Abstract
The cognitive theory of social anxiety disorder (SAD) is one of the most widely accepted accounts of the maintenance of the disorder in adults, yet it remains unknown if, or to what extent, the same cognitive and behavioral maintenance mechanisms that occur in adult SAD also apply to SAD among pre-adolescent children. In contrast to the adult literature, current models of SAD in children mostly account for etiology and maintenance processes are given limited attention. Consequently, their clinical utility for the treatment of SAD in children may be limited. This narrative review, first, critically examines the different theoretical conceptualizations of the maintenance of social anxiety in the child and adult literature and illustrates how these have resulted in different treatment approaches and clinical understanding. Second, it reviews the available evidence relating to hypotheses about the maintenance of SAD in children as derived from adult cognitive and etiological models. Third, it highlights the need to attend directly to child specific maintenance mechanisms in SAD, to draw on cognitive theory, and to account for the influence of childhood-specific contextual (e.g. family and school-based interactions) and developmental factors on children's social experiences.
Highlights
Children with social anxiety disorder (SAD) were not significantly more likely than non-anxious children to believe that positive non-social or negative social/ non-social events were likely to occur (r 1⁄4 0.28, 0.32, and 0.13, respectively), indicating that the negative expectations of children with SAD may be specific to positive social events
Children with SAD were not more likely than anxious or non-anxious controls to rate ambiguous stories that included information about potentially frightening physical symptoms (e.g. “You can feel your heartbeat”) as threatening (r 1⁄4 0.42 and 0.51, respectively), providing no evidence for enhanced emotional reasoning. These findings indicate that children with SAD may associate negative consequences, such as embarrassment, with physical symptoms, but the experience of these symptoms does not necessarily lead them to change their interpretation of particular situations
Studies recruiting non-clinical and clinical populations suggest that the presence of high social anxiety or SAD is significantly associated with the use of Safety-seeking behaviors (SSBs), but no studies have examined this association in relation to other anxiety symptoms/ disorders
Summary
The most widely cited and well-established disorder-specific cognitive behavioral models of adult SAD are those of Clark and Wells (1995) and Rapee and Heimberg (1997) Both models propose that dysfunctional beliefs and assumptions provoke a person with SAD to appraise social situations as dangerous and to interpret social events in an excessively negative fashion (Clark & McManus, 2002; Clark & Wells, 1995; Heimberg, Brozovich, & Rapee, 2010; Rapee & Heimberg, 1997). Heimberg et al (2010) suggest that people with SAD fear and attend to any evaluation-related cues, whether they are negative or positive, rather than focusing on fear of negative evaluation
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