Social anxiety disorder: recognition, assessment and treatment

This guideline covers recognising, assessing and treating social anxiety disorder (also known as social phobia) in children and young people (from school age to 17 years) and adults (aged 18 years and older). It aims to improve symptoms, educational, occupational and social functioning, and quality of life in people with social anxiety disorder.

# Introduction
This guidance updates and replaces the section of NICE technology appraisal guidance 97 (published February 2006) that deals with phobia.
Social anxiety disorder (previously known as 'social phobia') is one of the most common of the anxiety disorders. Estimates of lifetime prevalence vary but according to a US study, 12% of adults in the US will have social anxiety disorder at some point in their lives, compared with estimates of around 6% for generalised anxiety disorder (GAD), 5% for panic disorder, 7% for post-traumatic stress disorder (PTSD) and 2% for obsessivecompulsive disorder. There is a significant degree of comorbidity between social anxiety disorder and other mental health problems, most notably depression (19%), substance-use disorder (17%), GAD (5%), panic disorder (6%), and PTSD (3%).
Social anxiety disorder is persistent fear of or anxiety about one or more social or performance situations that is out of proportion to the actual threat posed by the situation. Typical situations that might be anxiety-provoking include meeting people, including strangers, talking in meetings or in groups, starting conversations, talking to authority figures, working, eating or drinking while being observed, going to school, going shopping, being seen in public, using public toilets and public performances such as public speaking. Although worries about some of these situations are common in the general population, people with social anxiety disorder worry excessively about them at the time and before and afterwards. They fear that they will do or say something that they think will be humiliating or embarrassing (such as blushing, sweating, appearing boring or stupid, shaking, appearing incompetent, looking anxious). Social anxiety disorder can have a great impact on a person's functioning, disrupting normal life, interfering with social relationships and quality of life and impairing performance at work or school. People with the disorder may misuse alcohol or drugs to try to reduce their anxiety (and alleviate depression).
Children may show their anxiety in different ways from adults: as well as shrinking from interactions, they may be more likely to cry, freeze or have tantrums. They may also be less likely to acknowledge that their fears are irrational when they are away from a social situation. Particular situations that can cause difficulty for socially anxious children and young people include participating in classroom activities, asking for help in class, joining activities with peers (such as attending parties or clubs), and being involved in school performances.
Social anxiety disorder has an early median age of onset (13 years) and is one of the most persistent anxiety disorders. Despite the extent of distress and impairment, only about half of those with the disorder ever seek treatment, and those who do generally only seek treatment after 1520 years of symptoms. A significant number of people who develop social anxiety disorder in adolescence may recover before reaching adulthood. However, if the disorder has persisted into adulthood, the chance of recovery in the absence of treatment is modest when compared with many other common mental health problems.
Effective psychological and pharmacological interventions for social anxiety disorder exist but may not be accessed due to poor recognition, inadequate assessment and limited awareness or availability of treatments. Social anxiety disorder is under-recognised in primary care. When it coexists with depression the depressive episode may be recognised without detecting the underlying and more persistent social anxiety disorder. The early age of onset means that recognition in educational settings is also challenging.
Some recommendations in this guideline have been adapted from recommendations in other NICE clinical guidance. In these cases the Guideline Development Group was careful to preserve the meaning and intent of the original recommendations. Changes to wording or structure were made to fit the recommendations into this guideline. The original sources of the adapted recommendations are shown in the recommendations.
The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual service users.
This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The service user (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council's good practice in prescribing and managing medicines and devices for further information. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
The recommendations relate to children and young people (from school age to 17 years) and adults (aged 18 years and older).

