British J Clinic Psychol - 2022 - Halldorsson - in The Moment Social Experiences and Perceptions of Children With Social

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Received: 4 January 2022 Accepted: 7 September 2022
DOI: 10.1111/bjc.12393
RESEARCH ARTICLE
In the moment social experiences and perceptions

of children with social anxiety disorder: A qualitative
study
Brynjar Halldorsson1,2,3,4 | Polly Waite1,2,5 | Kate Harvey5 |

Samantha Pearcey1 | Cathy Creswell1,2
1
Department of Experimental Psychology,
University of Oxford, Oxford, UK Abstract
2
Department of Psychiatry, University of Oxford, Objectives: Childhood social anxiety disorder (SAD) is a
Oxford, UK common and disabling condition. General forms of cogni-
3
Oxford Health NHS Foundation Trust, Oxford, UK tive behavioural treatments have demonstrated poorer effi-
4
Department of Psychology, Reykjavik University, cacy for childhood SAD when compared to other childhood
Reykjavik, Iceland
5
anxiety disorders and further understanding of the psycho-
School of Psychology and Clinical Language
Sciences, University of Reading, Reading, UK logical factors that contribute to the maintenance of child-
hood SAD is warranted. Examining the social experiences
Correspondence of children with SAD may help to identify relevant psycho-
Brynjar Halldorsson, Department of Psychiatry, logical factors and increase our understanding of what keeps
University of Oxford, Oxford, UK. childhood SAD going.
Email: [email protected]
Methods: The current study used reflexive thematic analy-
sis to analyse the transcripts of interviews with 12 children
aged 8–12 years with SAD who had been interviewed about
their ‘in the moment’ social experiences during a social stress
induction task. The interview topic guide included factors
hypothesized to maintain SAD in adult cognitive models of
the disorder.
Results: The interviews revealed both variety and common-
alities in the experiences and interpretations of social events
in children with SAD, captured in three related main themes:
(i) Discomfort being the centre of attention, (ii) (Lack of)
awareness of cognitions and (iii) Managing social fears.
Findings indicated likely developmental influences on which
maintenance mechanisms apply at which point in time.
Conclusions: There is variation in the psychological
mechanisms that children with SAD endorse and develop-
mental factors are likely to influence when specific mecha-
nisms are relevant. We now need further studies that take a
developmentally informed approach to understand the nature
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited.
© 2022 The Authors. British Journal of Clinical Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society.
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54 HALLDORSSON et al.
of the association between the factors identified in this study

and social anxiety in childhood to inform the development of
more effective interventions for childhood SAD.
KEYWORDS
CBT, maintenance mechanisms, qualitative, Social anxiety disorder,
treatment
Practitioner points
• This study focused on ‘in the moment’ social experiences and perceptions of pre-adolescent
children with social anxiety disorder (SAD) in order to inform a greater understanding of
what cognitive and behavioural factors play a role in maintaining SAD in children.
• This qualitative study is, to our knowledge, the first to directly explore how pre-adolescent
children with SAD map onto adult cognitive models of SAD.
• It seems likely that there are developmental influences on which maintenance mechanisms
apply at which point in time as only older children in the sample reported safety-seeking
behaviours, negative imagery and post-event processing.
• Existing treatments for childhood SAD may need to be adapted in order to target the different
psychological mechanisms that prevent children with SAD from overcoming their social
anxiety.
BACKGROUND
Social anxiety disorder (SAD) is the most common anxiety disorder, with up to 13% of the population
meeting the diagnostic criteria at any point in time (Beesdo et al., 2007; Kessler, Chiu, et al., 2005). The
median age of onset of SAD is estimated at 13 years (Kessler, Berglund, et al., 2005), and it is a commonly
diagnosed condition in clinical samples of pre-adolescent children (i.e., 12 years and younger; from here
on ‘children’) (Esbjørn et al., 2010; Waite & Creswell, 2014). In the absence of effective treatment, SAD
often runs a chronic course with poorer recovery rates than other anxiety problems (Bruce et al., 2005) and
in children, results in significant functional impairment across various domains, including academic, social
and family functioning (American Psychiatric Association, 2013; Beesdo et al., 2007; Beidel et al., 1999;
Schutters et al., 2011). Thus, early detection and effective treatment are essential for children with SAD.
