anxiety is excessive or unreasonable. A socially phobic
individual experiences intense distress while in or avoids
the feared social situations, which significantly interfere
with his or her normal routine, social activities, or
occupational\academic functioning. In order to be diag-
nosed with social phobia, an individual’s fear or avoid-
ance of social situations cannot be due to the direct
physiological effects of a substance or general medical
condition or be better accounted for by another mental
disorder. A specifier of ‘‘ Generalized ’’ is indicated,
‘‘ when the fears are related to most social situations ’’
(American Psychiatric Association, 1994, p. 412). The use
of this specifier will be discussed fully in a separate section
below.
Requests for reprints to : Olivia N. Velting, PhD, NYU Child
Study Center, 550 First Avenue, New York, NY 10016, U.S.A.
(E-mail : veltio01!popmail.med.nyu.edu).
DSM-IV outlines four specific provisions that incor-
porate and emphasize important developmental dif-
ferences between children and adults. First, a child with
social phobia must show the capacity for age-appropriate
social relationships with familiar people, and his or her
anxiety must occur in peer contexts, not just with adults.
Second, the anxiety brought on by social situations may
be evidenced in children by crying, tantrums, freezing, or
shrinking from social situations with unfamiliar people.
Third, due to limitations of cognitive and perceptual
skills in young children, children with social phobia need
not recognize that their fear in social situations is
excessive or unreasonable. Fourth, under the age of 18
years, there must be evidence of the social fears existing
for a minimum of 6 months. This final provision suggests
that many children experience less chronic, discrete
periods of intense self-conscious shyness or social anxiety,
which abate within a limited time period (Buss, 1980). In
fact, mild to moderate levels of social anxiety are seen as
a normal and necessary factor in effective social function-
ing and developmental growth.
Although, in previous versions of the DSM, its di-
agnosis in children and adolescents was not prohibited,
social phobia was infrequently diagnosed in this popu-
lation in part due to the fact that it was largely subsumed
by other disorders of childhood, including avoidant
disorder of childhood and overanxious disorder. Another
factor that may have affected the diagnostic rate of social
phobia in children under earlier versions of DSM was the
organization of the manual regarding anxiety disorders.

127
128 O. N. VELTING and A. M. ALBANO
A special section listed anxiety disorders commonly
diagnosed in childhood, in which social phobia was not
included. Thus, it is likely that diagnosticians inad-
vertently ignored social phobia as a childhood diagnosis.
Since the publication of DSM-IV in 1994, clinical
diagnostic rates, as well as interest in and advances in
research on social phobia in children and adolescents,
have increased substantially.
Studies estimated DSM-III and DSM-III-R rates of
social phobia in youth at approximately 1 % (e.g.,
Kashani & Orvaschel, 1990 ; McGee et al., 1990). At least
one study has provided evidence that DSM-IV diagnostic
rates of social phobia in children (in this sample ages 9–13
years) are approximately equal to rates of DSM-III-R
social phobia and avoidant disorder combined (Kendall
& Warman, 1996). Although epidemiological studies
have not yet revealed prevalence rates for social phobia in
children and adolescents using DSM-IV criteria, it is
recognized that social phobia is currently one of the more
common primary diagnoses in adolescents who present
for treatment (Albano, Chorpita, & Barlow, 1996 ; Last,
Perrin, Hersen, & Kazdin, 1992 ; Vasey, 1995). Tentative
support for this comes from recent studies of lifetime
prevalence rates of social phobia in adolescents. One
study reported a DSM-IV lifetime rate of social phobia of
16 % in a sample of 1035 adolescents (ages 12–17 years)
randomly selected from high schools in Germany (Essau,
Conradt, & Peterman, 1999). Another recent epidemiol-
ogical study found DSM-IV social phobia lifetime preva-
lence rates of 9n5 % and 4n9 % in a community sample
of 14–24-year-old females and males, respectively
(Wittchen, Stein, & Kessler, 1999). Studies of DSM-IV
social phobia prevalence rates in preadolescents do not
yet exist. Although studies have reported cases of social
phobia in children as young as 8 years of age (using
diagnostic criteria from prior versions of DSM), it is
more frequently diagnosed in adolescents (Beidel &
Turner, 1988 ; Vasey, 1995). A study using DSM-III-R
criteria found that the average age of onset of social
phobia falls between 11n3 and 12n3 years (Last et al.,
1992). Thus, social phobia appears to be a common
problem that typically emerges in preadolescence, war-
ranting serious attention in research and clinical practice
for youth with this disorder.
The primary purpose of this article is to discuss several
important and emergent areas of research related to
social phobia in children and adolescents. First, we focus
on advances in research regarding the developmental
pathways of childhood social anxiety into social phobia.
Additionally, the current arguments for and against the
subtyping of social phobia into generalized and non-
generalized subtypes are discussed. Next, we examine
what is known about the comorbidity of social phobia
with other disorders in children and adolescents. Relat-
edly, we review other sequelae of childhood social phobia,
especially long-term impairment in social and occupa-
tional functioning. Finally, we examine recent advances in
the treatment of social phobia in children and adolescents
and present further recommendations based upon impli-
cations from the present review.
Developmental Pathways to Social Phobia
Normative Developmental Factors
In children as young as 6 months through 3 years of
age, anxiety is evident and common in the forms of
stranger and separation anxiety. Self-consciousness is a
central prerequisite for the development of social phobia.
The abilities to see oneself as a social object and to
experience embarrassment may emerge around age 4 or
5 years (Buss, Iscoe, & Buss, 1979), while the abilities to
take others’ perspectives and then to anticipate and feel
clear concern over negative evaluation from others
probably do not fully develop until around 8 years of age
(Asendorpf, 1989 ; Bennett & Gillingham, 1991 ; Crozier
& Burnham, 1990). By adolescence, the cognitive de-
velopment prerequisites for social anxiety are put in
place : primarily, the awareness that one’s appearance
and behavior are the basis for evaluation by others and
the awareness that others can have different opinions
from one’s own (Crozier & Burnham, 1990).
Thus, by late childhood and early adolescence, social
and evaluation fears are forefront. Social phobia is
thought to evolve from normal anxiety that is magnified
by the social demands of preadolescence (Amies, Gelder,
& Shaw, 1983). At this age, children are regularly required
to negotiate social evaluative tasks, including answering
questions in class, giving oral reports, working or playing
in groups, taking tests, and performing musically and
athletically. Additionally, by early adolescence, parents
are typically no longer responsible for arranging social
interactions for their children ; thus, the initiation of
opportunities for socializing, including dating, is added
to the daily tasks of young adolescents. These demands,
in combination with the cognitive advancements in
perspective taking and self-awareness accomplished by
early adolescence, set the stage for the emergence of social
anxiety.
Although at least at some point during adolescence all
youth will experience some level of social anxiety,
obviously not everyone goes on to develop pathological
levels (i.e., social phobia). This is well illustrated in a
comparison of the results of two recent prevalence studies.
One study found social anxiety to be extremely prevalent
in 12–17-year-olds, with approximately 51 % of a
community sample of mixed genders reporting at least
one specific social fear (Essau et al., 1999). In contrast,
a recent epidemiological study by Wittchen et al. (1999)
found lifetime prevalence rates of social phobia (i.e.,
social anxiety meeting DSM-IV diagnostic criteria) of
9n5 % and 4n9 % in a community sample of 14–24-year-
old females and males, respectively. The difference in
the rates in these two studies highlights the distinction
between the more common phenomenon of social anxiety
and the less common diagnosis of social phobia. Below,
we discuss some of the temperamental, physiological,
genetic, and environmental factors potentially involved
in the transformation of normative social anxiety to
social phobia.