# General principles of care in mental health and general medical settings

## Improving access to services
Be aware that people with social anxiety disorder may:
not know that social anxiety disorder is a recognised condition and can be effectively treated
perceive their social anxiety as a personal flaw or failing
be vulnerable to stigma and embarrassment
avoid contact with and find it difficult or distressing to interact with healthcare professionals, staff and other service users
avoid disclosing information, asking and answering questions and making complaints
have difficulty concentrating when information is explained to them.
Primary and secondary care clinicians, managers and commissioners should consider arranging services flexibly to promote access and avoid exacerbating social anxiety disorder symptoms by offering:
appointments at times when the service is least crowded or busy
appointments before or after normal hours, or at home initially
self-check-in and other ways to reduce distress on arrival
-pportunities to complete forms or paperwork before or after an appointment in a private space
support with concerns related to social anxiety (for example, using public transport)
a choice of professional if possible.
When a person with social anxiety disorder is first offered an appointment, in particular in specialist services, provide clear information in a letter about:
where to go on arrival and where they can wait (offer the use of a private waiting area or the option to wait elsewhere, for example outside the service's premises)
location of facilities available at the service (for example, the car park and toilets)
what will happen and what will not happen during assessment and treatment. When the person arrives for the appointment, offer to meet or alert them (for example, by text message) when their appointment is about to begin.
Be aware that changing healthcare professionals or services may be particularly stressful for people with social anxiety disorder. Minimise such disruptions, discuss concerns beforehand and provide detailed information about any changes, especially those that were not requested by the service user.
For people with social anxiety disorder using inpatient mental health or medical services, arrange meals, activities and accommodation by:
regularly discussing how such provisions fit into their treatment plan and their preferences
providing the opportunity for them to eat on their own if they find eating with others too distressing
providing a choice of activities they can do on their own or with others.
Offer to provide treatment in settings where children and young people with social anxiety disorder and their parents or carers feel most comfortable, for example, at home or in schools or community centres.
Consider providing childcare (for example, for siblings) to support parent and carer involvement.
If possible, organise appointments in a way that does not interfere with school or other peer and social activities.

## Communication
When assessing a person with social anxiety disorder:
suggest that they communicate with you in the manner they find most comfortable, including writing (for example, in a letter or questionnaire)
-ffer to communicate with them by phone call, text and email
make sure they have opportunities to ask any questions and encourage them to do so
provide opportunities for them to make and change appointments by various means, including text, email or phone.
When communicating with children and young people and their parents or carers:
take into account the child or young person's developmental level, emotional maturity and cognitive capacity, including any learning disabilities, sight or hearing problems and delays in language development
be aware that children who are socially anxious may be reluctant to speak to an unfamiliar person, and that children with a potential diagnosis of selective mutism may be unable to speak at all during assessment or treatment; accept information from parents or carers, but ensure that the child or young person is given the opportunity to answer for themselves, through writing, drawing or speaking through a parent or carer if necessary
use plain language if possible and clearly explain any clinical terms
check that the child or young person and their parents or carers understand what is being said
use communication aids (such as pictures, symbols, large print, braille, different languages or sign language) if needed.

## Competence
Healthcare, social care and educational professionals working with children and young people should be trained and skilled in:
negotiating and working with parents and carers, including helping parents with relationship difficulties find support
managing issues related to information sharing and confidentiality as these apply to children and young people
referring children with possible social anxiety disorder to appropriate services.

## Consent and confidentiality
If the young person is 'Gillick competent' seek their consent before speaking to their parents or carers.
When working with children and young people and their parents or carers:
make sure that discussions take place in settings in which confidentiality, privacy and dignity are respected
be clear with the child or young person and their parents or carers about limits of confidentiality (that is, which health and social care professionals have access to information about their diagnosis and its treatment and in what circumstances this may be shared with others). .
Ensure that children and young people and their parents or carers understand the purpose of any meetings and the reasons for sharing information. Respect their rights to confidentiality throughout the process and adapt the content and duration of meetings to take into account the impact of the social anxiety disorder on the child or young person's participation.

## Working with parents and carers
If a parent or carer cannot attend meetings for assessment or treatment, ensure that written information is provided and shared with them.
If parents or carers are involved in the assessment or treatment of a young person with social anxiety disorder, discuss with the young person (taking into account their developmental level, emotional maturity and cognitive capacity) what form they would like this involvement to take. Such discussions should take place at intervals to take account of any changes in circumstances, including developmental level, and should not happen only once. As the involvement of parents and carers can be quite complex, staff should receive training in the skills needed to negotiate and work with parents and carers, and also in managing issues relating to information sharing and confidentiality..
Offer parents and carers an assessment of their own needs (see NICE's guideline on supporting adult carers) including:
personal, social and emotional support
support in their caring role, including emergency plans
advice on and help with obtaining practical support.
Maintain links with adult mental health services so that referrals for any mental health needs of parents or carers can be made quickly and smoothly.

