Social phobia in very young children often is seen as a closely related disorder: selective mutism.
SELECTIVE MUTISM
Lydia was an enchanting child—pretty, beautifully dressed, exceptionally bright. At the age of five she was already reading quite well. Her parents brought her to see me because most of the time Lydia did not speak. She could speak. She talked to her parents and to her brother a little, and once in a while she spoke to her grandparents. She read aloud. But otherwise she didn’t talk—even to respond to direct questions—and she never participated in sharing or “show and tell” at school. Neighbors, relatives, schoolmates, and teachers had been expressing their concern and their irritation. Her teacher was worried about passing her on from kindergarten to first grade.
At nine years old Alice had been going to school for several years, but she hardly ever talked. She had one friend to whom she’d occasionally whisper. When she had no other choice but to speak to her teacher, she would get up close and speak softly into her ear. Alice’s parents had been taking her for therapy for a couple of years. Every week for two years she’d go in and whisper to her therapist. The week before I saw Alice, the school had sent a letter home to the parents: “There’s a real problem with Alice,” it read. “We can’t really evaluate what she knows and what she doesn’t know. What’s even more important is that Alice is incredibly uncomfortable all of the time.”
A child’s failure to speak—called selective mutism—has many possible explanations. It could be perfectly normal shyness; many five-year-old kids aren’t crazy about chatting with strangers. It could be the result of a traumatic experience, such as physical or sexual abuse, but that connection is very rare. It might be caused by a problem with language; there is a higher than average incidence of selective mutism among children of non-English-speaking parents and among kids who have a developmental speech delay or a learning disability. Children who stutter sometimes decide not even to try to speak.
The most common cause of a child’s failure to speak is anxiety. Children who are selectively mute are, quite simply, too anxious and nervous to talk in front of others. For that and other reasons selective mutism (sometimes called elective mutism) may be regarded as a symptom, or at least a first cousin, of social phobia.
THE SYMPTOMS
Social phobia is divided into two general types. Type one is generalized, an anxiety marked by the avoidance of most daily social interactions. Eric, the child hiding under his bed, described at the beginning of this chapter, has the symptoms of generalized social phobia. Just about anything that involves other people makes Eric anxious.
Type two social phobia is characterized by discomfort in and the avoidance of specific situations, such as speaking in public, using public lavatories, and eating, writing, or speaking in front of others. (This is a form of pathological performance anxiety.) With type two, the phobia isn’t generalized; in fact, there may be just one situation that brings on anxiety. A college student I treated a few years ago was normal except for his terrible fear of using a public bathroom. He eventually had to move out of the dorm and into his own apartment because of it. When we talked about it, all he could say by way of explanation was: “I’m afraid someone will walk in on me.” A junior high school girl was fine too except for her fear of being called on in class. “I have the feeling that I won’t know the answer and I’ll say something stupid,” she told me. She would rather take a zero in class participation than respond to her teacher.
Communicating with some of these troubled children, especially the young ones, can be quite a problem. The difficulties with the kids who are selectively mute are obvious; we’re lucky to get them to speak at all. I’ve interviewed a five-year-old who did nothing but grunt and moan in response to my questions. One of my colleagues is treating a little girl through her father; the father does all her talking for her. It’s not at all unusual for these youngsters to have appointments and not show up. When the time comes to interact with a new person, they just can’t do it. What’s more, the very young children who do show up and do speak are not skilled at articulating the distress and dysfunction associated with social phobia. We’re not likely to hear, for instance, any version of, “Doctor, I’m afraid to answer questions in class because I’ll be embarrassed and humiliated by my peers” from a child with social phobia until he’s well into adolescence, if then.
Even when the kids are in their teens and very smart, talking to them is often like pulling teeth. I was treating a 16-year-old boy who was on the cusp of being a genius. He had a very high IQ, and he was a whiz at math and computers. Socially, however, he was completely lost; the only people he could converse with were his sister and his mother.
When kids are capable of communicating, they may not be willing to communicate; they’re reluctant to acknowledge, let alone describe the nature of, their symptoms. Many of them will dismiss symptoms as being nothing to worry about. An 18-year-old boy named Eugene was virtually dragged in to see me by his mother. He was finishing the first semester of his freshman year away at college, and his mother thought—correctly in my estimation—that he was having some serious problems. He’d been quiet and withdrawn his whole life, she told me in front of her son, but this year he’d gotten worse. All alone in his new school, Eugene hadn’t spoken to a soul in over a month.
For the first half-hour I couldn’t get any response out of Eugene at all. Eventually he told me, haltingly and with no eye contact: “I don’t know why my mother’s making such a big deal out of this. So I don’t speak in class. So I don’t talk to people. I just don’t have anything to say.”
