Therapy for children and teens with social anxiety

Cognitive behavioural therapy (CBT) is the best-tested treatment for anxiety in children and teenagers. A Cochrane review of 87 trials found that about 49 in 100 children who had CBT no longer had their main anxiety disorder at the end, compared with about 18 in 100 who were on a waiting list. Social anxiety can be harder to shift than other anxieties, so therapy that targets social fears directly is worth asking for.

What CBT for children involves

CBT for children is practical. Depending on age, it includes:

• learning about anxiety: what it does to the body, and why avoiding things keeps it going;
• facing fears in small steps (exposure), for example answering one question in class, then two;
• practising social skills, such as starting a conversation or joining a game;
• noticing scary thoughts and testing them (“Will everyone really laugh?”);
• help for parents to support brave steps at home.

UK guidelines (NICE) describe 8 to 12 sessions of about 45 minutes for individual CBT, or 8 to 12 sessions of 90 minutes in groups. They say medication should not routinely be offered to children and young people with social anxiety.

What the evidence shows

• CBT helps much more than waiting. In the Cochrane review, roughly 3 children needed CBT for 1 extra child to recover. CBT was not clearly better than other usual care, and the quality of the evidence was moderate to low.
• Social anxiety is harder to treat with general anxiety CBT. In a study of 1,519 children, those whose main problem was social anxiety did less well in standard anxiety CBT than those whose main problem was general worry.
• Therapy made for social anxiety looks promising for teens. In a trial in England with 43 teenagers aged 14 to 18, one group did an online version of cognitive therapy for social anxiety, guided by a therapist. At the end, 77 in 100 of them no longer had social anxiety disorder, compared with 14 in 100 on a waiting list. This was a small trial.

Do parents need to be in the sessions?

Often not. An overview of 25 reviews found that 21 of them showed no clear difference between CBT with or without parents in the sessions. CBT given only through parents tended to be the weakest version.

That doesn’t mean parents don’t matter. Parent-only programmes still help more than waiting: a review of 6 trials found that. One parent-only programme, SPACE, teaches parents to stop helping their child avoid fears and to respond with support and confidence. In a trial of 124 children aged 7 to 14, it worked as well as child CBT. This can be a good route when a child refuses to go to therapy.

NICE suggests involving parents especially with younger children. With teenagers, it is normal for the therapist to see them alone for much of the time.

What about VR?

Virtual reality lets a young person practise, for example, a class presentation in a virtual classroom. In a study of 27 teenagers with fear of public speaking, each had one 90-minute VR session with a cheap headset. Their fear dropped and stayed lower three months later. There was no comparison group, so we can’t be sure VR caused the change. A larger trial of VR exposure for 12- to 16-year-olds with social anxiety is under way. For now, VR for teens is promising but early. Ask a therapist if they use it. See VR exposure therapy.

What about medication?

NICE does not recommend routinely offering medication to children and teenagers for social anxiety. A specialist may sometimes suggest it, for example when therapy has not helped. Any decision should be made with a child psychiatrist or doctor. Never start or stop a medicine without them.

Finding therapy for your child

Ask your child’s doctor or school about local child and adolescent mental health services. When you contact a therapist, ask:

• “Do you have experience with social anxiety in children or teens?”
• “Do you use CBT with exposure, so my child practises, not just talks?”
• “How will you involve me, and how will you involve the school?”
• “Do you offer online sessions?” (Some teens find these easier at first.)

If your child is very low or talks about hurting themselves, tell their doctor straight away. If it is urgent, see crisis lines.