Dr Jacqueline Sperling Hello, I’m Dr Jacqui  Sperling. I’m faculty at Harvard Medical School, a   Clinical Psychologist, the Co-Program Director of  McLean Anxiety Mastery Program at McLean Hospital,   and the author of “Find Your Fierce How to Put  Social Anxiety in Its Place.” Today, I’m going to   be talking about social anxiety in children and  adolescents, what it is, and how to treat it. So, as I mentioned, I wrote a book called  “Find Your Fierce How to Put Social Anxiety   in Its Place,” it was published by the American  Psychological Association’s Magination Press. The   examples are geared to the young adult population,  but the tools apply to a broader range of ages. So, what are we going to talk about today? What  is social anxiety? And what’s the treatment   for it? So, as humans, we are wired to connect  and care about what others think of us. Social   anxiety goes above and beyond that care, and it  becomes this fear of being judged or embarrassed,   more so around peers than just around adults,  if one’s a child or an adolescent. And this   fear starts to get in the way of everyday  activities, and in order to meet criteria   for social anxiety disorder, the interference  has to be happening for at least six months. Sometimes social anxiety may focus on activities  that just have to do with performance, such as   giving speeches in class, and other times, it  can show up in a broader range of activities,   and I’ll give examples of some of those activities  in a moment. Before I do that, I also want to   mention how common social anxiety is. So, anxiety  disorders are the most common mental illnesses,   and social anxiety is the second most common  anxiety disorder next to a specific phobia,   such as a fear of needles. So, even though one may  feel really alone, because it’s not necessarily   visible on the outside, such as if someone needs  glasses, and the child is definitely not alone.   So, for example, if a teen has 400 people  in their class at school, that means about   36 of them have social anxiety disorder, given  the prevalence, they’re definitely not alone. So, as I mentioned, I was going to give some  examples of how social anxiety might show up,   and this list is not exhaustive. So, someone with  social anxiety may have difficulty eating in front   of others, and that may be because they’re worried  about making a mess, making loud noises when they   eat, or worried about having food stuck in their  teeth. They also may worry about being judged by   the kinds of foods that they’re eating. They  also may worry about using public restrooms,   and that may be because of making noises in  front of other people, or just being vulnerable   in a public space. Ordering at restaurants may  be difficult, and that may depend on the type   of restaurant, or it could be across all types of  restaurants, whether it’s sit-down, fast, casual. Participating in class also may be difficult, but  that may depend on whether one knows the answer,   if it’s a favourite class, how supportive  one finds the peers in their class,   if a class is harder, if a class is easier, if  there are group-based activities or individual   activities. Participating in extracurricular  activities also can be a challenge,   and that may be because there’s a concern  about performing in front of others,   or letting the team down. And speaking  in front of groups may be difficult,   whether it’s giving a speech in class,  that also can show up in large gatherings,   such as birthday parties. Exercising in front  of others also can be a challenge, so PE or gym   class often may be avoided, and that may be  because of performing in front of others, or   it could also be because of a concern of showing  physiological symptoms, like blushing or sweating. So, as much as social anxiety can get in  the way, in the list that I just showed you,   there it treatment that can help. So, what  is CBT? CBT is based on the foundational   three-component model that thoughts, feelings and  behaviours are all connected, and you may notice   that the arrows go both ways. That means that  it doesn’t just start with a thought and then   affect a feeling and then affect a behaviour,  it could be that it starts with a behaviour,   that then affects a thought, and then  a feeling. And the treatment teaches a   child tools to address maybe one component or two  components or three components at a time. And if   you address one component at a time, it still  may affect and improve the other components. ERP is a specific type of CBT, and it involves  gradually approaching feared situations, without   using usual avoidance or safety behaviours. So,  the safety behaviour keeps the anxiety safe,   but it doesn’t keep the person safe, so that  may be a form of avoidance, such as, avoiding   eye contact when one is in social situations, or  having a friend with you every time you go to a   social situation, have your friend speak for  you, or just not going to social situations. With exposure and response prevention,  you practice going to these situations,   without any form of avoidance. And that  may sound really scary, but hear me out,   ‘cause there’s a way to do it gradually, as  one’s pace. So, imagine there’s a swimming pool,   not on a hot day, but on a chilly day. And if  were to say, “Hey, why don’t you jump in the   deep end?” You might say, “Hey, no thanks.”  That’s reasonable. What about if I asked you   to dip your big toe in the shallow end? And  you’d say, “Well, alright.” And so, if you dip   your big toe in the shallow end, how might that  feel at first?” Maybe a little chilly at first. And then after, like, 15 minutes, what  happens? Maybe you get used to it a little bit,   knowing that that you could do it. Okay,  so then, what would happen if I asked   you to dip your next toe in? You might say,  “Alright.” And then up – maybe because then   you’ll be willing to go up to your ankles,  and up to your knees, and up to your waist,   and then to your neck. And by the time you’ve  gone to your neck, if I were to say, “Hey,   would you be willing to dunk your head?”  