# Identification and assessment of adults

## Identification of adults with possible social anxiety disorder
Ask the identification questions for anxiety disorders in line with recommendation 1.3.1.2 in the NICE guideline on common mental health problems, and if social anxiety disorder is suspected:
use the 3-item Mini-Social Phobia Inventory (Mini-SPIN) or
consider asking the following 2 questions:
Do you find yourself avoiding social situations or activities?
Are you fearful or embarrassed in social situations? If the person scores 6 or more on the Mini-SPIN, or answers yes to either of the 2 questions above, refer for or conduct a comprehensive assessment for social anxiety disorder (see recommendations 1.2.5 to 1.2.9).
If the identification questions (see recommendation 1.2.1) indicate possible social anxiety disorder, but the practitioner is not competent to perform a mental health assessment, refer the person to an appropriate healthcare professional. If this professional is not the person's GP, inform the GP of the referral.
If the identification questions (see recommendation 1.2.1) indicate possible social anxiety disorder, a practitioner who is competent to perform a mental health assessment should review the person's mental state and associated functional, interpersonal and social difficulties.

## Assessment of adults with possible social anxiety disorder
If an adult with possible social anxiety disorder finds it difficult or distressing to attend an initial appointment in person, consider making the first contact by phone or internet, but aim to see the person face to face for subsequent assessments and treatment.
When assessing an adult with possible social anxiety disorder:
conduct an assessment that considers fear, avoidance, distress and functional impairment
be aware of comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis and autism.
Follow the recommendations in the NICE guideline on common mental health problems for the structure and content of the assessment and adjust them to take into account the need to obtain a more detailed description of the social anxiety disorder (see recommendation 1.2.8 in this guideline).
Consider using the following to inform the assessment and support the evaluation of any intervention:
a diagnostic or problem identification tool as recommended in recommendation 1.3.2.3 in the NICE guideline on common mental health problems
a validated measure for social anxiety, for example, the Social Phobia Inventory (SPIN) or the Liebowitz Social Anxiety Scale (LSAS).
Obtain a detailed description of the person's current social anxiety and associated problems and circumstances including:
feared and avoided social situations
what they are afraid might happen in social situations (for example, looking anxious, blushing, sweating, trembling or appearing boring)
anxiety symptoms
view of self
content of self-image
safety-seeking behaviours
focus of attention in social situations
anticipatory and post-event processing
-ccupational, educational, financial and social circumstances
medication, alcohol and recreational drug use.
If a person with possible social anxiety disorder does not return after an initial assessment, contact them (using their preferred method of communication) to discuss the reason for not returning. Remove any obstacles to further assessment or treatment that the person identifies.

## Planning treatment for adults diagnosed with social anxiety disorder
After diagnosis of social anxiety disorder in an adult, identify the goals for treatment and provide information about the disorder and its treatment including:
the nature and course of the disorder and commonly occurring comorbidities
the impact on social and personal functioning
commonly held beliefs about the cause of the disorder
beliefs about what can be changed or treated
choice and nature of evidence-based treatments.
If the person also has symptoms of depression, assess their nature and extent and determine their functional link with the social anxiety disorder by asking them which existed first.
If the person has only experienced significant social anxiety since the start of a depressive episode, treat the depression in line with recommendations in the NICE guideline on depression in adults.
If the social anxiety disorder preceded the onset of depression, ask: "if I gave you a treatment that ensured you were no longer anxious in social situations, would you still be depressed?"
If the person answers 'no', treat the social anxiety (unless the severity of the depression prevents this, then offer initial treatment for the depression).
If the person answers 'yes', consider treating both the social anxiety disorder and the depression, taking into account their preference when deciding which to treat first.
If the depression is treated first, treat the social anxiety disorder when improvement in the depression allows.
For people (including young people) with social anxiety disorder who misuse substances, be aware that alcohol or drug misuse is often an attempt to reduce anxiety in social situations and should not preclude treatment for social anxiety disorder. Assess the nature of the substance misuse to determine if it is primarily a consequence of social anxiety disorder and:
-ffer a brief intervention for hazardous alcohol or drug misuse (see the NICE guideline on alcohol-use disorders or drug misuse in over 16s)
for harmful or dependent alcohol or drug misuse consider referral to a specialist alcohol or drug misuse service.