Temperamental Factors
Since the publication of the seminal writings of Chess
and Thomas (e.g., Chess, Thomas, Birch, & Hertzig,
1960), the role of temperament has been an essential
consideration in the study of developmental psycho-
pathology. The majority of recent research in the area of
temperamental factors in the development of social
phobia focuses upon behavioral inhibition (BI). As
identified by Jerome Kagan and his colleagues (Kagan,
Reznick, & Snidman, 1988), BI refers to a temperamental
style that is characterized by reluctance to interact with
 SOCIAL PHOBIA
and withdrawal from unfamiliar settings, people, or
objects. In infants, BI is typically manifest as irritability,
in toddlers as shyness and fearfulness, and in school-age
children as cautiousness, reticence, and introversion. BI
includes reactions that are both behavioral (e.g., in-
terrupting of ongoing behavior, ceasing vocalization,
comfort-seeking from familiar persons, and retreat from
and avoidance of unfamiliarity) and physiological (e.g.,
stable high heart rate, acceleration of heart rate to mild
stress, pupillary dilation, and increased salivary cortisol ;
Kagan et al., 1988). The physiological correlates of BI are
consistent with biological and neurophysiological theo-
ries of social phobia discussed below.
Several studies provide evidence that early BI is a risk
factor for high social anxiety and social phobia
(Biederman et al., 1990 ; Hirshfeld, Rosenbaum, &
Biederman, 1992 ; Wittchen et al., 1999). Although BI has
been considered a risk factor for anxiety disorders in
general, one recent study, using retrospective reports of
childhood BI, found a history of childhood BI to be more
strongly associated with social anxiety than with other
types of anxiety in young adults (Mick & Telch, 1998).
Research exploring the relationship between anxiety
disorders and BI in child and adolescent populations is
expansive, and a complete review of it is beyond the scope
of this review article. For a review of this literature, the
reader is referred to a recent chapter written by Jerome
Kagan (2001). What follows is a brief review of selected
relevant studies related to BI and social anxiety and
phobia in youth.
A study by Hayward, Killen, Kraemer, and Taylor
(1998) examined the risk of childhood BI for later onset
of social phobia in a nonclinical sample of 2242 high
school students. The students completed a self-report
measure to assess their levels of BI as elementary school
students and were interviewed with a structured di-
agnostic interview to establish current diagnostic status.
The data indicated that the adolescents who reported
having childhood BI were four to five times more at risk
for adolescent social phobia than those who did not
report having BI as children. Of note, because childhood
BI was reported retrospectively, the interpretability of
these results are constrained by recall bias, e.g., students’
current social anxiety may result in distorted childhood
memories.
Although not directly examining BI’s connection to
diagnosed social phobia, other studies have probed the
relationship between BI and levels of social anxiety.
Schwartz, Snidman, and Kagan (1999) conducted a 12-
year follow-up evaluation of 79 adolescents who had
been classified at age 2 years as inhibited or uninhibited.
The children’s originally identified temperaments at age 2
years were found to persist into adolescence, i.e., 61 % of
adolescents who were identified as BI as toddlers cur-
rently had social anxiety, whereas only 27 % of those
originally identified as uninhibited had current social
anxiety. Additionally, having been uninhibited as a
toddler appeared to provide a protective factor for the
development of social anxiety, as reflected in the fact that
only 20 % of those who had been inhibited reported never
having generalized social anxiety compared to 48 % of
those who had been uninhibited. However, it is important
to re-emphasize that in this study, 66 % of inhibited
toddlers did not develop severe social anxiety as adole-
scents, indicating that BI in early childhood does not
necessarily lead to the development social anxiety. An-
other finding of note from this study was the significant
129
relationship of reported early BI with adolescent general-
ized social anxiety but not with specific fears, separation
anxiety, or performance anxiety (Schwartz et al., 1999).
As in Mick and Telch’s (1998) retrospective study of BI,
this finding suggests specificity in the relationship of BI
and social anxiety, as opposed to early BI being a
precursor to anxiety disorders in general.
In another report of the longitudinal work described in
Schwartz et al. (1999), Kagan and his colleagues found
that only 18 % of high reactive infants were consistently
identified as such at every time point between ages 1 to 7
years (Kagan & Snidman, 1999). However, none of the
high reactive infants were found to be consistently
uninhibited during that time period. Kagan and Snidman
conclude that ‘‘ the relation between infant reactivity and
the later development of a consistently inhibited style is
real, but modest ’’ (p. 1540). They propose that the most
appropriate description of the effect of an infant’s
temperament on his or her later emotional and behavioral
profile is ‘‘ constraining ’’ rather than ‘‘ determining ’’
(Kagan & Snidman, 1999).
Overall, evidence to date suggests that a behaviorally
inhibited temperament may predispose a child to the
development of high social anxiety, although BI has yet
to be definitively identified as a necessary precursor to the
development of the clinical syndrome, social phobia.
Additional longitudinal studies, i.e. replications of the
work of the Harvard research group led by Kagan, are
essential to elucidate the relationship of BI and social
phobia.
Pathophysiological Factors
Many studies have examined the effect of introducing
various compounds (e.g., lactate, caffeine, CO , penta-
#
gastrin, and adrenaline) to patients with panic disorder
(e.g., Cowley & Arana, 1990 ; Holt & Andrews, 1989 ;
Tancer, Stein, & Uhde, 1991). In general, studies have
found that panic patients exhibit strong panic reactions,
particularly somatic symptoms, in response to these
chemical agents. This has implicated these agents, to
some extent, in the biology of panic attacks. The limited
amount of existing research examining the pathophysio-
logical factors involved in the development of social
phobia has been conducted with adults. Thus, the results
reviewed in this section are from studies of adults. A
recent review of the existing adult studies in this area
concluded that the studies fail to identify any clear
neurobiological abnormality in socially phobic individ-
uals, although social phobics’ status probably lies some-
where between normal controls and panic patients (Bell,
Malizia, & Nutt, 1999). Although these findings cannot
be directly extended to children and adolescents, they are
included here to acknowledge the continuing possibility
of pathophysiological factors in the etiology of social
phobia in youth and to encourage further research in this
area.
When facing phobic situations, social phobics com-
monly experience such symptoms as blushing, racing
heart, sweating, and increased respiration, all of which
are reactions associated with the autonomic nervous
system (ANS). However, few studies have examined ANS
functioning in social phobics. Results from these studies
are inconsistent, with some suggesting that social phobics,
when facing a social challenge, have higher heart rate and
blood pressure elevations than normal controls (e.g.,
Beidel, Turner, & Dancu, 1985 ; Davidson, Marshall,
130 O. N. VELTING and A. M. ALBANO
Tomarken, & Henriques, 2000 : Heimberg, Hope, Dodge,
& Becker, 1990) and others failing to confirm this (e.g.,
Hofmann, Newman, Ehlers, & Roth, 1995 ; Stein,
Asmundson, & Chartier, 1994).