What might you say? And you might say,   “Okay.” And because, why? And that’s because,  “Well, I’ve adjusted to the water and the rest   of my body learnt that I could do it, I’m  willing to dunk the rest of my body in.” And you got your whole body wet that way, you  could have gotten your whole body wet if you   jumped in the deep end, but that probably would  have felt like a shock to your system. In ERP,   you start with your big toe, and you go  as slowly as it feels feasible for you;   you go at your own pace. So, a child is the  expert on what their big toe is, and they will   go at their own pace, so the treatment’s  really collaborative and team-oriented.  And those create a fear hierarchy, the things they  fear the least to the things they fear the most at   the top. And it’s like leaning a ladder against  an office door, and if you start knocking off the   bottom rungs of the ladder, what happens to the  height of the ladder? Chu-chu-chu-chu-chu-chu. The   top of the ladder’s no longer as high, and  gets further down in height, and then it   feels more approachable. It’s like that deep  end of the swimming pool is no longer as far   away when you start easing yourself into it.  So, as someone starts gradually their fears,   they gain some momentum, and the things that  felt super scary at the top of their hierarchy,   or at the deep end of the swimming  pool, now may feel more approachable. So, before I get to how this treatment works,  I’m going to talk about a measurement system   that’s used in treatment, and we call it SUDS for  short, not soapsuds. It stands for Subjective,   how you feel, Units, because we’re measuring  it on a scale of zero to ten, of Distress,   and it’s a Scale, and, as I mentioned, because it  goes in incremental units by one point. And so,   you can imagine that zero is not feeling  distressed at all, and ten is the most distressed   one can feel. So, I often like to use examples to  illustrate how this feelings thermometer works. So, I might ask a child, “How would you feel,  if you’re sitting in comfortable clothing on the   couch, watching your favourite show while eating  your favourite snack?” And maybe you say, “Zero.”   And I would say, “Well, how would you SUDS be if  you had to sing your country’s national anthem   at a packed sports stadium?” Usually somewhere  upwards towards a ten, right? You can see there’s   a range. And we use this feelings thermometer to  help build that hierarchy that I mentioned, that   bravery ladder, and the things you fear the least  to the things you fear the most, to get a sense of   what is that way to gradually enter that swimming  pool or climb that ladder, for that child? And, as I mentioned, I’m going to talk about  the ERP model, so I’m going to talk about two   models. One is one that used to be used, and  one is one that we use now. And the reason   why I talk about both is, one, just to give  you a sense of how the models have evolved,   and, also, because if you’re going  to look for treatment for a child,   you’ll want to make sure that someone is  implementing the Inhibitory Learning Model. So, what’s the Habituation Model? The  Habituation Model uses this graph,   where on the X axis, or the horizontal line, is  time, and on the Y axis, or on the vertical line,   those are the SUDS. And so, using an example of  someone who’s afraid going to school, let’s say,   they get to the school door and their SUDS  are about a six, so a little bit more than   halfway. What might they have the urge to do?  Get out of there, right? And when they go home,   what happens to their SUDS? P-chu, done,  right? Phew, thank goodness I didn’t go to   that scary place. What do you think happens  when they go to the school door the next day   though? Are their SUDS higher, lower or the  same? If you said higher, you’re likely right. And why? Because the brain learnt, that’s a  scary place, I should not be going there. So,   when they get to the school door, what  do they have the urge to do? If you say,   “Run back home,” you’re likely right, get out of  there. And when they go back home, what happens to   their SUDS? P-chu. Thank goodness I didn’t go back  to that scary place, right? And then what do you   think happens when they get to the school door the  next day? If you said their SUDS are even higher,   you’re likely right, right? And then the cycle  continues, and the SUDS get higher and the SUDS   get higher, this really becomes a vicious cycle.  And then school really does become a scary place,   because the child’s behind in their work,  peers are starting to ask where they’ve been. So let’s pause, rewind, get back to that school  door and say, “What do you think might happen if   you actually stayed?” And if that person stays,  if you said that their SUDS might be a little   high at first, but then eventually go down, you  might be right. And why? Well, no-one can feel an   emotion forever, can’t feel anxious forever,  some thoughts and behaviours keep an emotion   going for a little bit longer, but you can’t be  any emotion – can’t feel any emotion forever. So, they also might learn that they could do it,  and so the next time they get to the school door,   what do you think happens? Are their SUDS higher  or lower or the same? If you said maybe lower,   probably right. And why? Because they  learnt that they could do it. And so,   actually, maybe it doesn’t take as long  to come down, and then the next time,   a little bit lower, and the anxiety  doesn’t take as long to come down.   