# Interventions for adults with social anxiety disorder

## Treatment principles
All interventions for adults with social anxiety disorder should be delivered by competent practitioners. Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:
receive regular, high-quality outcome-informed supervision
use routine sessional outcome measures (for example, the SPIN or LSAS) and ensure that the person with social anxiety is involved in reviewing the efficacy of the treatment
engage in monitoring and evaluation of treatment adherence and practitioner competence  for example, by using video and audio tapes, and external audit and scrutiny if appropriate.

## Initial treatment options for adults with social anxiety disorder
Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (based on the Clark and Wells model or the Heimberg model; see recommendations 1.3.13 and 1.3.14 in the section on delivering psychological interventions for adults).
Do not routinely offer group CBT in preference to individual CBT. Although there is evidence that group CBT is more effective than most other interventions, it is less clinically and cost effective than individual CBT.
For adults who decline CBT and wish to consider another psychological intervention, offer CBT-based supported self-help (see recommendation 1.3.15 in the section on delivering psychological interventions for adults).
For adults who decline cognitive behavioural interventions and express a preference for a pharmacological intervention, discuss their reasons for declining cognitive behavioural interventions and address any concerns.
If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (escitalopram or sertraline). Monitor the person carefully for adverse reactions (see recommendations 1.3.17 to 1.3.23 in the section on prescribing and monitoring pharmacological interventions in adults).
For adults who decline cognitive behavioural and pharmacological interventions, consider short-term psychodynamic psychotherapy that has been specifically developed to treat social anxiety disorder (see recommendation 1.3.16 in the section on delivering psychological interventions for adults). Be aware of the more limited clinical effectiveness and lower cost effectiveness of this intervention compared with CBT, self-help and pharmacological interventions.

## Options for adults with no or a partial response to initial treatment
For adults whose symptoms of social anxiety disorder have only partially responded to individual CBT after an adequate course of treatment, consider a pharmacological intervention (see recommendation 1.3.6 in the section on initial treatment options for adults with social anxiety disorder) in combination with individual CBT.
For adults whose symptoms have only partially responded to an SSRI (escitalopram or sertraline) after 10 to 12 weeks of treatment, offer individual CBT in addition to the SSRI.
For adults whose symptoms have not responded to an SSRI (escitalopram or sertraline) or who cannot tolerate the side effects, offer an alternative SSRI (fluvoxamine or paroxetine) or a serotonin noradrenaline reuptake inhibitor (SNRI) (venlafaxine), taking into account:
the tendency of paroxetine and venlafaxine to produce a discontinuation syndrome (which may be reduced by extended-release preparations)
the risk of suicide and likelihood of toxicity in overdose. At the time of publication (May 2013) fluvoxamine did not have a UK marketing authorisation for use in adults with social anxiety disorder. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.
For adults whose symptoms have not responded to an alternative SSRI or an SNRI, offer a monoamine oxidase inhibitor (phenelzine or moclobemide). At the time of publication (May 2013) phenelzine did not have a UK marketing authorisation for use in adults with social anxiety disorder. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.
Discuss the option of individual CBT with adults whose symptoms have not responded to pharmacological interventions.

