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Can social anxiety be caused by parents?

Verbal transmission of fear and threat from parents to children has been implicated in development of social anxiety. Negative parental verbal threats have been shown to lead to cognitive bias in ambiguous situations, hypervigilance to threats, and avoidance behaviors (Murray et al., 2014; Remmerswaal et al., 2016).

journals.healio.com - Familial Factors in the Development of Social Anxiety Disorder

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Introduction

The influence of nature and nurture on human behavior has been researched for decades. After completion of the Human Genome Project in 2003, one would think that the mystery behind genetic predisposition was solved. What was discovered is that genomes are complicated and developmental and health factors are influenced by multiple genes as well as environmental and lifestyle factors (National Human Genome Research Institute, 2019). Although many medical conditions have been shown to have a genetic predisposition, there are still unanswered questions about the influence of environment on the ultimate development of illness. Social anxiety disorder (SAD) is one example of a disorder in which there is a complex relationship between genetics and environment. Behind only specific phobias, SAD is the most common anxiety disorder in the United States, with approximately 13% of the population developing the disorder during their lifetime (Kessler et al., 2012). Among adolescents, the lifetime prevalence of SAD is 8.6% (Burstein et al., 2011; Kessler et al., 2012). Worldwide, lifetime prevalence of SAD is 4% (Stein et al., 2017). SAD is a marked, intense fear of social interactions with other people (American Psychiatric Association [APA], 2013). The onset of SAD is typically during childhood or adolescence (National Institute for Health and Care Excellence [NICE], 2013). A multitude of interrelated variables, such as genetic vulnerability, temperament, parental factors, and environmental influences contribute to the etiology and maintenance of SAD (Spence & Rapee, 2016). For individuals who struggle with SAD, symptoms can interfere with all areas of life, including relationships, occupations, and educational endeavors. The current article will explore familial factors that can influence the development of SAD in children and adolescents. Knowledge of familial factors provides insight on targeted treatments that prevent or minimize severity of the disorder.

Definition of Social Anxiety Disorder

SAD is extreme fear and anxiety in social situations leading to significant levels of distress (APA, 2013). Social situations may include carrying on a conversation with another person, public speaking, or eating a meal. A person with SAD fears acting in a way that will offend someone, humiliation from exposing anxiety symptoms in public, and scrutiny and negative evaluation from others (APA, 2013). The marked level of distress experienced by someone with SAD is often out of proportion to the actual situation (APA, 2013). Avoidance or anxious anticipation of the feared situation is common (NICE, 2013). In young children, social anxiety symptoms may include severe and prolonged crying episodes, becoming physically immobilized, shrinking away from others, excessive clinging, or being unable to speak in social situations (APA, 2013).

Genetic Predisposition

The etiology of SAD is often described in the literature in such terms as puzzle, delicate interplay, and complex interaction. There are multiple pathways to the development of SAD, however, the presence of several risk factors does not automatically lead to SAD (Spence & Rapee, 2016). One strongly implicated pathway is genetic transmission (Scaini et al., 2014). A positive association has been found between development of SAD in children who have parents with SAD (Halldorsson et al., 2018; Isomura et al., 2015; Telman et al., 2018). Unfortunately, heritability rates vary greatly among studies, ranging from 13% to 76% (Moreno et al., 2016). Researchers have postulated that individual differences in the development of SAD stem from a multidimensional relationship between genetic factors and environmental factors, such as parenting, peer relationships, illness, early life trauma, and cumulative stress (Chubar et al., 2020; Scaini et al., 2014; Schiele & Domschke, 2018; Shimada-Sugimoto et al., 2015). Yet even gene–environment models contradict or inaccurately predict those who will go on to develop SAD (Ziegler et al., 2015). More recently, epigenetics has been identified as the potential “missing link” in the heritability of anxiety disorders (Schiele & Domschke, 2018, p. 4). Epigenetics is a mechanism in which cell molecules modify gene expression, without changing the inherited DNA code, to promote or inhibit symptoms or diseases, such as cancer, depression, addiction, and anxiety (Schuebel et al., 2016). Environmental stressors, such as child abuse, maternal separation, or early trauma, may influence genetic expression of anxiety when occurring at critical developmental stages of life, including infancy or adolescence (Bartlett et al., 2017). Subsequently, a child or adolescent may not only inherit genetic tendencies for SAD but also have critical periods of vulnerability to individual epigenetic stressors (Schiele & Domschke, 2018). Two genetically transmitted behavioral traits implicated in the development of SAD are behavioral inhibition and anxiety sensitivity (Chronis-Tuscano et al., 2018; Graham & Weems, 2015; Muris et al., 2011; Papachristou et al., 2018; Spence & Rapee, 2016). Anxiety Sensitivity Anxiety sensitivity is the fear of anxiety-related physical sensations (McNally, 2002). Alkozei et al. (2014) discovered that children with SAD had higher levels of anxiety sensitivity and were more likely to view scenarios with unclear social threats and ambiguous endings as anxiety provoking. Children and adolescents with SAD believed that physical anxiety symptoms would be observed by others, leading to humiliation, mental incapacitation, illness, or increased anxiety levels (Alkozei et al., 2014; Papachristou et al., 2018). Not only do individuals with anxiety sensitivity overestimate the meaning of physical anxiety symptoms, but they also generate escalating mental scenarios in which they feel unable to cope (Riskind et al., 2013).