At present, the most frequently used psychological treatment for childhood SAD is multi-disorder-fo-
cused cognitive behavioural therapy (CBT), that is CBT programmes that can be applied across a range
of anxiety disorders (e.g., Kendall & Hedtke, 2006). This is partly driven by the clinical characteristics
of child anxiety disorders, in that there is a high level of comorbidity between them. However, there
is evidence to suggest that the presence of SAD in the diagnostic spectrum is associated with poorer
response to general forms of CBT compared with other anxiety disorders (Evans, Clark et al., 2021;
Ginsburg et al., 2011; Hudson et al., 2013). The reasons why children with SAD have worse outcomes
than children with other types of anxiety disorders are not clear. It is possible that these treatments do
not target psychological maintenance mechanisms that are specific to childhood SAD. For example, it
has been suggested that children with SAD have social skills deficits which should be targeted in treat-
ment (Rapee & Spence, 2004; Spence et al., 2000; Spence & Rapee, 2016). Notably, however, evidence
for social skills deficits in childhood SAD is mixed (Halldorsson & Creswell, 2017; Pearcey et al., 2020)
and approximately 30%–50% of children with SAD still retain their SAD diagnosis after receiving
disorder-specific treatments for childhood SAD that target social skills deficits (Beidel et al., 2000, 2007;
Donovan et al., 2015; Öst et al., 2015; Spence et al., 2000).
SOCIALLY ANXIOUS CHILDREN’S IN THE MOMENT SOCIAL EXPERIENCES 55
In contrast, highly effective CBT treatments have been developed specifically for adults with SAD
which directly target cognitive and behavioural mechanisms that maintain SAD (Clark et al., 2006;
Mörtberg et al., 2007; Stangier et al., 2003), specifically: (i) interpretation biases (including dysfunctional
beliefs); (ii) self-focused attention and self-monitoring; (iii) misleading internal information (e.g., negative
images, body arousal); (iv) safety-seeking behaviours; and (v) detailed and catastrophic anticipatory and
post-event processing (for further details see Clark, 2005). To date, we know very little about what psycho-
logical mechanisms maintain childhood SAD (Halldorsson & Creswell, 2017). Instead, recent conceptual-
izations of SAD in children have typically focused on development (Ollendick & Benoit, 2012; Ollendick
& Hirshfeld-Becker, 2002; Rapee & Spence, 2004; Spence & Rapee, 2016) rather than maintenance so do
not directly inform treatment and its components.
In a recent review to examine whether, or to what extent, the same cognitive and behavioural mainte-
nance processes that occur in adult SAD also apply to childhood SAD, Halldorsson and Creswell (2017)
found (albeit limited) evidence that, compared with non-anxious children, children with SAD have a
tendency to interpret social situations as threatening, use safety-seeking behaviours, focus their attention
inwards and engage in negative anticipatory/post-event processing. However, the review did not identify
any studies that examined the other putative maintenance mechanisms: dysfunctional beliefs, negative
distorted images and diffused body perception within the context of childhood SAD. Turning to studies
examining social anxiety in adolescents, a recent review (Leigh & Clark, 2018) and emerging experimental
studies (Leigh et al., 2020, 2021) have provided support for the application of Clark and (1995) model to
this age group.
A clear understanding of the maintenance of SAD in childhood must also consider the possible influ-
ence of children's cognitive developmental status. The human brain undergoes significant development
throughout the pre-adolescent period (Burnett et al., 2011; Crone & Van Der Molen, 2007; Sebastian
et al., 2010; Supekar et al., 2009), particularly in brain regions implicated in emotion- and social-processing
and self-awareness (Casey et al., 2005). Thus, it is possible that specific processes outlined in the adult
SAD cognitive models may not come ‘online’ until children have reached certain developmental stages.
For example, children's cognitive capacity to see themselves as others see them may not fully develop
until late childhood (Cole et al., 2001). Also, there is evidence to suggest that children and adults process
facial emotional expressions differently (Thomas et al., 2001), use distinctive neurocognitive strategies
for making self-referential judgements (Pfeifer et al., 2007), and that children are less effective than
adults in analysing the intentionality of other's behaviour and mental states during social interactions
(Güroğlu et al., 2009). Furthermore, the role of social-environmental factors, including the influence of
other people (e.g., parents, peers and teachers) on children's developing cognitions, changes markedly
throughout development (Cole et al., 1997, 2001). Thus, developing further understanding of the cogni-
tive, behavioural and environmental factors that contribute to the maintenance of SAD and treatment
outcomes in psychological treatments, and how they operate across development and among children
with SAD, will be critical to enable us to continue to improve treatment outcomes for this population.
Clark (2004) described a sequential approach to empirical research that has been particularly helpful
in both identifying adult SAD maintenance mechanisms and devising a highly effective and acceptable
psychological treatment. This involves (i) conducting clinical/qualitative interviews to formulate a theory
of the processes hypothesized to maintain the disorder, followed by (ii) testing the theory using experi-
ments and prospective longitudinal studies, (iii) developing and evaluating a specialized cognitive interven-
tion that targets the maintenance mechanisms and (iv) disseminating the resulting intervention. Looking
to the first stage of this approach, we know surprisingly little about ‘in the moment’ experiences (and
pre- and post-event experiences) of children with SAD and how contextual and developmental factors
influence these experiences. The limited existing studies have mainly focused on children's negative cogni-
tions, indicating that, compared with non-anxious children, children with SAD experience more negative
thoughts during social-evaluative tasks (e.g., Spence et al., 1999; Tuschen-Caffier et al., 2011), but we
know little about other cognitive and behavioural ‘in the moment’ processes. Thus, in order to ultimately
inform understanding of the maintenance of childhood SAD, we interviewed children with SAD about
their experiences during a social stress induction task. Reflexive thematic analysis (Braun et al., 2018) was
applied with the aim of increasing our understanding of what cognitive and behavioural factors may play
a role in maintaining social anxiety in children.
METHODS
Participants
A total of fifteen children aged 8–12 years diagnosed with SAD as their primary presenting problem
was invited to participate in the study. Children were not excluded on the basis of comorbid diagnoses
to reflect a typical clinical population. Exclusion criteria for the recruiting clinical service were active
suicidality or severe self-harm, significant physical or intellectual impairment and/or diagnosis of autism
spectrum disorders. Three families (one child and two parents) declined participation (the child did not
give a specific reason; and the parents declined due to time constraints), resulting in a final sample of 12
participants. The concept of information power (Malterud et al., 2016) was used as a guide for ascertain-
ing a sample size for reflexive TA. Information power indicates that the more information relevant to the
study aim that a sample holds, the fewer participants are needed. Given the nature of this sample and the
challenges in recruiting socially anxious children, it was considered appropriate. Sample size was assessed
throughout the analysis, and we agreed as a team that we had reached sufficient information power when
we had detailed and sufficiently rich information on how social anxiety presented in this group. Children
were recruited (consecutively) following a referral by local health and education service personnel to a
specialist anxiety and depression clinic and research centre in the United Kingdom. All children with a
diagnosis of SAD that came through the clinic were invited to take part in the study during the recruit-
ment phase of the study.
Measures
Structured diagnostic interviews
Children and adolescents were assigned diagnoses on the basis of semi-structured diagnostic interviews
based on DSM-IV, with minor amendments to enable diagnoses consistent with DSM-5 diagnostic
criteria. The Anxiety Disorder Interview Schedule for DSM-IV for children, child and parent versions
(ADIS-C/P; Silverman & Albano, 1996) was used to assess anxiety disorders and behavioural disorders,
and the Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS; Kaufman et al., 1997)
was used to assess depressive disorders. As is conventional with both assessments, the interviews were
conducted with the child and their parent/s separately. Reliability for presence or absence of anxiety
diagnosis on the ADIS-C/P was κ = 1.00 and CSR ICC = .93. For the K-SADS, depression diagnoses
were based on the combined information obtained from both interviews, as is standard, and inter-rater
reliability was k = 1.00.
The Revised Child Anxiety and Depression Scale (RCADS; Chorpita et al., 2000) was completed separately
by parents and children. The RCADS is a 47-item parent and child report scale which assesses symp-
toms of separation anxiety disorder, social anxiety disorder, generalized anxiety disorder, panic disor-
der, obsessive–compulsive disorder and major depressive disorder. Responders rate how often each item
applies on a scale of 0 (‘never’) to 3 (‘always’). The RCADS has been shown to have robust psychometric
properties in children and young people from 7 to 18 years of age (Chorpita et al., 2005). Internal consist-
ency based on data from the current sample was good (Cronbach's α .91 for parent report and .95 for
child report).
The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-C/A; Masia-Warner et al., 1999)
was administered to assess children's self-reported social anxiety symptoms. The self-report version of
the LSAS-C/A was used and includes 24 items, rated on a scale from 0 ‘none’ to 3 ‘severe’, to assess
fear and avoidance of social interaction and performance (Masia-Warner et al., 1999). A cut-off score
of 22.5 is considered to distinguish between individuals with SAD and normal controls. The LSAS-C/A
has well-established psychometric properties when administered to children and young people from 7
to 18 years of age (Masia-Warner et al., 2003) with good internal consistency from the current sample
(Cronbach's α = .88 for fear subscale and .89 for avoidance subscale).
Social stress task
In order to gain access to ‘in the moment’ social experiences of the participants (rather than relying on
recall or hypothetical discussion), the qualitative interviews were conducted in front of a pre-recorded
audience of similar-aged children. The children in the recording were broadly attentive and neutral in
their responses. Participants were told that the audience was pre-recorded but asked to imagine that they
were standing in front of a live audience. To maintain the social-evaluative nature of the situation, the
audience was filmed in a classroom setting with children of a similar age to the participants and the video
was projected life-size (playing audio of a busy classroom) to create a sense of a live audience (in line with
similar recordings; e.g., Westenberg et al., 2009).
Indicative topic guide
A topic guide (Appendix S1) was developed to explore children's experiences relating to mechanisms
hypothesized to maintain SAD in adult cognitive models of the disorder during an in vivo social stress task.
The topic guide questions were based on the literature (in particular Clark and Wells (1995) and Rapee
and Heimberg (1997) cognitive models) and discussions with experts and explored children's tendency
to engage in (or experience): pre- and post-event processing; self-focused attention and self-monitoring;
negative images; and safety-seeking behaviours. The topic guide was used flexibly, allowing for variation
in the order and wording of questions and ensuring children had the opportunity to discuss issues that
departed from the prepared areas of questioning. The topic guide was modified iteratively, as the inter-
views and concurrent data analysis proceeded, to incorporate new information and focus progressively
on themes.
In order to help children to understand the questioning and be able to express themselves, several
items and prompts were used. For example, when children were asked about their cognitions, they were
encouraged to write down or illustrate their thoughts using ‘thought bubbles’; when expressing negative
imagery, they were given access to paper and coloured pens to illustrate the images. To identify bodily
symptoms of anxiety, children were shown pictures of people experiencing common physical symptoms
of anxiety as prompts (e.g., a person holding their tummy). Furthermore, complicated constructs such as
self-focused attention were explained using several prompts; a torch (pointed towards the pre-recorded
audience and the self) and printed pictures (explaining the difference between first person and third
person perspective). Interviews lasted between 20 and 40 min (with the video running most of the time
on a loop). They were audio and video recorded, and all content was transcribed in full and anonymized
at the point of transcription. Observations from the video recording and the researcher's fieldnotes
contributed to the dataset.
Procedure
Parents of all participants gave written informed consent and children provided assent. All procedures
received University and National Health Service ethical approval (reference number removed for blind
review). Once consent/assent was gained and eligibility confirmed, participants were invited to attend
the research session. Upon arrival, children and their parent/s completed the questionnaires described
below. They were then directed into the laboratory, and the child was informed that they would shortly
see a video projected onto a wall of a pre-recorded audience (of similar age children), which would likely
trigger feelings of anxiety and their task involved answering questions whilst the video was playing. Once
children had settled in, parents were asked to leave the room and the interview began. Children were
encouraged to keep watching the video whilst answering the questions. Participants were told that they
could stop the interview at any point. In order to keep the flow of the video going, it was not stopped
whilst children's answers were elicited. Participants were given the opportunity for discussion once the
video ended. One week later, participants were invited to answer further questions (via phone or in person
and lasting approximately 5–10 min) focussing on post-event processing but without the pre-recorded
audience. Participants received a voucher for their help and time with the study. The topic guide and social
stress task procedures were piloted with three children and amendments made based on their feedback.
Data analysis
The consolidated criteria for reporting qualitative research (Tong et al., 2007) checklist were followed.
We used Nvivo V12 to support reflexive thematic analysis of participant transcripts (Tong et al., 2007).
Reflexive thematic analysis was chosen because it is a theoretically flexible method of analysis (Braun
et al., 2018; Braun & Clarke, 2013), which allows a focus on both the identification of commonalities and
variations in children's social experiences. Coding involved both an inductive and deductive approach as
our aim was both on theory building (inductive) and testing an existing theory (deductive; e.g., mainte-
nance mechanisms identified in the adult models). Data from both interviews (those focused on in the
moment social experiences and those focused on post-event processing) were analysed together as one
broad dataset. The analysis followed Braun and Clarke (2006, 2013) and Braun et al. (2018) six-phase
approach: (i) Familiarization with the data, (ii) Coding; (iii) Generating initial themes, (iv) Reviewing
themes, (v) Defining and naming themes and (vi) Writing up. Each phase builds on the previous, with
movement back and forth between phases (Braun & Clarke, 2006, 2013).
The first author, a clinical psychologist with experience in delivering CBT for SAD, completed all
interviews, transcribed the data, led the analysis and discussed each stage in the process with KH (a qual-
itative researcher with no experience in treating children with SAD), PW and CC (both clinical psycholo-
gists experienced in treating childhood SAD). During discussions, the authors encouraged each other to
clarify and refine their interpretations–with the aim of optimizing the rigour and quality of the analysis.
Initial stages involved developing a set of themes to capture the children's experiences of social anxiety.
The team then moved to a more deductive approach, where the authors attempted to explore how chil-
dren's experiences mapped onto adult models of SAD. This led to further refining of the themes, which
were again discussed by the whole research team, thereby increasing our confidence in the robustness of
our thematic structure to capture the range of experience described by the children in the study.
RESULTS
Demographic information
Child characteristics, clinical severity ratings and child- and parent-reported anxiety are reported in Table 1.
Qualitative results
When asked, most children reported (and appeared) feeling anxious before and after standing in front
of the pre-recorded audience and expressed relief once the video-recorded audience was turned off,
suggesting that the projection of a video-recorded audience successfully induced anxiety. Notably, a
subset of children experienced debilitating levels of anxiety during the interview. This was evident from
their behaviour and body language, such as covering their faces with their hair, fiddling with their hands,
avoiding looking at the screen, crying, whispering or in some cases not speaking at all. Three interviews
(participants EE, JJ and LL) had to be stopped before they could be completed, due to children's distress.
The interviews revealed both variety and commonalities in the experiences and interpretations of
social events in children with SAD, captured within three main themes. The first theme ‘Discomfort
T A B L E 1 Child characteristics, clinical severity and levels of social anxiety
ADIS Child Parent Child

CSR RCADS RCADS LSAS-
for total total C/A
ID Sex Age Ethnicity SAD Comorbid anxiety disorder (ADIS CSR) (t-scores) (t-scores) total
AA Male 12 White 7 GAD (4) 62 >80 86
BB Female 11 White 7 GAD (5); PHO (5); SEP (4) 52 70 93
CC Male 11 White 6 GAD (5) 61 >80 112
DD Male 12 White 6 SEP (4) 58 >80 86
EE Female 12 White 6 GAD (4) 52 64 99
FF Female 11 White 6 PHO (5); GAD (5); SEP (4); PAN (4) 49 75 60
GG Female 9 White 4 – 36 60 25
HH Female 12 White 7 GAD (6); SEP (6); MDD (6) 70 >80 110
II Female 12 White 5 – 76 78 89
JJ Female 11 White 5 – 45 64 77
KK Female 10 White 6 SEP (6); PHO (6) 40 65 45
LL Male 8 White 4 – 45 58 103
Abbreviations: CSR, clinical severity rating (0–8); GAD, generalized anxiety disorder; LSAS, Liebowitz social anxiety scale for children and
adolescents; MDD, major depressive disorder; PAN, panic disorder; PHO, specific phobia; RCADS, revised children's anxiety and depression scale;
SEP, separation anxiety disorder.
being the centre of attention’ contained three, related, subthemes (‘I will do something wrong’; ‘I am
being judged’ and; ‘Sense of being stared at’) and concerned why children with SAD find social situa-
tions threatening. The second theme, ‘(Lack of) awareness of cognitions’, concerned children's ability
to identify (or articulate) their cognitions, with participants reflecting one of four main types: those who
were able to report their cognitions (‘Knowing what I and others are thinking’); those who reported not
having any thoughts but a strong emotional reaction (‘It is just a feeling’); those who reported ‘Finding it
hard to explain’ what they were thinking, and; those who were unclear about cognitions (‘Not knowing’).
Theme three, ‘Managing social fears’ contained two related subthemes (‘Wanting to get out of here’ and
‘Trying to come over as likeable’) and concerned how the children try to manage their social fears and
associated anxiety. Relationships between the themes were evident. Anonymized (through pseudonyms)
participant comments are provided below to evidence the findings.
Theme one: Discomfort being the centre of attention
I will do something wrong
All of the children endorsed the view that social situations were threatening, and experienced great
discomfort when they perceived they were the centre of attention.
When asked to report on what they were thinking and if there was anything they were concerned
about, children typically expressed concerns about their own social performance:
CC (age 11): …I will say something wrong.

DD (age 12): I will make a fool of myself.
Notably, two of the older children who reported fears about doing something embarrassing, also
spoke about ‘not knowing’ what to do in social situations, indicating negative beliefs about their ability to
manage social interactions:
AA (age 12): Usually in [social] situations, I'm meant to do something, and I'm scared I'm going to
fail to do it…I don't know what to do.
DD (age 12): …all I know is that when people are looking at me I just get ‘oh what do I do?’ Do
I stand still, or do I move…I don't know.
I am being judged
In addition to being concerned about their own social performance, it was evident that many participants
perceived that the children in the pre-recorded audience were judging them negatively. For example, both
KK (age 10) and HH (age 12) said the others found them ‘boring’ and DD (age 12) said the children
were thinking ‘he's a fool’. Notably, none of the children reported that the children in the pre-recorded
audience had positive thoughts about them and/or liked them.
HH (age 12): They wouldn't want to make friends with me
Furthermore, although the children in the recording were neutral in their responses and showed no
signs of laughing, some participants perceived that they were being laughed at:
JJ (age 11): There were these three girls laughing, and I thought they were laughing at me.
Whilst most children had specific ideas about what the children in the audience were thinking of
them, others were less sure. For example, FF (age 11) said she was ‘not sure’ what the children were think-
ing, but her non-verbal behaviour (e.g., avoiding looking at the screen, appearing distressed) and further
questioning indicated it was something negative. Notably, FF's explanation here suggests that she is aware
that her negative predictions may not necessarily be true:
FF (age 11): …I'm not sure what they are thinking, I kind of think for them, like make up what
they are thinking.
Interviewer: And is that negative?
FF (age 11): Yeah.
Sense of being stared at
Several children commented that they perceived the other children in the audience to be staring at them.
KK (age 10): …they are staring at me in like… a like… a weird way… Eh… I feel like different
because like they are staring at me.
It was noticeable that KK reported that the sense of being stared at made her feel ‘different’. The
other children used a range of words that suggested this feeling of being stared at had a significant impact
on how they felt, for example ‘overwhelmed’ (II, age 12); ‘confused’ (DD, age 12) and ‘freaked out’ (FF;
age 11). Notably, when participants were interviewed again 1 week later to specifically ask them about
post-event processing, FF was the only participant that appeared to engage in this behaviour and the
thought content was focused on being looked at and the experience of embarrassment:
Interviewer: Over the last week, did you have any thoughts about the video?
FF (age 11): I spoke to mom [after the session] and thought they were all looking at me.
Interviewer: Any other thoughts you have?
FF (age 11): Like… embarrassing one. And how they are all staring.
For two of the oldest children, the sense of being stared at did trigger negative images and when
asked to describe how they ‘saw’ themselves in the image they said:
II (age 12): …like red, and hot and ehm… just ehm… sweaty.
DD (age 12): Bigger than I am… looking like an idiot? Just standing out from everyone else. Kind
of behind everyone else.
Theme two: (Lack of) awareness of cognitions
Knowing what I and others are thinking
Some children engaged well with questions about their cognitions throughout the interview and were able
to respond quickly with thoughts about being ‘unlikeable’ (KK, age 10) or give more detailed answers
describing how different children in the pre-recorded audience had different views about them:
KK (age 10): She [pointing at a girl in the pre-recorded audience] might be thinking ‘she is not
very nice’.
Interviewer: What about the boys, what are they thinking?
KK: That one looks a bit nervous. And the other one is really serious….He could be worried and
doesn't want to show it…
Interviewer: They might not like me, they might start laughing at me.
It is just a feeling
Although many participants engaged well with questions about their cognitions, others could not describe
specific thoughts or fears associated with anxious feelings. For example, LL (age 8) said he was worried
about feeling ‘nervous’ but answered ‘no’ when asked whether there was anything specific he was worried
about. Similarly, AA (age 12) said he often did not know what he was afraid of and described judging
social situations on how they made him feel:
Interviewer: Okay, so I can see you're feeling anxious now. And I can see that you're not looking
at them. Is there a reason for that?
AA (age 12): I just don't want to see them.
Interviewer: Can I ask why?
AA: It's just a feeling.
Probing encouraged some children to express thoughts, but not everyone. For example, despite being
visibly very anxious and reporting that her tummy hurt, BB (age 11) whispered when asked what she was
thinking:
BB (age 11): I don't have any thoughts.