## Delivering psychological interventions for adults
Individual CBT (the Clark and Wells model) for social anxiety disorder should consist of up to 14 sessions of 90 minutes' duration over approximately 4 months and include the following:
education about social anxiety
experiential exercises to demonstrate the adverse effects of self-focused attention and safety-seeking behaviours
video feedback to correct distorted negative self-imagery
systematic training in externally focused attention
within-session behavioural experiments to test negative beliefs with linked homework assignments
discrimination training or rescripting to deal with problematic memories of social trauma
examination and modification of core beliefs
modification of problematic pre- and post-event processing
relapse prevention.
Individual CBT (the Heimberg model) for social anxiety disorder should consist of 15 sessions of 60 minutes' duration, and 1 session of 90 minutes for exposure, over approximately 4 months, and include the following:
education about social anxiety
cognitive restructuring
graduated exposure to feared social situations, both within treatment sessions and as homework
examination and modification of core beliefs
relapse prevention.
Supported self-help for social anxiety disorder should consist of:
typically up to 9 sessions of supported use of a CBT-based self-help book over 34 months
support to use the materials, either face to face or by telephone, for a total of 3 hours over the course of the treatment.
Short-term psychodynamic psychotherapy for social anxiety disorder should consist of typically up to 2530 sessions of 50 minutes' duration over 68 months and include the following:
education about social anxiety disorder
establishing a secure positive therapeutic alliance to modify insecure attachments
a focus on a core conflictual relationship theme associated with social anxiety symptoms
a focus on shame
encouraging exposure to feared social situations outside therapy sessions
support to establish a self-affirming inner dialogue
help to improve social skills.

## Prescribing and monitoring pharmacological interventions in adults
For guidance on safe prescribing of antidepressants and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms.
Before prescribing a pharmacological intervention for social anxiety disorder, discuss the treatment options and any concerns the person has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:
the likely benefits of different drugs
the different propensities of each drug for side effects, discontinuation syndromes and drug interactions
the risk of early activation symptoms with SSRIs and SNRIs, such as increased anxiety, agitation, jitteriness and problems sleeping
the gradual development, over 2 weeks or more, of the full anxiolytic effect
the importance of taking medication as prescribed, reporting side effects and discussing any concerns about stopping medication with the prescriber, and the need to continue treatment after remission to avoid relapse.
Arrange to see people aged 30 years and older who are not assessed to be at risk of suicide within 1 to 2 weeks of first prescribing SSRIs or SNRIs to:
discuss any possible side effects and potential interaction with symptoms of social anxiety disorder (for example, increased restlessness or agitation)
advise and support them to engage in graduated exposure to feared or avoided social situations.
After the initial meeting (see recommendation 1.3.18), arrange to see the person every 24 weeks during the first 3 months of treatment and every month thereafter. Continue to support them to engage in graduated exposure to feared or avoided social situations.
For people aged under 30 years who are offered an SSRI or SNRI:
warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
see them within 1 week of first prescribing and
monitor the risk of suicidal thinking and self-harm weekly for the first month. .
Arrange to see people who are assessed to be at risk of suicide weekly until there is no indication of increased suicide risk, then every 24 weeks during the first 3 months of treatment and every month thereafter. Continue to support them to engage in graduated exposure to feared or avoided social situations.
Advise people taking a monoamine oxidase inhibitor of the dietary and pharmacological restrictions concerning the use of these drugs as set out in the British National Formulary.
For people who develop side effects soon after starting a pharmacological intervention, provide information and consider 1 of the following strategies:
monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person)
reducing the dose of the drug
stopping the drug and offering either an alternative drug or individual CBT, according to the person's preference..
If the person's symptoms of social anxiety disorder have responded well to a pharmacological intervention in the first 3 months, continue it for at least a further 6 months.
When stopping a pharmacological intervention, reduce the dose of the drug gradually. If symptoms reappear after the dose is lowered or the drug is stopped, consider increasing the dose, reintroducing the drug or offering individual CBT.