Chemical challenge studies have generally found that
socially phobic adults do not appear to have particularly
abnormal responses to lactate (Liebowitz et al., 1985) and
adrenaline (Papp et al., 1988), but may have slight
sensitivities to pentagastrin (McCann, Slate, Geraci,
Roscow-Terrill, & Uhde, 1997), CO (Caldirola, Perna,
#
Arancio, Bertani, & Bellodi, 1997), and caffeine (Tancer,
Stein, & Uhde, 1994). However, as per reports from the
social phobics in many studies, the anxiety that is
produced by these challenges is not similar to the anxiety
they experience naturally when faced with the phobic
stimuli. Bebchuk and Tancer (1999) interpreted this
finding as suggesting that social phobics’ responses to
such challenges are more likely to be related to heightened
basal arousal rather than specific underlying neuro-
biological abnormality.
The amygdala is a small region in the forebrain
integrally involved in the output of conditioned fear
responses, e.g., freezing-up behavior, blood pressure
changes, stress hormone release, and the startle reflex
(LeDoux, 1996). Drawing from animal-based studies, it
has been proposed that socially phobic individuals have
amygdalas that are hypersensitive, particularly in relation
to social threat cues (Pine, 1999). Two recent studies
using functional magnetic resonance imaging (fMRI)
found that, when exposed to slides of neutral faces paired
with a negative odor and later to the faces alone, adult
patients with social phobia have an increased activation
response in the amygdala (Birbaumer et al., 1998 ;
Schneider et al., 1999). In contrast, normal controls had
decreased activity in the amygdala when exposed to the
faces alone, despite their subjective reports of negative
affect in relation to the neutral faces after the conditioning
(i.e., their subjective reports were similar to those of the
social phobia patients).
In accord with these findings, Jerome Kagan has
hypothesized that hypersensitivity in the neural circuitry
that centers on the amygdala may be responsible for
behavioral inhibition in children (1997). Although stud-
ies with adult social phobics provide some support for
this hypersensitivity model (e.g., Birbaumer et al., 1998 ;
Schneider et al., 1999), studies have not yet directly
examined the relationship between amygdala functioning
and either behavioral inhibition or social phobia in
children.
Clearly, studies have only just begun to explore the
pathophysiology of social phobia. Currently developing
neuroimaging technologies, including fMRI, and radio-
nucleide imaging (PET—Positron Emission Tomography
and SPECT—Single Photon Emission Computed Tom-
ography), provide some of the most promising methods
of testing hypotheses regarding the physiological de-
velopmental pathways of social phobia (Bell et al., 1999 ;
Pine, 1999). The application of these methods to children
and adolescents may prove to be especially useful in
elucidating the continuities and differences between social
phobia in youngsters and in adults.
Genetic Factors
Twin studies. Twin studies provide one of the most
powerful research designs for establishing the relative
contributions of genetics and of environment to a
disorder. Unfortunately, the few twin studies examining
social phobia, taken as a whole, are inconclusive. One
study examined the rates of 6 different disorders, in-
cluding social phobia, in 446 pairs of adult twins
(Andrews, Stewart, Allen, & Henderson, 1990). Although
symptoms of disorders appeared genetically connected,
the overall results failed to find a genetic contribution to
the inheritance of diagnosable cases of the specific
disorders.
Similarly, another twin study reported the prevalence
rates of social phobia to be equal in co-twins of anxiety-
disordered probands and controls (Skre, Onstad, Torger-
sen, Lygren, & Kringlen, 1993). However, the number of
twins who met criteria for each disorder examined in the
study was low, thus limiting the interpretability of the
findings.
In contrast, a study of 2163 pairs of female twins
conducted by Kendler, Neale, Kessler, Heath, and Eaves
(1992) found a higher concordance rate of social phobia
in monozygotic than in dizygotic twins. However, their
best fitting models found that environmental factors
accounted for approximately two thirds of the factors
responsible for the development of social phobia (versus
one third from genetics). In addition to being limited by
the sample being entirely female, Kendler and colleagues’
work has limited implications for current theory because
they diagnosed social phobia based on DSM-III criteria.
More twin studies have examined the heritability of
shyness and social fears than the clinical presentation, i.e.
social phobia. Warren, Schmitz, and Emde (1999) re-
cently conducted behavioral genetic analyses of self-
reported anxiety in a sample of 326 same-sexed mono-
zygotic and dizygotic 7-year-old twins. These researchers
found that genetic influences accounted for approxi-
mately one third of the variance in the children’s social
anxiety scores, whereas shared environment did not make
a significant contribution. At the same time, results
indicated that unique or nonshared environmental factors
accounted for the largest proportion of variability in all
anxiety scores, including social anxiety. These results are
in accord with other research that has examined the
heritability of related constructs, such as behavioral
inhibition and shyness, in twins (e.g., DiLalla, Kagan, &
Reznick, 1994 ; Robinson, Kagan, Reznick, & Corley,
1992 ; Rose & Ditto, 1983 ; Torgersen, 1979). Overall,
these studies suggest that genetics play a modest to
moderate role in the development of symptoms and
temperamental traits associated with social phobia.
Family studies. Studies examining the rates of social
phobia in the offspring or in other first-degree relatives of
socially phobic individuals also provide evidence in terms
of the heritability of the disorder. For example, Fyer,
Mannuzza, Chapman, Martin, and Klein (1995), upon
interviewing a large sample of anxiety-disordered, normal
control adults and the relatives of the two groups, found
a moderate familial aggregation of social phobia, with a
significant two-fold risk increase in the first-degree
relatives of the social phobia proband. Another im-
portant result from the Fyer et al. study is that familial
aggregation of social phobia was found to be specific to
the social phobia proband (as opposed to the specific
phobia and panic-agoraphobia probands). Similarly,
Reich and Yates (1988) used a family history meth-
odology and found that patients with social phobia had
higher rates of relatives with social phobia (6n6 %) than
did patients with panic disorder (2n2 %) or normal
controls (0n2 %). However, again these studies consist of
 SOCIAL PHOBIA
adult patients and adult relatives, limiting the impli-
cations in relation to child and adolescent populations.
Only one family study has been conducted with social
phobics’ offspring under the age of 18 years. This study
examined the rates of anxiety disorders in the 47 offspring
of 26 social phobic outpatients (Mancini, Van Amerin-
gen, Szatmari, Fugere, & Boyle, 1996). The offspring,
who ranged in age from 4 to 18 years, met criteria for
DSM-III-R diagnoses of overanxious disorder (30 %),
social phobia (23 %), separation anxiety disorder (13 %),
and simple phobia (13 %). Although the interpretability
of this study is limited by its lack of a control group, these
results in young offspring of social phobics lend some
support to results from the adult family studies described
above (i.e., Fyer et al., 1995 ; Reich & Yates, 1988) that
there is a high prevalence of social phobia in the relatives
of individuals with social phobia.
Although not directly examining rates of social phobia,
two more recent studies provide further evidence of a
significant connection between social anxiety in parents
and in their offspring. One of these studies reported that
having more than one parent with an anxiety disorder
significantly increases the risk of social phobia in children
(Merikangas, Avenevoli, Dierker, & Grillon, 1999).
Although the specific anxiety diagnoses of the parents
were not identified, this study found that the offspring of
two parents with anxiety disorders had a three-fold
increased risk for social phobia over the offspring of one
parent with anxiety and one without, and an even larger
risk over those who had neither parent with an anxiety
disorder. Another recent study examined the association
between childhood social inhibition and maternal social
phobia (Cooper & Eke, 1999). In this study, the mothers
of shy 4-year-olds were found to have significantly higher
rates of social phobia than did mothers of normal
controls.