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Family Factors

Family is an essential component in the learning, growth, and development of children. In addition, the family is an important source of recreation and social interaction, especially in early childhood years. There is a substantial body of evidence regarding the influence of parenting and the family in the etiology of SAD.

Clinical Implications in Treating Social Anxiety Disorder

Many interrelated factors, including genetics, family, and environment, potentially lead to SAD in children and adolescents. Left untreated, SAD causes pervasive problems with academic performance, romantic and personal relationships, victimization, loneliness, future college endeavors, and professional goals (de Lijster et al., 2018). Unfortunately, challenges exist for mental health practitioners in diagnosing and treating the disorder. SAD is often underrecognized, with long delays between onset of symptoms and initiation of treatment (Nagata et al., 2015; Zarger & Rich, 2016). Zarger and Rich (2016) found that only 13% of adolescents with SAD had ever disclosed their social fears to a professional. There are several reasons postulated for the poor detection rates of SAD in children and adolescents. First, the nature of SAD is to fear negative evaluation and avoid social encounters. As such, individuals with SAD usually hide or refrain from seeking help (Neufeld et al., 2020). Second, there is a high comorbidity with other mental health disorders, including depression, GAD, agoraphobia, panic disorder, and specific phobia (Adams et al., 2016; Chapdelaine et al., 2018; Creswell et al., 2014; Garcia-Lopez et al., 2016; Halldorsson et al., 2019). SAD shares some of the same characteristics of personal failure beliefs, social communication difficulties, fears, worry, intolerance of uncertainty, somatic complaints, and internalized distress (Counsell et al., 2017; Crome & Baillie, 2015; Halls et al., 2015; Hearn et al., 2017; Mobach et al., 2020; Pearcey et al., 2018; Sackl-Pammer et al., 2018). Subsequently, subtle symptoms of SAD may be difficult to detect when a youth presents with more disabling symptoms of depression or panic disorder. One hallmark feature that distinguishes SAD from other disorders is dysfunctional social beliefs (Mobach et al., 2020). A child or adolescent with SAD expects negative evaluation or rejection from others and subsequently becomes hyper-vigilant to threats in the social environment (Weymouth et al., 2019). Additional features specific to SAD include rumination after a social encounter, fear of visually displaying anxiety symptoms, and avoiding feared social situations (APA, 2013; Halldorsson et al., 2019; Kodal et al., 2017; Norton & Abbott, 2016; Weymouth et al., 2019). Third, many individuals with SAD believe that symptoms are a part of their personality, attributable to shyness, or not severe enough to warrant treatment (Hyett & McEvoy, 2018; Nagata et al., 2015; Zarger & Rich, 2016). Fourth, although children with anxiety disorders rely on parents to recognize problems and seek help, parents may not find the behaviors to be a difficulty or perceive the need for professional support (Reardon, Harvey, et al., 2018). Finally, the presentation of SAD encompasses a wide range of symptoms, internalized fears, and levels of severity leading to diagnostic errors (Crome & Baillie, 2015; Hyett & McEvoy, 2018). Several cues can aid mental health practitioners and teachers in early identification of SAD. Children and adolescents with a primary diagnosis of SAD have endorsed a greater severity and number of somatic complaints, including stomach pain, fatigue, sudden heart complaints, and dizziness (Sackl-Pammer et al., 2018). Furthermore, school refusal behaviors and dropout have correlated with social anxiety (Gonzálvez et al., 2019; Ranta et al., 2016; Waite & Creswell, 2014). Peer victimization, substance use, academic delays, and fewer or lower quality friendships are other cues to identifying SAD in children or adolescents (APA, 2013; Early et al., 2017; Mekuria et al., 2017; Pickard et al., 2018; Ranta et al., 2016). Unfortunately, designations by school counselors or teachers are not consistently accurate (Ecklund & Dowdy, 2013; Sweeney