Children later diagnosed with social phobia come to see me for three main reasons: they don’t speak, they don’t go to school, and they have no friends. In many cases these problems have existed for quite some time, but something has happened to make the situation intolerable. For example, one young woman’s social phobia caused her to drop out of college. First she dropped an American history class because she was asked to make an oral report. The moment she stood in front of the class, she started sweating and felt light-headed. After reading only three lines of her report she had to sit down; she was sure she was going to faint. Then she dropped biology because of the lab work; it meant interacting with other people, and she just couldn’t deal with it. She finally got so anxious that she dropped out of school completely. Other adolescents who have been suffering for some time may be brought in by their parents because they’ve started using drugs and alcohol to ease their anxiety. By the time they reach me, many young people with social phobia show symptoms of other related disorders. Studies show that some 50 percent of people with social phobia will have other anxiety disorders, and many others will eventually require treatment for depression.
THE DIAGNOSIS
Making a diagnosis of generalized social phobia is not always easy. Sifting through the underbrush of family troubles, extraneous symptoms, and other facts that occasionally clutter up the diagnostic landscape can be quite challenging, particularly if the child has been sick for some time. Penny, a 16-year-old high school senior, came to me because her homeroom teacher told the parents that there was a problem. Penny was acting strange in class—a little “nutty,” her parents called it. According to the teacher, she almost never spoke in class, but she would often giggle uncontrollably, sometimes so much that she disrupted the class. (It’s not unusual to hear complaints about the behavior or the attitude of children with social phobia. Many of them, especially the young ones, come off as rude and defiant.)
As I learned during our first visit, Penny had other symptoms as well: frequent urination, depressive complaints, and some anxieties. There were some conflicts at home too. Penny’s parents were in the process of getting a divorce, and her sister was quite ill. It took me some time to explore the issues of anxiety with Penny, distracted as I was by the family crises. But when I did get her to talk about what she was worried about, I discovered that she was a mass of fears and anxiet
ies. Even getting on the school bus every morning scared her. “I’m nervous about saying hello to the bus driver,” she told me. “I might say it wrong and sound really stupid.”
Symptoms related to social phobia must be carefully assessed before a diagnosis is made. Taking a history from the child himself is only the beginning. Besides, we can’t always count on what the youngsters report, because they’re usually nervous about making a bad impression—one of the key factors in social phobia. We make it a point to get a detailed history from the child’s parents and teachers. Teachers are not always ideal sources of information either. Some children with social phobia are completely ignored by teachers. After all, they sit quietly—very quietly—in the back of the classroom, not bothering anybody. They appear shy or withdrawn, as if they’re watching the scene rather than participating in it. Sometimes they’re perceived as being stuck up or judgmental, but it’s fear that keeps them from taking part in the action. They don’t want to say or do anything that will get them into trouble. The disruptive disorders are the ones that usually get a teacher’s attention.
In making a diagnosis for social phobia we have to rule out other diseases with similar symptoms, especially separation anxiety disorder (described in Chapter 9), obsessive compulsive disorder (Chapter 8), and generalized anxiety disorder (Chapter 11). Schizoid disorder must be ruled out as well. A teenager sits at the table at a large family holiday dinner. She doesn’t socialize with her cousins or the other guests and leaves the table as quickly as possible. The behavior could be that of an adolescent with schizoid disorder, a chronic condition that may start in late adolescence and is characterized by detachment and limited interest in others, or these could be the actions of someone with schizophrenia (Chapter 16). If the girl is silent and withdrawn because she’s convinced that she will say something stupid, she has social phobia. It’s important to note that people with schizoid disorder are not uncomfortable or anxious in social situations; they just have peculiar interactions. In the case of schizophrenia the youngster will be anxious and nonresponsive with everyone, while the girl with social phobia may be a chatterbox with her parents once the dinner guests go home.
Another important distinction is in the patient’s desire to get well. People with social phobia aren’t comfortable with their disorder; they want to go to school, speak out in class, and play with their friends. They’d like to go to a birthday party without being terrified of looking silly. They know they’re in pain, and they want to feel better.
Psychiatrists look for—and frequently find—signs of depression (see Chapter 14) associated with social phobia. In the course of a recent study of adolescent depression it was discovered that 47 percent of the children with depression also had an anxiety disorder, most often either separation anxiety disorder or social phobia. Of those adolescents 84 percent had the anxiety disorder before the depression. What the study did not say was whether the connection between anxiety disorders and depression is biological—that is, dictated by brain chemistry—or causal. Perhaps social phobia, and the social isolation it usually brings, contribute to depression.
Social phobia is underdiagnosed and undertreated. Parents often wait a long time—too long—before seeking professional help for their kids with social phobia. “He’s just shy. He’ll outgrow it,” is their perfectly reasonable response. They resist going to a child psychologist or psychiatrist because they’re afraid, quite naturally, to find out that their child’s behavior is not quite normal. “We’ve waited six months. Let’s wait a year.” “We’ve waited a year. Let’s wait another six months.” So goes the typical reaction of parents who are faced with a child who is not getting better.