Overall, these studies suggest that social phobia is at
least moderately familial and possibly specific in its
transmission. However, family studies cannot specifically
sort out the relative contributions of genetic influences
and family environmental influences on the development
of a disorder. Thus, the mechanisms behind this familial
connection in social phobia still need clarification. In the
next section, we review studies that examine the influence
of specific parenting and family environmental charac-
teristics on the development of social phobia in children
and adolescents.
Parenting\Family Environment Factors
As noted above in the discussion of social phobia
family studies, environmental factors related to the family
are likely to be involved in the development of social
phobia. A recent treatment study found that anxious
children with at least one anxious parent had poorer
outcomes after a course of cognitive behavioral treatment
than did children who had no anxious parents (Cobham,
Dadds, & Spence, 1998). These results were interpreted as
signifying that parental anxiety is, at the very least, a
significant maintaining factor in children’s anxiety dis-
orders. Other studies have gone beyond these results and
have attempted to identify the specific aspects of anxious
parents that are responsible for the differences between
their offspring and the offspring of nonanxious parents.
Information regarding the influence of parental and
other family environmental factors on the development
and maintenance of social phobia come from several
131
sources, with the largest source being studies that examine
adult social phobics’ retrospective reports of their par-
ents’ parenting styles and early home environments. In
one early study in this area, a group of adult social
phobics recalled their parents as being more controlling\
overprotecting and as expressing less affection than did
normal controls (Parker, 1979). Another study confirmed
these results and also found social phobics to report
significantly less affection from their parents than did
agoraphobics (Arrindell et al., 1989).
Bruch and Heimberg (1994) examined other aspects of
adult social phobics’ perceptions of their parents. They
found that their sample of 70 social phobics, as compared
to a group of 39 normal controls, perceived their parents
as placing excessive concern on the opinions of others
and as having promoted less family sociability.
However, the retrospective nature of these studies
makes the results tenuous, i.e., adult social phobics’ recall
of childhood circumstances is likely to be confounded by
many factors. For example, another study, by means of
retrospective reports, examined adult patients’ reports of
their parents’ characteristics during their first 16 years of
life (Parker et al., 1997). As compared to 70 patients
without any anxiety disorders, 80 patients with social
phobia reported significantly higher rates of maternal
protection and over-control. These findings were no
longer significant, however, when social phobics who had
developed depression after developing social phobia were
taken out of the analyses. These findings illustrate how
significantly various intermediate factors, e.g., depres-
sion, can affect social phobics’ recall of their parents
styles of parenting.
With the results of retrospective reports being ob-
viously compromised by recall bias, it is surprising that
no studies have examined current parental practices in
socially phobic children and adolescents. A few studies
have examined parental characteristics in youth who are
socially anxious, withdrawn, or generally anxious. One
recent study by Caster, Inderbitzen, and Hope (1999)
reported adolescents’ opinions of their parents’ child-
rearing styles and family environment. Of the 2708
students included in the sample (grades 7, 8, 9, and 11),
those with higher levels of social anxiety perceived their
parents as more socially isolating of their children (i.e., of
the students themselves), less socially active, overly
concerned about the opinions of others, and more
ashamed of their children’s shyness and poor perform-
ance, as compared to adolescents with lower social
anxiety.
Using a sample of younger children (3rd–6th graders),
Messer and Beidel (1995) found that anxiety-disordered
children described their families as more restrictive than
did normal controls and those who were test-anxious
only. Additionally, results reported that fathers of both
the anxious and test-anxious groups had more rigid
personality styles, i.e., they possessed more obsessive-
compulsive symptoms than fathers of normal controls
did.
Another study examined maternal beliefs about ap-
propriate styles for teaching social skills to and res-
ponding to maladaptive behaviors in their preschoolers
(Rubin & Mills, 1990). The mothers of withdrawn
preschoolers (N l 6) were more likely than the mothers
of socially average preschoolers (N l 60) to believe that
teaching of social skills should be done in a directive
manner and that peer-directed aggression should be
responded to in a strongly coercive manner. Beyond
132 O. N. VELTING and A. M. ALBANO
being limited by the small sample size, these results are
difficult to translate into implications for socially phobic
children because the similarity of the children’s with-
drawal behaviors to behaviors characteristic of social
phobia is not reported.
Although not specifically examining children with
social phobia or with behaviors characteristics of the
disorder, one research group has studied parent-child
interactions using a method that holds great potential
for revealing parent influences in social phobia (Barrett,
Rapee, Dadds, & Ryan, 1996 ; Dadds, Barrett, Rapee, &
Ryan, 1996). In these studies, children were presented
with ambiguous scenarios (e.g., you see a group of
children playing one of your favorite games) and asked to
provide plans of action. Each child was then joined by his
or her parents, with whom the scenario and plans were
discussed. After this discussion, each child was asked to
state a final plan of action. On this task, 152 clinically
anxious, 27 oppositional, and 26 nonclinical children
ages 7–14 years were compared, and their initial responses
showed that the anxious and oppositional children were
more likely than the nonclinical children to perceive the
ambiguous scenarios as threatening. Additionally, com-
pared to the other two groups, the anxious children chose
more avoidant solutions (Barrett, Rapee, et al., 1996). In
Dadds et al. (1996), the children’s discussions with their
parents were examined, and it was discovered that, in
comparison to the nonclinical group, the parents of the
anxious children were more likely to reciprocate their
children’s avoidant plans and actively discourage their
children from making nonavoidant plans. Finally, after
discussions with their parents, the anxious children’s
plans increased in avoidance and the oppositional child-
ren’s plans increased in aggression (Barrett, Rapee, et al.,
1996). This phenomenon was labeled the FEAR effect
(family enhancement of avoidant and aggressive res-
ponses). As in the other studies described above, this
work cannot disentangle the impact of the anxious child
on the parents’ behaviors from the parents’ develop-
mental influence on their child’s anxiety. However, if
employed in longitudinal studies of children at risk for
social phobia, the method used in Barrett and colleagues’
studies could clarify this relationship (e.g., over time,
before and after discussions with their parents, examine
the degree of social avoidance in children’s plans of
action for social scenarios, as well as the degree of social
avoidance encouraged by parents).
A recent study provides some preliminary evidence of
the FEAR effect in socially phobic adolescents (Logsdon-
Conradsen et al., 2000). Twenty-three socially phobic
Caucasian 13–17-year-olds were presented with two
problem social situations (e.g., giving an oral report in
front of popular kids ; being in the cafeteria with popular
kids who are making plans for the weekend) and were
asked to provide plans for each situation before and after
discussions with their parents. Results were mixed in
terms of their support of the FEAR effect. Whereas
parental anxiety levels were found to be significantly
higher in the adolescents who chose avoidant plans of
action versus those who chose proactive plans, the
adolescents’ plans of action and anxiety levels were not
found to significantly change after discussions with their
parents. Further studies of this type, especially those
using control groups and more ethnically diverse samples,
are clearly needed.
In sum, parent characteristics and family environment,
through such mechanisms as modeling of avoidant
responses and restricted exposure to social situations, are
likely to have at least a moderate affect on the de-
velopment of social phobia in children and adolescents.
An obvious gap in this area is research using socially
phobic children or children at high risk for social phobia,
and this needs to be filled before the developmental
impact of parental and family factors can be specified.