# Identification and assessment of children and young people

## Identification of children and young people with possible social anxiety disorder
Health and social care professionals in primary care and education and community settings should be alert to possible anxiety disorders in children and young people, particularly those who avoid school, social or group activities or talking in social situations, or are irritable, excessively shy or overly reliant on parents or carers. Consider asking the child or young person about their feelings of anxiety, fear, avoidance, distress and associated behaviours (or a parent or carer) to help establish if social anxiety disorder is present, using these questions:
"Sometimes people get very scared when they have to do things with other people, especially people they don't know. They might worry about doing things with other people watching. They might get scared that they will do something silly or that people will make fun of them. They might not want to do these things or, if they have to do them, they might get very upset or cross."
"Do you/does your child get scared about doing things with other people, like talking, eating, going to parties, or other things at school or with friends?"
"Do you/does your child find it difficult to do things when other people are watching, like playing sport, being in plays or concerts, asking or answering questions, reading aloud, or giving talks in class?"
"Do you/does your child ever feel that you/your child can't do these things or try to get out of them?"
If the child or young person (or a parent or carer) answers 'yes' to one or more of the questions in recommendation 1.4.1 consider a comprehensive assessment for social anxiety disorder (see recommendations 1.4.5 to 1.4.11 in the section on assessment of children and young people with possible social anxiety disorder).
If the identification questions (see recommendation 1.4.1 in the section on identification of children and young people with possible social anxiety disorder) indicate possible social anxiety disorder, but the practitioner is not competent to perform a mental health assessment, refer the child or young person to an appropriate healthcare professional. If this professional is not the child or young person's GP, inform the GP of the referral.
If the identification questions (see recommendation 1.4.1 in the section on identification of children and young people with possible social anxiety disorder) indicate possible social anxiety disorder, a practitioner who is competent to perform a mental health assessment should review the child or young person's mental state and associated functional, interpersonal and social difficulties.

## Assessment of children and young people with possible social anxiety disorder
A comprehensive assessment of a child or young person with possible social anxiety disorder should:
provide an opportunity for the child or young person to be interviewed alone at some point during the assessment
if possible involve a parent, carer or other adult known to the child or young person who can provide information about current and past behaviour
if necessary involve more than one professional to ensure a comprehensive assessment can be undertaken.
When assessing a child or young person obtain a detailed description of their current social anxiety and associated problems including:
feared and avoided social situations
what they are afraid might happen in social situations (for example, looking anxious, blushing, sweating, trembling or appearing boring)
anxiety symptoms
view of self
content of self-image
safety-seeking behaviours
focus of attention in social situations
anticipatory and post-event processing, particularly for older children
family circumstances and support
friendships and peer groups, educational and social circumstances
medication, alcohol and recreational drug use.
As part of a comprehensive assessment, assess for causal and maintaining factors for social anxiety disorder in the child or young person's home, school and social environment, in particular:
parenting behaviours that promote and support anxious behaviours or do not support positive behaviours
peer victimisation in school or other settings.
As part of a comprehensive assessment, assess for possible coexisting conditions such as:
-ther mental health problems (for example, other anxiety disorders and depression)
neurodevelopmental conditions such as attention deficit hyperactivity disorder, autism and learning disabilities
drug and alcohol misuse (see recommendation 1.2.12 in the section on planning treatment for adults diagnosed with social anxiety disorder)
speech and language problems.
To aid the assessment of social anxiety disorder and other common mental health problems consider using formal instruments (both the child and parent versions if available and indicated), such as:
the LSAS  child version or the Social Phobia and Anxiety Inventory for Children (SPAI-C) for children, or the SPIN or the LSAS for young people
the Multidimensional Anxiety Scale for Children (MASC), the Revised Child Anxiety and Depression Scale (RCADS) for children and young people who may have comorbid depression or other anxiety disorders, the Spence Children's Anxiety Scale (SCAS) or the Screen for Child Anxiety Related Emotional Disorders (SCARED) for children.
Use formal assessment instruments to aid the diagnosis of other problems, such as:
a validated measure of cognitive ability for a child or young person with a suspected learning disability
the Strengths and Difficulties Questionnaire for all children and young people.
Assess the risks and harm faced by the child or young person and if needed develop a risk management plan for risk of self-neglect, familial abuse or neglect, exploitation by others, self-harm or harm to others.
Develop a profile of the child or young person to identify their needs and any further assessments that may be needed, including the extent and nature of:
the social anxiety disorder and any associated difficulties (for example, selective mutism)
any coexisting mental health problems
neurodevelopmental conditions such as attention deficit hyperactivity disorder, autism and learning disabilities
experience of bullying or social ostracism
friendships with peers
speech, language and communication skills
physical health problems
personal and social functioning to indicate any needs (personal, social, housing, educational and occupational)
educational and occupational goals
parent or carer needs, including mental health needs.

