SingaporeMotherhood | Parenting
December 2024
Social Anxiety Disorder: Not Shy, Not an Introvert, Not Rude, just Overwhelming Fear in Social Settings
Caleb (not his real name) was in Primary 3 when he started to come home from school in tears. He seemed stressed, and avoided some of his friends. No one at home realised then that he had Social Anxiety Disorder. Covid came when Caleb was in P4, and the circuit breaker happened. The implementation of home-based learning meant he had little opportunity to meet up with his friends or socialise. It was a year later, when Caleb was in P5, that the symptoms emerged. When forced to by his parents, Caleb would drag himself to school. Otherwise he preferred to do nothing at home. His grades plummeted.
By the time Caleb was in P6, he would be easily agitated and angry. He threw tantrums, and was argumentative. “During the PSLE (Primary School Leaving Examination) his teacher had to come to our house to bring him to school for the exam,” his father said.
Caleb passed his PSLE and made it to Secondary 1. He made a promise to his parents that he would go to school everyday. But his emotions were triggered by a spate of bullying and name calling, and he started to avoid school again. On average, his father shared, Caleb was in school for three to eight days a month.
Behind Caleb’s behaviour: Social Anxiety Disorder
A psychiatric test revealed that Caleb had severe anxiety and mild depression, co-occuring conditions caused by Social Anxiety Disorder (SAD). As defined by the National Institute of Mental Health this mental health condition is characterised by an intense, persistent fear of being judged, embarrassed, or humiliated in social situations.
This fear can often lead to an avoidance of social interactions, which causes significant distress and can impair a person’s ability to function in daily life, whether in personal relationships, work, or school.
People with SAD may experience physical symptoms such as sweating, trembling, or a racing heart when faced with social situations. These feelings can be overwhelming and debilitating.
While there are no formal figures to ascertain the prevalence of SAD in Singapore, Dr Adrian Loh, a psychiatrist at Promises Healthcare who specialises in child and adolescent psychiatry, reckons (based on prevailing world figures) that there is at least one child with SAD for every two classes in a typical primary school. He tells us more below.
Children with Social Anxiety Disorder: Misunderstood as Shy or Having Bad Manners
Not all children express their emotions in the same way. It’s a misconception to expect that they should always be happy, smiling, and chatty.
Social anxiety disorder can cause children to feel an overwhelming sense of fear in social settings, making them appear withdrawn, quiet, or even distressed. This behaviour doesn’t mean they are unhappy overall. Rather, they are struggling with anxiety that can be very difficult to manage. This is especially so in social environments where they feel they may be judged or embarrassed.
Children with social anxiety may avoid eye contact, freeze up, or have difficulty speaking in front of others. These behaviours are often misunderstood as shyness or bad manners. In reality, they are signs of a deeper mental health issue that requires understanding and support, not judgment.
In my experience, it is typical for children with SAD to avoid a wide range of social situations. This includes attending school, eating in the school canteen, taking part in outside activities, and so on.
When these situations are avoided, there will often be relief of underlying anxiety, which reinforces the problem.
I also often find that these children can become somewhat dependent on their caregivers for emotional and practical support.
Signs of Social Anxiety Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists these behavioural traits through which SAD can be diagnosed:
- Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). The individual fears that they will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.
- Social situations almost always provoke fear or anxiety. Note: In children, this may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak.
- The fear or anxiety is out of proportion to the actual threat posed by the social situation.
- The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The fear, anxiety, or avoidance: is persistent, typically lasting for six months or more. It cannot be attributed to the physiological effects of a substance (e.g., drugs, medication) or another medical condition. Furthermore it is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
- If another medical condition (e.g., obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
When should I seek help for my child?
Seek help for your child if their social anxiety begins to interfere with daily functioning. They may avoid school, refuse to participate in social activities. They may also complain of physical symptoms like headaches or stomach aches before social events.
