A 5-year-old male came to clinic for his well child examination. He had always been a quieter child who was more reticent to join in peer games, but would readily do so with children and adults he knew. In new situations his parents would allow him to sit next to them for awhile watching and then slowly encourage him to engage with the other children and activities. They reported that it would take him awhile to do so but usually he was having a good time by the end of the activity. They reported that he was nervous about starting school. They had toured the school and met the teachers in the spring. They also had gone to play on the playground during the summer so he would be familiar with it. The past medical history was non-contributory. The family history was positive for maternal post-partum depression.
The pertinent physical exam showed a quiet male who was slow to warm up during the visit but did by the end of it. His vital signs were normal and his growth parameters were 10-50%. His examination was normal. The diagnosis of of a somewhat shy boy was made. The pediatrician suggested that they identify another student who would be riding on the bus with him to be his “bus-buddy” and also maybe identify someone before who would have the same lunch (“lunch buddy”) or recess times. In that way the child would already know someone and hopefully feel a little more comfortable. She also suggested that they go over his routine for getting on and off the bus, especially who would be there to meet him at the bus stop or at home. Additionally the parents could contact the teacher so that the teacher was aware and could look for opportunities to assist the child. A few weeks later, the pediatrician saw the family in the community and they said that the first few days were difficult as he was crying at school and home but then he became more comfortable. He also had joined the local Boy Scout troop because one of his friends was joining and that the first meeting had gone well.
“Shyness is a temperamental trait that refers to wariness and discomfort in the face of social novelty and/or in situation of perceived social evaluation.” Shy people often avoid or withdraw from familiar and unfamiliar people and situations. Their anxiety prevents them from social life participation when they need or want to.
Social withdrawal, isolation and social anxiety disorders are defined differently.
- Social withdrawal is the behavioral expression of solitude. It is self-isolation where children and adults isolate themselves from their peer groups. These are non-anxious introverts.
- Isolation is the result of the peer group rejecting or isolating the affected child or adult. Both social withdrawal and isolation do not necessarily involve fear of negative social evaluation or increased social anxiety as shyness does.
- Social anxiety disorder, according to the DSM-V, is when the child or adult has significant distress that is out of proportion to the situation in their ordinary activities of daily living that occur in normal social settings such as school or work. The affected individual must also realize that the distress is unreasonable or excessive.
About 30-40% of people label themselves as shy. Shyness is generally a stabile characteristic overtime. Toddlers and preschoolers show more instability, but this trait is generally stabile from early to mid-childhood onward. Shyness may become more disabling and can lead to functional impairments in 13% or more of cases. Shyness affects boys and girls equally but boys are more strongly associated with peer exclusion and rejection than girls. Patients tend to be quiet and have decreased social participation. Infants do have normal increases of stranger anxiety at 9 months or separation anxiety around 18 months, but for shy individuals these tendencies do not disappear. For children who are having complications of shyness, some research supports improvements with exposure (to general or specific environments or situations), social skills training (verbal and non-verbal communication skills, modeling and social problem solving) and peer-mediated interventions (shy and non-shy children engage in joint-task activities together).
Potential complications of shyness include:
- Anxiety – often significant, and most common
- Poor self esteem
- Academic impairment
- “Missing out” on various life opportunities
- Relationship problems such as exclusion, rejection, neglect or victimization
- Substance abuse
Questions for Further Discussion
1. What questions could you ask to help determine if a shy child is needs intervention?
2. What are potential treatment options for social anxiety disorder?
3. When should a child with shyness be referred to a mental health professional?
- Symptom/Presentation: Behavior Problems
- Age: School Ager
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Cheek JM. Shyness in Behavioral and Developmental Pediatrics. Parker and Zukerman B. eds. Little Brown and Co. Boston, MA. 1995;285-288.
Greco LA, Morris TL. Treating childhood shyness and related behavior: empirically evaluated approaches to promote positive social interactions. Clin Child Fam Psychol Rev. 2001 Dec;4(4):299-318.
Rubin KH, Coplan RJ, Bowker JC. Social withdrawal in childhood. Annu Rev Psychol. 2009;60:141-71.
Karevold E, Ystrom E, Coplan RJ, Sanson AV, Mathiesen KS. A prospective longitudinal study of shyness from infancy to adolescence: stability, age-related changes, and prediction of socio-emotional functioning. J Abnorm Child Psychol. 2012 Oct;40(7):1167-77.
American Psychiatric Association. Social Anxiety Disorder. DSM5.org.
Available from the Internet at http://www.dsm5.org/Documents/Social%20Anxiety%20Disorder%20Fact%20Sheet.pdf (rev. 5/2013, cited 8/31/15).
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital