Many kids go through a shy or "awkward" phase at some point in adolescence, but shyness can become more than a stint of social timidity. Twelve percent of youths who call themselves "shy" may actually be socially phobic, according to research from the Nation Institute of Mental Health. The research, published Monday, appears in the journal Pediatrics.
Some scholars, however, hesitate to classify social phobia as a mental disorder, suggesting that doing so could "medicalize" normal shyness and lead to overmedication of young people who in the past were merely considered introverted.
After surveying more than 10,000 kids between the ages of 13 and 18, as well as 6,000 of their parents, however, researchers have concluded that social phobia is in fact a debilitating psychological disorder that affects about one in 10 "shy" kids.
"Adolescents were asked to rate their shyness around people their own age whom they didn't know very well on a scale from four to one. Parents were asked to rate their child on the same questions," says Kathleen Merikangas, co-author of the study and chief of the Genetic Epidemiology Research Branch at the National Institute of Mental Health.
Shyness was extremely prevalent among those polled -- about 47 percent of kids reported they were shy, and 62 percent of parents reported their child was shy. Researchers found that in a small subset of those who reported shyness, shyness was just one symptom of a larger psychological problem, social phobia.
"Shyness is a temperamental trait that has differences across [childhood and adolescent] development. Shy people are not necessarily disturbed by their reserved nature," says Merikangas. "Although social phobia can be considered an extreme form of shyness, there was not complete overlap."
Merikangas said that unlike those who were merely shy, those with social phobia were debilitated by their fear of social interactions, impaired in their ability to do schoolwork and participate in social activity and family relationships. They often experienced severe anxiety reactions during social interactions, including blushing, sweating, rapid pulse and trembling.
"People with social phobia report the reaction is excessive and unreasonable, and they suffer from an inability to extinguish the fear reaction and extreme concern that others will observe the fear reaction," she says.
Those with social phobia were also more likely to experience other psychological problems, such as anxiety, depression, behavioral issues and substance abuse, but were no more likely to be on psychiatric medication than their peers without social phobia. This may mean, authors noted, that teens with this debilitating disorder may not be seeking the help they need.
"The results also suggest that the majority of young people with social phobia are not receiving effective and appropriate treatment," says Dr. David Fassler, clinical professor of psychiatry at the University of Vermont College of Medicine.
But when does social awkwardness or a reserved nature become not just a personality trait, but a psychiatric disorder?
Although the study authors argue that social phobia is a psychiatric disorder somewhat separate from normal shyness, the two lie on the same spectrum, says Dr. Mark Reinecke, chief psychologist at Northwestern Memorial Hospital.
"I don't know that shyness and social anxiety are discriminately different phenomena. Rather, I would suggest that social introversion can be viewed on a continuum," he says.
But because the two are so related, telling the two apart – and making the decision to treat the condition with therapy or medication, becomes difficult, says Alan Hilfer, associate director of Child Adolescent Outpatient Service at Maimonides Medical Center.
"Being able to differentiate and identify the two is the real issue and one must be careful not to over pathologize a kid who is just not sure of themselves and evidences a degree of inhibition or shyness. Many children are shy but with some encouragement or peer support they are able to find their voice. Others shrink from even the thought of a social encounter," he says.
So when should parents become worried?
"If [shy kids] are able to function, have friends do well in school and manage themselves then it doesn't necessarily warrant treatment," says Hilfer.
"When children refuse or are distressed about going to school or social gatherings ... and such distress continues over time," Merikangas says, then parents should try to inquire as the "nature of the fear" and potentially seek out some of the many websites that offer self assessment to determine if this distress is outside the realm of normal adolescent shyness."