Another important factor is the level of distress your child experiences. If their fear of social situations is overwhelming and does not improve with time or support from family and friends, it is essential to consult a mental health professional.
Untreated anxiety can lead to academic and social difficulties, impacting a child’s long-term development. With the experience of significant losses in life such as friendships and achievements, children with SAD may go on to develop conditions such as depression.
“We had a lot of arguments about school. He would say that he had a tummy ache, headache, was not feeling well, was sleepy, and so on, just to avoid going. As a family, we felt stressed and overwhelmed. Our son was not going to school, and he had been diagnosed with anxiety and depression.”
Caleb’s father
Not an Introvert, Not Shy
The key difference between SAD and introversion or shyness is in the intensity and impact of the fear. Introversion is a personality trait where individuals naturally prefer solitude or small group interactions and may feel drained after large social gatherings.
However, introverts do not typically experience significant distress or marked avoidance due to social interactions.
Shyness, on the other hand, is a mild form of social discomfort. Individuals may feel uneasy or self-conscious in new situations or with unfamiliar people, but this discomfort usually diminishes over time and does not interfere with their daily functioning.
SAD involves a more profound level of fear that can lead to a cycle of avoidance, reinforcing the anxiety and making it increasingly difficult to engage in social situations.
While an introvert might choose to spend time alone to recharge, and a shy person might feel nervous but still attend a social event, someone with SAD might avoid the event altogether due to the overwhelming fear of negative evaluation.
This avoidance can severely limit opportunities for social connection and personal growth. Hence SAD is a much more serious condition than mere shyness or introversion.
How are Children with Social Anxiety Disorder Treated?
It’s important to realise that social anxiety is a recognised condition, much like any physical health issue, and that children who experience it need a safe, non-judgmental space to work through their fears.
Treatment typically involves cognitive behavioural therapy (CBT). This has been shown to be effective in reducing symptoms of social anxiety in children and adolescents. The duration of treatment can vary depending on the severity of the disorder.
Therapy can help them gradually build confidence, but it’s important to approach them with empathy rather than pressure or unrealistic expectations.
What Caleb’s Father Did
“I tried to find resources on how to manage this situation and condition. I read books, searched the internet, and watched videos on how to manage this, and how parents can support and provide encouragement.
We started to have routine discussions at night before bed, just easy and non-judgemental conversations. I tried to find activities that he would like. Got him engaged in fixing things like a handyman. Did clean up chores together. Tried fishing, played badminton, went brisk walking, and played on scooters.
What got him interested was cooking. He likes to watch YouTube videos on cooking, so I encouraged him to try it out. He saved money to buy a cookbook, tried recipes, and I provided positive feedback to get him to do more cooking.
He also likes to play music on the kalimba, an African musical instrument with a wooden soundboard and metal keys. We bought him the kalimba so that he could learn a new skill set. The idea was to get him to know that he could do many things, and to build his self-esteem and confidence.”
Caleb’s father
Supporting Children who have Social Anxiety Disorder
It’s crucial to recognise that children, like adults, have emotional complexities that may not always align with societal norms of happiness. Adult caregivers can find opportunities to explain to others regarding the unique concerns being faced by their child, and ask for understanding.
“I attended training sessions like on caregiving, parenting, Hypnotherapy, and NLP (neuro linguistic programming). The sessions taught me how to have better conversations with my son, and gave me insight and understanding into what he had been going through. I learnt to listen with empathy and validate what he said, and that direct encouragement or providing too much feedback will backfire. After this he was more open to communication and suggestions.”
Caleb’s father
Early intervention is crucial for preventing the disorder from persisting into adulthood. Thus reaching out to a professional as soon as you notice significant symptoms is the best course of action.
“Now my son is doing fine at home, though he still needs a little bit more time to get back to school. He is helpful and caring, and will occasionally help with chores. He shares what he feels and has open communication with us. He is also happy to demonstrate his kalimba skills to other people.”
Caleb’s father
Featured image: jcomp on Freepik
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