Subtypes of Social Phobia
Under the current diagnostic system, a diagnosis of
social phobia can be specified as ‘‘ generalized ’’ if the
individual’s fear encompasses most situations. ‘‘ Non-
generalized ’’ social phobia, sometimes also described as
‘‘ discrete, ’’ ‘‘ circumscribed, ’’ ‘‘ limited, ’’ or ‘‘ perform-
ance, ’’ occurs when social anxiety is limited to a few
specific contexts (e.g., eating in front of others, writing,
public speaking) (Heckelman & Schneier, 1995). Ac-
cording to DSM-IV, the nongeneralized subtype is
composed of a heterogeneous group of individuals whose
social phobia may be limited simply to performance
situations or include several but not ‘‘ most ’’ social
situations. In order to differentiate between subtypes, a
thorough assessment of an individual’s anxiety in many
different types of social situations is necessary (Kessler,
Stein, & Berglund, 1998).
The existence of distinct generalized and nongeneral-
ized social phobia subtypes has been questioned. Specifi-
cally, there is debate regarding whether the two subtypes
are simply the same disorder at different points on a
severity continuum or are, in fact, qualitatively different
enough to warrant subtype status. This is particularly
questionable in children and adolescents, a population in
which very little work has examined the evidence of social
phobia subtypes.
Subtypes in Children and Adolescents
It has been hypothesized that, rather than remaining
specific to one or two situations, social fears in children
tend to generalize and become part of the phenom-
enological expression of anxiety characteristic of general-
ized social phobia or overanxious disorder (Albano,
DiBartolo, Heimberg, & Barlow, 1995). However, this
hypothesis is only partially supported by the two existing
studies examining social phobia subtypes in adolescents.
In one of these studies, Hofmann et al. (1999) categorized
the feared situations of 33 socially phobic adolescents
into 4 domains : formal speaking\interactions, informal
speaking\interactions, observation by others, and as-
sertion. About half (45n5 %) of the adolescents reported
feared situations that fell into all four domains, thus
earning the label ‘‘ generalized subtype. ’’ As compared to
the nongeneralized social phobics, the generalized social
phobics were found to have significantly higher levels of
comorbid psychopathology based upon self-report meas-
ures. Diagnostic interview data of the adolescents, how-
ever, did not find any significant differences between the
two subtypes in terms of their rates of comorbid anxiety
and mood disorders. The authors speculated that these
findings indicate that socially phobic adolescents with the
generalized subtype diagnosis may not develop comorbid
diagnoses in their teens but have a stronger vulnerability
to developing comorbid mood and anxiety disorders later
in life (Hofmann et al., 1999). Of particular importance in
 SOCIAL PHOBIA
interpreting the results of this study is the atypical
definition of generalized social phobia used. To classify
the adolescents as generalized or nongeneralized socially
phobic, this study used the number of domains of social
situations as the criteria rather than the number of
social situations themselves, as is typically used. Thus,
adolescents who endorsed fears of several situations (e.g.,
conversations with friends on the phone, hanging out at
my locker, going on a date) that all fell into the same
domain (e.g., informal speaking\interactions) were classi-
fied in this study as nongeneralized, whereas in other
studies their fears would have been considered general-
ized.
Using a community sample of 3021 individuals aged
14–24 years, a study by Wittchen et al. (1999) provides
evidence supportive of the subtype distinction in social
phobia. Their definition of generalized social phobia
required the individual to report fearing three or more
specific social situations. In this study, 50 % of the
generalized social phobics versus 19 % of the non-
generalized social phobics reported onset of symptoms
before age 12 years. Compared to nongeneralized social
phobics, generalized social phobics had more impairment
in terms of their work, school, and household man-
agement but not in terms of their leisure activities.
Generalized social phobics were also found to have higher
comorbid disorders (i.e., other anxiety disorders, dys-
thymia, eating disorders, major depression, and nicotine
dependence), with comorbidity increasing by age group.
Of note, these results are in accord with the speculations
of Hofmann et al. (1999) that, as they age, generalized
socially phobic adolescents are at an increased risk of
developing comorbid disorders. Finally, in terms of
differential risk factors, generalized social phobics were
more likely than nongeneralized social phobics to have
histories of high behavioral inhibition, long-lasting sep-
aration from either parent during childhood or early
adolescence, and a parental history of psychopathology
(Wittchen et al., 1999).
Thus, these two studies provide preliminary evidence
for distinct social phobia subtypes in adolescent and
young adult populations. Specifically, generalized
socially phobic adolescents appear to be distinguishable
from those who are nongeneralized by age of onset, level
of impairment, risk for developing comorbid disorders,
parental psychopathology, and early childhood circum-
stances and temperament. Further studies are needed not
only to validate these findings, but also to see if subtypes
exist in preadolescent social phobics.
Subtypes in Adults
Studies investigating subtypes of social phobia in adults
are more abundant (for a review see Heimberg, Holt,
Schneier, Spitzer, & Liebowitz, 1993). One study that
specifically set out to determine the reliability and validity
of social phobia subtypes provides several important
findings in support of the subtypes as distinct categories
(Mannuzza et al., 1995). Two clinicians independently
classified a sample of 129 adult patients at an anxiety
clinic as generalized and nongeneralized social phobics
based upon whether they feared ‘‘ most ’’ or ‘‘ less than
most ’’ of 10 specific social situations. The two raters
achieved good reliability (kappa l n69). Furthermore,
significant differences between the two groups were
found : compared to the nongeneralized social phobics,
generalized social phobics had lower rates of marriage,
133
early onsets of social phobia, greater number of fears,
higher rates of atypical depression and alcoholism, and
higher rates of social phobia in relatives. However, it
should be noted that the generalizability of these results is
limited because the patients were all seen in an anxiety
clinic, thus whether or not such results are seen in the
general population or in other clinical populations is
uncertain (Mannuzza et al., 1995).
Another study provides mixed evidence of differences
between social phobia subtypes in terms of family factors
and early experiences. Bruch and Heimberg (1994)
compared generalized and nongeneralized social phobics
on family-related variables and their experiences as
adolescents. No differences were found between the
generalized and nongeneralized social phobic groups on
parental use of shame as discipline, level of parental
emphasis on the opinions of others, and age of onset of
symptoms. On the other hand, the generalized social
phobics reported significantly more pervasiveness of
symptoms during adolescence than the nongeneralized
social phobics, and generalized social phobics perceived
at least one parent as having isolated them from others
and having promoted less socialization outside of the
family, as compared to nongeneralized social phobics and
controls.
A recent study by Boone and colleagues examined
behavioral, physiological, and verbal responses of 41
adult outpatients with nongeneralized social phobia (fear
of giving speeches only), generalized social phobia (fear
in two or more different types of social situations), and
generalized social phobia with avoidant personality
disorder (Boone et al., 1999). Using two behavioral tests
to directly assess overt behavioral data, these researchers
found, in general, that the generalized social phobics fell
between the other two groups on all measures. The
primary significant differences between groups were
between the speech phobics and generalized social pho-
bics with avoidant personality disorder. The two excep-
tions to this were that speech phobics reported signifi-
cantly lower levels of anxiety and depression on a variety
of self-report measures and also had higher heart rates
when giving a speech as compared to the generalized
social phobics without avoidant personality disorder
(Boone et al., 1999). Although not directly relevant to the
present paper because of its insignificance to children and
adolescents, this study calls attention to the possibility
that other studies examining social phobia subtypes have
most likely included individuals with avoidant person-
ality disorder, which may account for the significant
differences reported between generalized and non-
generalized groups.