It was noticeable that both participants BB and AA showed a particularly tense body posture during
the task—appearing as if they were frozen. Indeed, AA (age 12) specifically commented that he ‘usually
just stand[s] there, frozen’ when asked how he normally felt whilst standing in front of his peers at school
(e.g., reading in front of the class).
Finding it hard to explain
Others appeared to imply that their social anxiety was linked to specific negative cognitions but found it
hard to explain what they were:
Interviewer: Anything that you are anxious about?

DD (age 12): ehmm…Sort of.
Interviewer: Sort of. Ok. Can you tell me what that is?
DD: Eh…no it is hard to explain.
Later on, DD reported that this is how he normally felt before and after social interactions—that is,
anxious and worried, but finding it hard to explain why.
Not knowing
Other children (particularly younger participants) commonly said ‘I don't know’ or ‘I'm not sure’ when
asked about their cognitions. For these children, it was unclear whether they felt anxious without a clear
associated negative cognition or whether they could not explain or articulate what they were thinking.
For example, one child said loudly: ‘No, no no…’ (LL, age 8) when the pre-recorded audience appeared
on the wall and ran to hide behind the interviewer and asked for the video to be turned off. When asked
what it was that was making him anxious, he replied: ‘I don't know’. Furthermore, despite our efforts to
try to explain concepts in age-appropriate ways and give participants opportunities to express imagery in
a number of ways (e.g., through drawing)—most participants found it hard to engage with discussions
about imagery and looked blank when asked about this concept.
Theme three: Managing social fears
Wanting to get out of here
The children identified several strategies that they used to manage their social fears and associated anxiety.
Unsurprisingly, most children reported that they typically tried to avoid social interactions:
LL (age 12): … I will try to look busy, like go on my phone, try to look away so I have to talk to
someone.
Within-situation avoidance behaviours, such as avoidance of eye contact, were also commonly
reported across the age range:
GG (age 10): …if I feel nervous, I don't like to look at people when I'm talking. I actually look at
something that is not looking back at me.
When avoidance was not possible, children commonly endorsed attempting to escape from social
situations:
AA (age 12): I just want to get out and stop focusing on how I say things and look at other people.
Trying to come over as likeable
When children were asked specifically about other cognitive and behavioural safety-seeking behaviours
(i.e., if there was anything they were doing to help themselves feel less anxious either at that moment
or in other social situations where they could not avoid or escape), the younger children struggled to
engage with the conversation, whereas the older children were more likely to provide examples. One
child commented specifically about trying to ‘look normal’ (DD, age 12) but was unable to say what that
involved. Another child said she tried to act friendly to make herself feel safer and less anxious:
FF (age 11): …[I] try to make contact, like nice contact…and, just smile and try to be nice… I try
to make them think I'm a nice person.
Two (older) children reported engaging in cognitive safety-seeking behaviours, specifically preparing
what to say in advance:
II (age 12): I'm thinking of what I say before I say stuff.
Children also appeared to describe engaging in what appeared like soothing behaviours, such as ‘play
with a string’ (FF, age 11) or ‘[Have] my hands in my pockets to mess around’ (DD, age 12) to distract
themselves from their social anxiety.
DISCUSSION
This is the first qualitative study that we are aware of that is focussed upon ‘in the moment’ social expe-
riences and perceptions of pre-adolescent children with SAD, in order to inform a greater understanding
of the maintenance of the disorder. Discomfort being the centre of attention was evident for all the chil-
dren, and in many cases, this was driven by the negative belief/s that they would do something wrong, be
judged and/or stared at by others. This led to a variety of emotional and behavioural reactions intended
to deal with the perception of threat, some of which have been described in the previous literature with
socially anxious children and some which have not. More specifically, as noted in previous research recruit-
ing pre-adolescent children with SAD (e.g., Alkozei et al., 2014; Kley et al., 2012; Spence et al., 1999), there
was evidence that the children's negative beliefs reflected a sense of social threat, ambiguous neutral
stimuli (e.g., the neutral facial expressions of children in the pre-recorded audience) were interpreted in
an overly negative fashion, and within-situation avoidance was seen as a ‘helpful’ strategy to avert feared
outcomes. Notably, among the older children in the study, potential maintenance factors were described
that have not previously been systematically examined in the (pre-adolescent) child-focused literature on
SAD; including the use of safety-seeking behaviours, post-event processing and experience of negative
imagery, which appeared to reinforce children's negative belief/s about how they appeared to others. In
contrast to the adult CBT models (Clark & Wells, 1995; Rapee & Heimberg, 1997), children's narratives
did not indicate that they experienced diffused body perception or a felt sense (i.e., reported using their
internal experiences as evidence that others were judging them or described a compelling feeling that
encapsulated their social fear). For example, none of the children reported feeling embarrassed, shaking,
sweating and/or stupid and interpreting such feelings as evidence that others saw they were embarrassed,
and noticed that they were shaking and sweating and/or felt they came across as stupid.