I encountered some parents who said exactly that for nearly three years while their daughter got progressively sicker. Rita was seven when I first saw her. For two years and nine months the only people Rita had spoken to were her mother, her grandmother, and two of her four siblings. She had barely said a word to her teacher or to any of her classmates since the first day of nursery school, but she’d recently started mouthing words to her teacher. In fact, this concerned teacher was the reason Rita finally made it to my office. At a recent parent-teacher conference she sat the mother and father down and told them to take Rita to see a professional or else. “We’re very worried. You have to deal with this. You are neglecting your daughter,” she said sternly. Mom brought Rita to see me, of course, but she didn’t accept the teacher’s assessment of the situation. “Rita’s really much better,” said the mother. “She’s mouthing words to her teacher now. And last week I think she whispered something to her cousin.” Parents, feeling protective of their child, become defensive and may have a hard time accepting negative reports from the school.
THE BRAIN CHEMISTRY
Certain children are born with a genetic predisposition for social phobia. In plain English: excessive shyness runs in families. Supporting this theory is the fact that if one twin has social phobia, the other is more likely also to have it if he or she is an identical twin (with the same genetic makeup) rather than fraternal (with similar but not identical genes)—even if the twins are raised apart. Children adopted at an early age show a great similarity to their biological mothers on ratings of shyness. Parents of behaviorally inhibited children, kids who are fearful or withdrawn in new or unfamiliar situations are much more likely to have social phobia or to have had the disorder as children than are parents of normal or uninhibited youngsters.
What specific brain chemistry do children with social phobia have? As always, we can’t be sure, but we can make an educated guess. Most probably the brain has too much norepinephrine and not enough serotonin. Certainly the effective medication for this disorder supports that theory. The medications that are most useful in the treatment of social phobia are the MAOIs (monamine oxidase inhibitors) and the SSRIs (selective serotonin reuptake inhibitors), both of which have an impact on norepinephrine and serotonin. TCAs (tricyclic antidepressants) have no effect on this disorder.
The animal model adds support to the argument. Studies done with rhesus monkeys have been able to identify two different behavioral styles—laid-back or uptight—and to determine that the uptight monkeys have a different brain chemistry from those who are laid-back. When given an SSRI, the uptight monkeys become more sociable and more comfortable, more like their laid-back fellow monkeys.
There’s some evidence that with social phobia “nurture” plays a part as well as “nature.” The basic assumption is that infants come into the world with a predisposition for anxiety. After that, any of several scenarios are possible. For example, a temperamentally inhibited infant is very reactive and hard to comfort, and a parent may find this distressing and be less attentive. The lack of attention affects the parent-child relationship, of course, and it may make the child insecure and less inclined later on to participate in other social contacts. To take another example, a shy mother or father with a shy infant is less likely to expose that child to social situations, so the child never learns to be comfortable socially. His parent, not wanting to cause the child discomfort, continues to “protect” him from the outside world. In both of these examples the children, with limited social experience, become even more anxious.
THE TREATMENT
A five-year-old boy being treated for selective mutism is making progress, but it’s slow, very slow. So far the treatment has consisted only of behavioral therapy, mostly directed toward modifying the boy’s behavior in school. His teacher is working with us on a program by which the child is rewarded with stars and stickers for communicating. The first step was a yes or no answer to a direct question. Step two required more than one word as an answer. Now, three months after the treatment began, there are lots of stars and plenty of stickers but no qualitative gains. The child is still uncomfortable and largely dysfunctional; his teacher said he looks pained all the time.
We give the boy a small dose of Prozac, much smaller than the customary dose—about a quarter of a teaspo
on, or 5 milligrams, in liquid form from a dropper each day—and continue the therapy. Within a month the boy is communicating easily with everyone. “He became a different person almost immediately,” his mother said. “He’s talkative, he’s friendly, and he feels at ease.” Six months later we discontinued the Prozac, and the boy continued to be fine.
There’s no such thing as a “good” brain disorder, but if there were, social phobia would be it. With active treatment social phobia can be cured. Behavioral therapy is an effective and necessary part of the treatment of social phobia, but because of the nature of the disorder—the patient is afraid to interact with and be judged by other people, including psychiatrists and psychologists—it is almost always a good idea for the child to be medicated as well. (Sometimes medication is all that a child with this disorder needs. I’ve seen it happen many times.) Medicine alleviates a child’s anxiety so that he can benefit from the behavioral therapy. Most of the children we treat for selective mutism and social phobia simply couldn’t do the work without the medication.
The first line of medication treatment used for children with social phobia and selective mutism is the SSRIs, specifically Prozac, Luvox, and Zoloft. With their minimal and infrequent side effects (occasional nausea, weight loss, restlessness, drowsiness, moodiness, and insomnia), these medicines are the drugs of choice. Also effective are the antianxiety agents, such as Klonopin, Xanax, and BuSpar. Klonopin and Xanax work fast and are quite effective in reducing the anxiety children experience before certain events. The most common side effect is drowsiness.
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