Results from the National Comorbidity Study were
examined for evidence of social phobia subtypes (Kessler
et al., 1998). Some significant differences were found
between the two subtypes, with generalized social phobics
reporting greater impairment (e.g., interference with life
or activities ; has sought treatment), longer persistence of
symptoms, greater comorbidity (mood disorder, other
anxiety disorder, and antisocial personality disorder),
and higher rates of maternal generalized anxiety disorder.
However, as in Boone and colleagues’ study described
above (1999), in these results, the nongeneralized subtype
group consisted of individuals with pure public speaking
fears. When a more clinically typical group of non-
generalized social phobics (i.e., consisting of individuals
with performance fears beyond speaking fears, such as
eating and writing in public) was examined, no differences
134 O. N. VELTING and A. M. ALBANO
were found between the generalized and nongeneralized
social phobic groups (Kessler et al., 1998). Considering
these results, the researchers’ final conclusions were
uncertain as to whether there are true subtypes in social
phobia or, rather, the so-called subtypes are actually
‘‘ different severity thresholds on a single dimension of
extensiveness of social fears ’’ (p. 617).
Another study questioned the validity of subtypes in
social phobia. Weinshenker and colleagues (1996–97)
classified 176 socially phobic adults as generalized or
nongeneralized and compared the two groups on a
number of measures. They found no statistically signifi-
cant differences between the two subtypes on age of
onset, current comorbidities, treatment-seeking behav-
iors, health, functioning in social roles, and adverse child-
hood events. The one difference suggestive of a qualitative
difference between groups was a greater reported fear of
public speaking in the nongeneralized group (Wein-
shenker et al., 1996–97).
The above results provide a rather mixed picture of the
validity and clinical utility of subtyping social phobia.
The lack of clarity is most likely to be due to the nebulous
distinction between generalized and nongeneralized
social phobia. One related aspect that stands out in the
studies reviewed above is that some studies used in-
dividuals with phobias of making speeches as their
nongeneralized social phobics (e.g., Boone et al., 1999),
while others included individuals with broader public
speaking fears (e.g., Mannuzza et al., 1995). As indicated
by the results from the National Comorbidity Study
reviewed above (Kessler et al., 1998), considering a fear of
making speeches equivalent to a diagnosis of non-
generalized social phobia can significantly affect the
significance of differences between generalized and non-
generalized social phobics. These results indicate a need
for more precise criteria for diagnosis of the generalized
subtype of social phobia. Also, as indicated by the work
of Boone and colleagues, inclusion of individuals with
avoidant personality disorder in some samples of social
phobics but not in others may also contribute to the
mixed results, at least in adult samples.
Differences in etiology, nature, and treatment are the
basis for distinct categories in classification (Rapee,
1995). Although some of the results discussed above
indicate that generalized and nongeneralized social pho-
bic adults may differ in childhood levels of behavioral
inhibition, certain family characteristics, level of im-
pairment, and comorbid psychopathology, the differen-
tial responses of the two social phobia subtypes to
treatments has only begun to be examined (Heimberg
et al., 1993).
Comorbidity and Sequelae
Clinical Correlates
In the study of social phobia and anxiety disorders in
general, the issue of comorbidity is essential to under-
standing the underlying risk factors, the relationships
among anxiety symptoms, the developmental continuities
and discontinuities, and the validity of the major anxiety
syndromes themselves (cf. Albano et al., 1996). Because
comorbid disorders in childhood tend to occur more
often than ‘‘ pure ’’ diagnostic profiles (e.g., Anderson,
Williams, McGee, & Silva, 1987), it is difficult to draw
meaningful conclusions about the characteristics of any
particular childhood anxiety syndrome without consider-
ation of the comorbid disorders, their potential influ-
ences, and their underlying latent constructs (cf. Lilien-
feld, Waldman, & Israel, 1994). Along these lines,
research on the nature and temporal relationships of
social phobia and comorbid conditions may inform
prevention and intervention efforts geared at the primary
and additional disorders at critical developmental time
periods.
A consistent finding of research focused on youth with
social phobia are high rates of comorbidity among social
phobia and other anxiety disorders and mood disorders
(Beidel, Turner, & Morris, 1999 ; Brady & Kendall, 1992 ;
Last et al., 1992 ; Strauss & Last, 1993). For example,
using DSM-III-R criteria, Strauss and Last found 66 %
of social phobic youth met criteria for additional anxiety
disorders, and 17 % had an additional affective disorder.
More recently, Beidel et al. reported comorbidity rates
using DSM-IV criteria in a sample of social phobic
children ages 7 to 13 years (mean l 10n1). Sixty per cent
of these children had an additional Axis I diagnosis, of
which 36 % were anxiety disorders. The highest comor-
bidity rates were for generalized anxiety disorder (10 %),
ADHD (10 %), and specific phobia (10 %). Selective
mutism was diagnosed in 8 % of the sample, while
affective disorders were present in 6 %. The relatively low
rate of affective disorders may reflect the young age of
this sample ; that is, adolescent samples typically show
higher rates of comorbid mood disorders. In addition to
studies documenting the types of comorbid conditions,
the number of disorders co-occurring with social phobia
are of interest. Albano et al. (1996) described a sample of
138 clinic-referred youth in which 30 % received a DSM-
III-R principal diagnosis of social phobia (ages 8–17). Of
the children diagnosed with social phobia, 29 % received
no additional diagnosis, 26 % received one additional
diagnosis, 26 % received two additional diagnoses, and
19 % received three or more diagnoses. The most frequent
comorbid diagnoses with this social phobic sample were
overanxious disorder (43 %), simple phobia (26 %), and
mood disorder (19 %). Social phobia often precedes the
development of comorbid conditions. Wittchen et al.
(1999) report that social phobia precedes 85n2 % of
comorbid substance abuse disorders, 81n6 % of the
depressive disorders, and 64n6 % of other anxiety dis-
orders, with the exception of specific phobia, which
likewise onsets at earlier ages. Of interest, research
suggests that individuals who develop major depression
prior to the onset of social phobia have a significantly
better chance of recovery than those who report an onset
of depression following the social phobia (DeWit,
Ogborne, Offord, & MacDonald, 1999). Overall, the
aforementioned studies suggest that youth with social
phobia are significantly compromised by a complex and
severely disabling comorbidity pattern that extends well
into adulthood.
Sequelae of Social Phobia
Children and adolescents with social phobia fear a
range of situations and activities including speaking,
eating, writing, or performing in front of others, initiating
or maintaining conversations, attending parties and after-
school activities, speaking to authority figures, acting in
an assertive manner, and informal social situations
(Beidel et al., 1999 ; Hofmann et al., 1999). In addition to
the clinical comorbidities of social phobia, affected youth
 SOCIAL PHOBIA
suffer from high levels of dysphoria, loneliness, and
general anxiety (Beidel, 1991 ; Beidel et al., 1999 ; LaGreca
& Lopez, 1998). Children with social phobia (ages 7 to 14
years) are found to have impaired social skills relative to
nonanxious controls (Beidel et al., 1999 ; Spence,
Donovan, & Brechman-Toussaint, 1999). High levels of
social anxiety exert a negative impact on the interpersonal
functioning and perception of friendships and social
support in adolescents (LaGreca & Lopez, 1998). Both
males and females reporting high levels of social anxiety
felt less accepted and supported by peers, and also less
romantically attractive to others. Moreover, adolescent
girls with high levels of social anxiety appeared more
severely compromised than their peers, by reporting
having fewer close friends, and perceiving these friend-
ships as lower in intimacy, companionship, and social
support than the friendships of girls with lower levels of
social anxiety. These findings suggest that social anxiety
may interfere specifically with the development of close
interpersonal relationships, especially for girls.