And this process repeats and repeats  until anxiety is at a manageable dose. And we don’t want to get rid of anxiety  altogether, and you might be thinking, why   not? It’s wreaking havoc. And that’s because we  need some anxiety. All humans experience anxiety,   it’s a universal emotion. It helps us prepare for  things. Before you cross the street, what do you   do? Look both ways, if you didn’t, that would be  bad news. When a student has a test the next day,   what’s helpful to do? Study, it helps them  prepare for the test. We need some anxiety,   we just don’t need it to boss us  around. And the Habituation Model   is based on this premise that you more you  do exposures, the more your SUDS come down. Now, that would be great and relieving if that  happened, but what we’ve learnt is that actually   your SUDS don’t need to come down in order for  the exposures to work. What actually is at play   is the Inhibitory Learning Model. The Inhibitory  Learning Model is based on two possible outcomes   that can happen with exposures. The exposure  either wasn’t as bad as you thought it would be,   the expectancy violation, and/or you learn that  you could do it. So, even if it – your SUDS were   higher than you thought they would be, you thought  they’d be a six and they turned out to be an   eight when you do an exposure, you learn that you  could do it, that’s still a successful exposure. I’m going to use another analogy to demonstrate  how this model works. So, neurons are the cells in   your brain that talk to each other and communicate  with each other, and imagine they’re like cars,   and every time the body does a behaviour,  does something, the brain paves cement on   a highway. It learns something. So, when someone  gets to that school door and they avoid, the brain   starts paving cement on an avoid highway, and  the more that one avoids, the more cement gets   paved on this avoid highway, and the more often  those neurons start driving on that highway. How does the Inhibitory Learning  Model work with exposures? Well,   the exposures create a construction zone, and they  put up a “Do Not Enter” sign and show the neurons,   “Oh, wait a second, school’s not as bad  as I thought it would be,” or, “Oh well,   that was even harder than I thought it would be,  but do you know what? I learnt that I could do   it.” And the brain starts paving cement on  an approach highway. And the more that one   approaches or fear situation, the more the  cement gets paved on the approach highway,   and the more that the neurons or the cars  start driving on that approach highway. Now, here’s the thing. Highways can’t be  erased. The brain can’t unlearn a behaviour. So,   on stressful days or windy days, sometimes  that “Do Not Enter” sign gets knocked down,   and the neurons and the cars are like, “What’s  over here? Oh, do not go to school, avoid, avoid,   avoid,” and start driving on that avoid highway.  All is not lost, remember what I said, the brain   cannot erase highways. That approach highway is  still there. With extra practice, with exposures,   you can remind the brain, “Oh, put that “Do Not  Enter” sign back up. Oh, that’s right, school’s   not as bad as I thought it would be,” or whatever  the feared situation, it’s not as bad as you   thought it would be. Or, “Oh wow, that was as bad  as I thought it would be, and even harder maybe,   yet I still learnt that I could do it.” And  remind the cars to drive on the approach highway. So, I mention this because, as I mentioned, the  SUDS don’t need to come down in order for the   exposure to work. If you do the exposure, even  though your SUDS are higher than they thought   they would be, that’s a success. You’re  approaching something that was scary,   and learning that you could do it. And,  also, to remember, that the trajectory,   or the road to recovery, when treating anxiety,  is bumpy. And that – to show that, like,   some windy days or stressful days, that “Do Not  Enter” sign may be knocked down, and the cars may   drive on that avoid highway, all is not lost. You  can remind the brain about that approach highway. So, I’ve been talking about behavioural treatment,  and that’s not the only treatment out there,   there are other resources for support. So,  medication is another option. One class of   drug that’s been demonstrated to be helpful is  the selective serotonin reuptake inhibitors class,   and – or SSRIs, and I’ll be using another  analogy to demonstrate how they might be   helpful, and I like to talk about  professional basketball players. Now, they’re talented. They still have  to practice to keep up their skills,   right? They typically don’t practice  barefoot. So the practice is like the   CBT we’ve been talking about, and they  typically wear basketball shoes to give   ‘em a boost. The basketball shoes are like  medication, they give the players a boost. So,   combining the practice with the basketball shoes,  the CBT with the medication, can enhance treatment   outcomes, and one might find it helpful to take  medication, while also practicing CBT with ERP. There also are self-help books. I mentioned  the book that I wrote. It’s not the only   book out there. I have provided a link  that shares some other book resources,   and that’s not the only link available,   it’s just one suggestion. Know that there is a  range of options out there that can be helpful. If you know the child or adolescent that’s  been struggling with social anxiety,   remember that there are resources out there  that can help. And the first step that may   be helpful to accessing that may be for the  child to meet with a Paediatrician and the   Paediatrician can offer the family referrals  of resources available in the area. As much   as social anxiety can take over the whole  family and spill over into other settings,   such as school, there’s help  out there. Hang in there.