# Interventions for children and young people with social anxiety disorder

## Treatment principles
All interventions for children and young people with social anxiety disorder should be delivered by competent practitioners. Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:
receive regular high-quality supervision
use routine sessional outcome measures, for example:
the LSAS  child version or the SPAI-C, and the SPIN or LSAS for young people
the MASC, RCADS, SCAS or SCARED for children
engage in monitoring and evaluation of treatment adherence and practitioner competence  for example, by using video and audio tapes, and external audit and scrutiny if appropriate.
Be aware of the impact of the home, school and wider social environments on the maintenance and treatment of social anxiety disorder. Maintain a focus on the child or young person's emotional, educational and social needs and work with parents, teachers, other adults and the child or young person's peers to create an environment that supports the achievement of the agreed goals of treatment.

## Treatment for children and young people with social anxiety disorder
Offer individual or group CBT focused on social anxiety (see recommendations 1.5.4 and 1.5.5) to children and young people with social anxiety disorder. Consider involving parents or carers to ensure the effective delivery of the intervention, particularly in young children.

## Delivering psychological interventions for children and young people
Individual CBT should consist of the following, taking into account the child or young person's cognitive and emotional maturity:
12 sessions of 45 minutes' duration
psychoeducation, exposure to feared or avoided social situations, training in social skills and opportunities to rehearse skills in social situations
psychoeducation and skills training for parents, particularly of young children, to promote and reinforce the child's exposure to feared or avoided social situations and development of skills.
Group CBT should consist of the following, taking into account the child or young person's cognitive and emotional maturity:
12 sessions of 90 minutes' duration with groups of children or young people of the same age range
psychoeducation, exposure to feared or avoided social situations, training in social skills and opportunities to rehearse skills in social situations
psychoeducation and skills training for parents, particularly of young children, to promote and reinforce the child's exposure to feared or avoided social situations and development of skills.
Consider psychological interventions that were developed for adults (see the section on interventions for adults with social anxiety disorder) for young people (typically aged 15 years and older) who have the cognitive and emotional capacity to undertake a treatment developed for adults.

# Interventions that are not recommended to treat social anxiety disorder
Do not routinely offer pharmacological interventions to treat social anxiety disorder in children and young people.
Do not routinely offer anticonvulsants, tricyclic antidepressants, benzodiazepines or antipsychotic medication to treat social anxiety disorder in adults.
Do not routinely offer mindfulness-based interventions or supportive therapy to treat social anxiety disorder.Mindfulness-based interventions include mindfulness-based stress reduction and mindfulness-based cognitive therapy.
Do not offer St John's wort or other over-the-counter medications and preparations for anxiety to treat social anxiety disorder. Explain the potential interactions with other prescribed and over-the-counter medications and the lack of evidence to support their safe use.
Do not offer botulinum toxin to treat hyperhidrosis (excessive sweating) in people with social anxiety disorder. This is because there is no good-quality evidence showing benefit from botulinum toxin in the treatment of social anxiety disorder and it may be harmful.
Do not offer endoscopic thoracic sympathectomy to treat hyperhidrosis or facial blushing in people with social anxiety disorder. This is because there is no good-quality evidence showing benefit from endoscopic thoracic sympathectomy in the treatment of social anxiety disorder and it may be harmful.

# Specific phobias

## Interventions that are not recommended
Do not routinely offer computerised CBT to treat specific phobias in adults.# Research recommendations
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

# Adults' uptake of and engagement with interventions for social anxiety disorder
What methods are effective in improving uptake of and engagement with interventions for adults with social anxiety disorder?

## Why this is important
Effective interventions exist for social anxiety disorder but access to and uptake of services is limited and over 50% of people with social anxiety disorder never receive treatment; of those who do receive treatment many wait 10 years or more for it.
This question should be addressed by a programme of work that tests a number of strategies to improve uptake and engagement, including:
Development and evaluation of improved pathways into care, in collaboration with low users of services, through a series of cohort studies with the outcomes including increased uptake of and retention in services.
Adapting the delivery of existing interventions for social anxiety disorder in collaboration with service users. Adaptations could include changes to the settings for, methods of delivery of, or staff delivering the interventions. These interventions should be tested in a randomised controlled trial (RCT) design that reports short- and medium-term outcomes (including cost effectiveness) of at least 18 months' duration.