et al., 2015). Several brief screening tools have been helpful in identifying social anxiety in low resource mental health settings and schools (Beale et al., 2018; Garcia-Lopez et al., 2015; O'Connor & Fitzgerald, 2020; Reardon, Spence, et al., 2018; Sweeney et al., 2015). Due to the high likelihood of comorbidity, researchers recommend screening for SAD when a child or adolescent presents with another mental health disorder, such as depression or GAD (Adams et al., 2016; Garcia-Lopez et al., 2016). Universal screening in schools or pediatrician offices has been suggested (Ecklund & Dowdy, 2013; Zarger & Rich, 2016). Focusing on children and adolescents in families experiencing significant stressors, such as interparental conflict, parental mental illness, or serious illness, may be another option. Finally, benefits have been noted with multi-informant approaches, keeping in mind that parent reports should be prioritized for children and adolescent self-reports contribute essential data about their own peer-related impairments (Beale et al., 2018; Reardon, Spence, et al., 2018). A multitude of options exist for treating SAD in children and adolescents. The gold standard is individual treatment with cognitive-behavioral therapy (CBT) incorporating social skills training, modification of cognitive biases, exposure to situations, and education (Asbrand et al., 2020; NICE, 2013; Nordh et al., 2017; Scaini et al., 2016; Spence et al., 2017). Treatment techniques are recommended that encourage the individual to discover how social anxiety is maintained and target cognitive distortions (Leigh & Clark, 2018; Lisk et al., 2018; Neufeld et al., 2020). Unfortunately, individuals with SAD treated with CBT have demonstrated poorer outcomes and lower likelihood of remission than other anxiety disorders (Hudson, Rapee, et al., 2015; Kodal et al., 2018; Leigh & Clark, 2018; Lundkvist-Houndoumadi & Thastum, 2017). Possible reasons cited include parental psychopathology, difficulties establishing a therapeutic relationship with the practitioner, longer time to SAD diagnosis leading to more resistant behaviors, generic manualized CBT programs, and comorbid mood disorders (Adams et al., 2016; Hudson, Keers, et al., 2015; Hudson, Rapee, et al., 2015; Kodal et al., 2018). Parental involvement in treatment is essential, as problematic parenting behaviors, psychopathology, and stress may perpetuate the child's social anxiety (Garcia-Lopez et al., 2014; Leigh & Clark, 2016; Manassis et al., 2014; Schleider et al., 2015; Weijers et al., 2018; Yang et al., 2019). Involving the parents is particularly essential when working with young children (NICE, 2013). Parent treatment approaches should encompass education on how to manage personal anxiety and negative cognitive biases as well as how to facilitate exposures to anxious situations, model healthy coping, reward brave behavior, and assist in preventing relapse (Chronis-Tuscano et al., 2018; Leigh & Clark, 2016, 2018; Manassis et al., 2014). Advantages may exist for parent-only treatments (Luke et al., 2017; NICE, 2013; Reuland & Teachman, 2014). In situations where CBT is ineffective, other options should be considered, such as family psychoeducation, modeling by practitioner, assertiveness training group therapy, relaxation, and possibly CBT plus medication (Higa-McMillan et al., 2016; NICE, 2013). Although significant strides have been made in the literature regarding SAD in children and adolescents, future research is still needed to identify best practices for preventing, diagnosing, and treating the disorder.

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Conclusion

Family represents the most important social group from infancy to early adolescence. For children with a genetic vulnerability for SAD, it is essential to recognize familial factors that contribute to the development of SAD. SAD is a pervasive disorder that impacts all aspects of life including personal and professional relationships. Knowledge of familial factors helps in recognition and treatment for children and adolescents thereby preventing or minimizing the disorder.

journals.healio.com - Familial Factors in the Development of Social Anxiety Disorder

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