Although the social psychologist Philip Zimbardo
conducted his work with shy adolescents (not diagnosed),
his data indicates that shy youth are at risk for suicidal
attempts (see Zimbardo & Radl, 1981). The relationship
of social phobia to suicidal ideation or attempts in youth
has not yet been directly studied, yet social phobia in
adults is associated with increased suicide attempts
(Davidson, Hughes, George, & Blazer, 1993 ; Rapee,
1995). Over the long term, social phobia is associated
with a number of personal costs for affected individuals
and their support systems, including impairments in role
functioning and quality of life (cf. Forthofer, Kessler,
Story, & Gotlib, 1996 ; Kessler, Foster, Saunders, &
Stang, 1995). As with other severe psychiatric conditions,
social phobia is associated with failure to complete high
school in females, and failure to enter and complete
college in males and females (Kessler et al., 1995).
Educational success is critical for career and vocational
achievement, financial security, and the development and
maintenance of a healthy lifestyle and wellbeing
(Henderson & Zimbardo, in press ; Kessler et al., 1995).
Beyond costs at the individual level, truncated edu-
cational attainment is associated with a number of
adverse life-course and societal consequences including
less training of the workforce, decreased participation
and functioning in civic activities, and greater demands
on the social welfare system (see Kessler et al., 1995).
Thus, the potential consequences of the disorder are
broad, impacting the emotional, occupational, and social
functioning of the individual over the long term, with
individuals suffering functional impairments in the areas
of school, social relations, family life, and employment
(Kessler et al., 1995 ; Schneier, Johnson, Hornig,
Liebowitz, & Weissman, 1992 ; Weiller, Bisserbe, Boyer,
Lepine, & Lecrubier, 1996).
To summarize, social phobia places a child or ado-
lescent at risk for long-term problems with education,
employment, social relationships, and independent adult
functioning, in addition to suffering with comorbid
conditions such as depression or substance abuse. Youth
with social phobia are in need of early identification and
effective intervention. The proper treatment of affected
youth holds implications for arresting the anxiety process
and fostering appropriate developmental growth and full
functioning status. In the following section we describe
the current status of treatments for social phobia in
youth.
135
Treatment of Social Phobia in Youth
Cognitive-Behavioral Treatment
Treatment from the cognitive-behavioral perspective
assumes that social anxiety is a normal and expected
emotion. Problematic social anxiety is that which exceeds
expected developmental levels resulting in significant
distress and impairment at home, school, and in social
contexts (Albano et al., 1996 ; Kazdin & Weisz, 1998).
Anxiety is assumed to be a tripartite construct in terms of
etiological mechanisms and phenomenological expres-
sion, involving physiological, cognitive, and behavioral
components (see Barlow, 1988). Cognitive behavioral
treatment (CBT) involves specific psychoeducation, skills
training, exposure methods, and relapse prevention plans
for addressing the nature of anxiety and its components.
Psychoeducation provides corrective information about
anxiety and feared stimuli ; somatic management tech-
niques target autonomic arousal and related physio-
logical responses ; developmentally appropriate cognitive
restructuring skills are focused on identifying malad-
aptive thoughts and teaching realistic, coping-focused
thinking ; exposure techniques involve graduated, sys-
tematic, and controlled exposure to feared situations and
stimuli ; and relapse prevention methods focus on con-
solidating and generalizing treatment gains over the long
term.
A number of studies have examined the efficacy of CBT
for childhood anxiety disorders as a group, which
includes avoidant disorder or social phobia, separation
anxiety disorder, and generalized anxiety disorder (e.g.,
Barrett, Dadds, & Rapee, 1996 ; Flannery-Schroeder &
Kendall, in press ; Kendall, 1994 ; Kendall et al., 1997 ;
Kendall & Southam-Gerow, 1996). These studies each
examine Kendall’s Coping Cat program for young people
ages 8 through 13, although adaptations of the program
were made for the Barrett et al. study. In the first study
(Kendall, 1994), 47 children between the ages of 8 and 13
years were randomized to either the CBT program
(Kendall et al., 1992) or a wait-list control condition. In
addition to improvements on self- and parent-report
measures, 66 % of treated children evidenced complete
remission of their primary anxiety diagnosis at post-
treatment. Results were maintained at 1-year follow-up.
In a further 2- to 5-year follow-up study (mean l 3n5 yrs),
36 treated children were reassessed and gains were
maintained on self-report, parent-report, and diagnostic
interview measures (Kendall & Southam-Gerow, 1996).
Similar results were obtained in a second, randomized
trial (Kendall et al., 1997). Ninety-four children ages 9–13
years were randomized to the CBT protocol or a wait-list
condition. Over 50 % of treated youth were free of their
primary diagnosis at post-treatment, with significant
reductions in clinical severity for youth remaining symp-
tomatic. Gains were maintained at 1-year follow-up, with
the majority evidencing greater gains over time. Other
investigators have also demonstrated efficacy for CBT in
group format (Cobham et al., 1998 ; Flannery-Schroeder
& Kendall, in press ; Silverman et al., 1999) with samples
including avoidant or social phobic youth.
Beidel and colleagues (Beidel, Turner, & Morris, in
press) caution that although promising, it is difficult to
generalize results gained from mixed diagnostic samples
to outcomes for social phobia in particular. These authors
identify diagnostic issues (i.e., the inclusion of avoidant
disorder), less stringent control conditions, and the failure
136 O. N. VELTING and A. M. ALBANO
to include measures specific to assessing the construct of
social phobia as limiting the generalizability of results. In
contrast to general programs, two promising and develop-
mentally appropriate programs have been developed
specifically to treat social phobia in children and ado-
lescents.
Social Effectiveness Therapy for Children (SET-C ;
Beidel & Turner, 1998) is appropriate for youth ages 8
through 12 and involves 24 treatment sessions held over a
12-week period. Each child participates in one group
social skills training session and one individual exposure
session each week, with structured homework assign-
ments serving to promote generalization of the within-
session experience to the child’s real life. The SET-C
program involves same-age peer helpers, recruited from
the community, to afford youth a credible, in vivo
exposure to practice and refine social skills and anxiety
management techniques. Beidel and colleagues (in press)
report outcomes for 67 children randomized to either
SET-C or a psychotherapy control condition (a non-
specific treatment for test anxiety). At post-treatment,
67 % of the SET-C group did not meet diagnostic criteria
for social phobia, as compared to 5 % in the control
condition. Children treated with SET-C were also signi-
ficantly improved on multiple dimensions, including
improved social skills, reduced self-reported social anxi-
ety and fear, and increased social interactions. Treatment
gains were maintained at 6-month follow-up. The in-
clusion of an active treatment control condition rep-
resents an improvement in design over other studies,
although an evaluation of treatment credibility was not
included in the Beidel study.
Based upon the success of Cognitive Behavioral Group
Treatment for adult social phobia (Heimberg, Dodge,
Hope, Kennedy, & Zollo, 1990 ; Heimberg, Salaman,
Holt, & Blendell, 1993), Albano and colleagues adapted
the protocol (CBGT-A) for adolescents ages 13 through
17 (Albano, Marten, Holt, Heimberg, & Barlow, 1995).