# Specific versus generic CBT for children and young people with social anxiety disorder
What is the clinical and cost effectiveness of specific CBT for children and young people with social anxiety disorder compared with generic anxiety-focused CBT?

## Why this is important
Children and young people with social anxiety disorder have commonly been treated with psychological interventions that cover a broad range of anxiety disorders, rather than interventions specifically focused on social anxiety disorder. This approach may be considered to be easier and cheaper to deliver, but emerging evidence suggests that children and young people with social anxiety disorder may do less well with these generic treatments than those with other anxiety disorders. There have, however, been no direct comparisons of treatment outcomes using generic compared with social anxiety-specific treatment programmes.
This question should be answered using an RCT design, reporting short- and medium-term outcomes (including cost-effectiveness) with a follow-up of at least 12 months. The outcomes should be assessed by structured clinical interviews, parent- and self-reports using validated questionnaires and objective measures of behaviour. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators (in particular the child or young person's age) should be investigated.

# The role of parents in the treatment of children and young people with social anxiety disorder
What is the best way of involving parents in the treatment of children and young people (at different stages of development) with social anxiety disorder?

## Why this is important
There is very little evidence to guide the treatment of social anxiety disorder in children aged under 7 years. It is likely that treatment will be most effectively delivered either wholly or partly by parents. Parenting interventions have been effective in treating other psychological difficulties in this age group, and this guideline found emerging evidence that these approaches might be useful for the treatment of young socially anxious children.
Furthermore, when considering all age groups, parental mental health difficulties and parenting practices have been linked with the development and maintenance of social anxiety disorder in children and young people. This suggests that interventions targeting these parental factors may improve treatment outcomes. However, interventions for children and young people with social anxiety disorder have varied widely in the extent and manner in which parents are involved in treatment and the benefit of including parents in interventions has not been established.
This question should be addressed in 2 stages.
Parent-focused interventions should be developed based on a systematic review of the literature and in collaboration with service users.
The clinical and cost effectiveness of these interventions at different stages of development should be tested using an RCT design with standard care (for example, group CBT) as the comparison. It should report short- and medium-term outcomes (including cost effectiveness) with a follow-up of at least 12 months. The outcomes should be assessed by structured clinical interviews, parent- and self-reports using validated questionnaires and objective measures of behaviour. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators (in particular the child or young person's age) should be investigated.

# Individual versus group CBT for children and young people with social anxiety disorder
What is the clinical and cost effectiveness of individual and group CBT for children and young people with social anxiety disorder?

## Why this is important
The majority of systematic evaluations of interventions for social anxiety disorder in children and young people have taken a group approach. Studies with adult populations, however, indicate that individually-delivered treatments are associated with better treatment outcomes and are more cost effective.
This question should be addressed using an RCT design comparing the clinical and cost effectiveness of individual and group-based treatments for children and young people with social anxiety disorder. It should report short- and medium-term outcomes (including cost effectiveness) with a follow-up of at least 12 months. The outcomes should be assessed by structured clinical interviews, parent- and self-reports using validated questionnaires and objective measures of behaviour. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators (in particular the child or young person's age and familial and social context) should be investigated.

# Combined interventions for adults with social anxiety disorder
What is the clinical and cost effectiveness of combined psychological and pharmacological interventions compared with either intervention alone in the treatment of adults with social anxiety disorder?

## Why this is important
There is evidence for the effectiveness of both CBT and medication, in particular SSRIs, in the treatment of social anxiety disorder. However, little is known about the effects of combined pharmacological and psychological interventions despite their widespread use. Understanding the costs and benefits of combined treatment could lead to more effective and targeted combinations if they prove to be more effective than single treatments. The study will also provide important information on the long-term benefits of medication.
This question should be addressed in a large-scale 3-arm RCT comparing the clinical and cost effectiveness of combined individual CBT and SSRI treatment with individual CBT or an SSRI alone. Trial participants receiving medication should be offered it for 1 year. The study should report short- and medium-term outcomes (including cost effectiveness) with a follow-up of at least 24 months. The primary outcome should be recovery, with important secondary outcomes being retention in treatment, experience and side effects of medication, and social and personal functioning. The study needs to be large enough to determine the presence of clinically important effects, and mediators and moderators should be investigated.