CBGT-A involves 16 group sessions incorporating psy-
choeducation, skills training (cognitive, social, and prob-
lem solving), and behavioral exposures. Preliminary
testing of the protocol proved promising with five
adolescents (Albano, Marten, et al., 1995), prompting a
randomized clinical trial. Although the trial is still in
progress, 27 youth (ages 13 to 17 ; mean l 14n67 ; SD l
1n44), through random assignment, participated in either
CBGT-A with four sessions of parent involvement, or the
protocol without parental involvement. Tracey et al.
(1999) report preliminary results suggesting that there
were no significant differences between groups, such that
the parental component may not be necessary in the
treatment of adolescents. There were significant changes
from pre-treatment to post-treatment and 6-month
follow-up for all youth, with independent diagnosticians
rating the youth as significantly improved following
treatment, with 70 % of the youth no longer meeting
diagnostic criteria for the disorder. Self-reported social
anxiety also decreased over time, in addition to a
reduction in the number of situations rated as signifi-
cantly fear producing and prompting behavioral avoid-
ance.
In an independent evaluation, Hayward and colleagues
(2000) present a preliminary evaluation of the CBGT-
A protocol delivered without parental involvement to
adolescent girls. At immediate post-treatment, 12 ado-
lescent girls treated with the CBGT-A protocol dem-
onstrated significant reductions in self-reported social
anxiety and clinician-rated impairment as compared with
a wait-list control group (N l 23). As compared with
control subjects, a significant proportion of treated youth
were diagnosis free at post-treatment. However, at 1-year
follow-up there were no differences by treatment condi-
tions. Subjects were free to access community treatments
during the follow-up phase, although these treatments
were not systematically coded. Moreover, there was a
trend for the treated youth to have a lower risk for
developing major depressive disorder during the follow-
up period, particularly when there was a prior history of
depression. Thus, combining social phobia and major
depression as the outcome produced significant and more
robust effects for the treated group at the 1-year follow-
up. These results suggest that CBGT-A may provide a
more general protection against conditions of negative
affect or the clinical sequelae of social phobia, and call for
a test of the protocol with credible treatment control
conditions, a longer treatment phase, and\or planned
maintenance sessions.
Pharmacotherapy
The study of pharmacologic treatments for social
phobia has traditionally lagged behind that of other
anxiety disorders. Liebowitz and Marshall (1995) at-
tribute this to the symptoms of social phobia being
viewed as a normal variation of personality or shyness, or
as a narrowly defined phenomenon akin to circumscribed
performance anxiety. For these reasons and because
social phobia itself was not introduced into the DSM
until 1980, the typical symptoms of social anxiety were
traditionally treated in psychotherapy (cf. Liebowitz &
Marshall, 1995). Fortunately, the study of pharmaco-
logical treatments for social phobia in adults burgeoned
with the introduction of DSM-III. To date there is
demonstrated efficacy in adults for the MAOI phenelzine,
the SSRI paroxetine, and the benzodiazepine clonazepam
(Van Ameringen, Mancini, Farvolden, & Oakman, 1999).
Beta-blockers have been used in the treatment of adult
performance anxiety, but there is no controlled data to
support their use in pediatric samples (see Labellarte,
Ginsburg, Walkup, & Riddle, 1999). At present, general
consensus is that the first-line treatment of choice rests
with the SSRIs, with paroxetine approved for use in
social phobia (see Van Ameringen et al. for a review).
Attention is just turning to the evaluation of pharma-
cologic agents for the treatment of social phobia in youth,
and anxiety disorders in general for this population.
SSRIs are demonstrating the most promise in treating
anxiety in youth. Birmaher et al. (1994) evaluated
fluoxetine in an open-label study with 21 children (ages 11
to 17) with overanxious disorder and comorbid sep-
aration anxiety disorder or social phobia. Moderate to
marked improvement was evident in 81 % of youth after
6 to 8 weeks of treatment. Similarly, Manassis and
Bradley (1994) reported a decrease in anxiety symptoms
after 6 weeks of open-label fluoxetine treatment in 5
children aged 5 to 11 years.
Only two studies directly addressed social phobia or its
variant, selective mutism. A 12-week double-blind,
placebo-controlled study of fluoxetine in 15 children with
selective mutism demonstrated significant improvement
on parental ratings of anxiety and mutism in the treated
group (Black & Uhde, 1994). More recently, Mancini,
Van Ameringen, Oakman, and Farvolden (1999) re-
 SOCIAL PHOBIA
ported on a series of seven youth ages 7 to 18 years
successfully treated with a variety of serotonergic agents.
In response to the dearth of controlled pharmacologic
trials, the National Institute of Mental Health has
established the Research Units in Pediatric Pharma-
cology (RUPP), a division focused on the controlled
evaluation of psychotropic medications for use in chil-
dren younger than 18 years of age. RUPP investigations
focus on testing the efficacy of specific compounds for the
range of emotional and behavioral disorders in youth. In
the first completed RUPP anxiety trial, 128 youth (ages
6–17) with primary diagnoses of social phobia, separation
anxiety, or generalized anxiety disorders were randomly
assigned to receive fluvoxamine (FLV) or placebo for 8
weeks of double-blind treatment. Subjects were assessed
using self, parent, and clinician rating on anxiety symp-
tom rating scales and measures of global improvement.
Children on FLV were significantly more improved on
multiple outcome measures of anxiety and impairment.
Specifically, 48\63 (76 %) of children responded to FLV
compared to 10\65 (29 %) of children on placebo. Parent
and child self-reports also demonstrated the superiority
of FLV over placebo but the results were less robust than
those based on clinician’s ratings (Vitiello, for the RUPP
Anxiety Study Group, 2000). This study supports short-
term efficacy but does not inform about the maintenance
treatment with SSRIs, nor long-term benefit after medi-
cation discontinuation. In general, most pediatric psy-
chiatrists will agree that treatment of anxious youth
should begin with, or be initiated in conjunction with,
CBT. It is unusual and not recommended for medication
to be considered as the sole treatment for anxious youth
(American Academy of Child and Adolescent Psychiatry,
1997). Upon completion of preliminary studies evaluating
the efficacy of pharmacologic agents, a next step is the
conduct of randomized, controlled clinical trials exam-
ining the comparative efficacy of medication treatment,
CBT, and their combination in the treatment of youth
with social phobia.
Conclusion
Social phobia, once called ‘‘ the neglected anxiety
disorder, ’’ has proven itself to be a chronic and debilit-
ating condition that onsets early and can extend into
adulthood. Exciting and essential research efforts are
under way, bringing together scientists from different yet
interrelated disciplines to understand the psychological
and pathophysiological pathways to social phobia. Such
efforts will aid in our understanding of risk and protective
factors for the disorder, and serve to inform primary
prevention efforts developed for both universal and
targeted programs, along with refining our continuing
intervention efforts. Similarly, research focused on delin-
eating the symptoms and associated clinical sequelae of
social phobia, from studies of subtyping to those eluci-
dating the broad functional impairment of affected youth,
will likewise guide future intervention efforts. The field is
poised to evaluate and test specific treatment algorithms
for youth presenting with certain symptom and im-
pairment patterns, and to thus inform front-line clinicians
on the best course of cognitive-behavioral therapy,
pharmacotherapy, or their combination. The ultimate
goal of these efforts are to increase the quality of life of
affected youth, by providing them with the means to
overcome this debilitating condition and engage in
137
everyday activities by choice, rather than avoid them due
to fear.
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Manuscript accepted 11 September 2000