At present, the most frequently used psychological treatment for childhood SAD is multi-disorder-fo-
cused CBT (e.g., Kendall & Hedtke, 2006). This typically includes a core combination of challenging
negative thoughts and behavioural exposure (often to target avoidance). Thus, whilst a number of
mechanisms identified here are directly targeted in multi-disorder-focused CBT, others (in particular
safety-seeking behaviours, negative imagery and self-focused attention) are not explicitly addressed.
Furthermore, even though many of the main mechanisms that are targeted in multi-disorder CBT do
seem to apply for pre-adolescent children with social anxiety, they appear to apply to a greater or lesser
extent across individuals. For example, there was variation in children's awareness of their negative cogni-
tions. Whilst some children had no difficulty articulating their social fears, other children reported no links
between their social anxiety and negative cognitions, or were unable to explain what they were thinking,
or reported not having any thoughts at all. In addition, it seems likely that there are developmental influ-
ences on which maintenance mechanisms apply at which point in time as only older children in the sample
reported safety-seeking behaviours, negative imagery and post-event processing, indicating that more
disorder-specific CBT interventions may apply in early adolescence. Human brain development under-
goes vast developmental changes between childhood and adulthood which affect key social and cognitive
capabilities such as self-awareness, peer influence and sensitivity to social rejection (Kilford et al., 2016).
It is likely that the development of these social and cognitive capabilities influences the presentation and
timing of several psychological mechanisms. In support of this, we note that older children in this study
were more likely to engage in sophisticated safety-seeking behaviours like impression management than
younger participants, indicating that this may potentially develop with age. Notably, a recent study (Evans,
Chiu, et al., 2021) reported age-related effects on the use of particular safety-seeking behaviours. That
is, older adolescents engaged more frequently than younger adolescents in safety-seeking behaviours (in
particular, impression management behaviours) that are considered to require complex social cognitive
skills. It should also be noted that the two subthemes identified in this study (i.e., ‘Wanting to get out of
here’ and ‘Trying to be likeable’) that focused on children's safety-seeking behaviours, align with findings
from factor analytic studies with adults with SAD (e.g., Gray et al., 2019; Plasencia et al., 2011) and more
recently adolescents with SAD (Evans, Chiu, et al., 2021; Evans, Clark et al., 2021) that suggest that
safety-seeking behaviours in SAD can be subdivided into two broad categories: avoidance and impres-
sion management strategies. We also note that only two participants (whom both were among the oldest
participants in the study) reported experiencing distorted negative self-imagery. It is possible that the
lack of negative imagery in our sample results from limited experiences of distressing (traumatic) social
events (e.g., bullying, being humiliated) among our participants, as such events have been linked to the
development of negative imagery in adults with SAD (Hackmann et al., 2000). However, it is also possible
that this finding reflects developmental variation in the association between cognition and affect. Specif-
ically, whilst it is well-established that pre-adolescent children experience and use imagery (e.g., imaginary
play; Tobin et al., 2013), it has been argued that the relationship between social anxiety and imagery likely
changes during the course of childhood and adolescence as individual's competence in mental imagery
(e.g., ability to generate and reflect on an image) is likely to alter with age (Heyes et al., 2013). Clearly,
future studies should take a developmentally informed approach to help us to understand the nature of
the association between these factors and social anxiety in childhood and how that may change through
development.
Given the preliminary nature of the findings of this study, any implications for how treatment may be
adapted in order to make it more targeted and efficient must be extremely tentative and further research
is needed to make any strong recommendations. However, the preliminary findings highlight the impor-
tance of understanding from the beginning of treatment what maintenance mechanisms apply to each
child, followed by the delivery of treatment in a flexible manner where specific treatment components are
added or modified to meet the individual needs of the child. For example, experiencing negative imagery
and engaging in safety-seeking behaviours—two processes described by DD—are typically not targeted in
multi-disorder-focused CBT. Children like DD may benefit from the use of video feedback—a core tech-
nique for addressing safety-seeking behaviours in cognitive therapy for adults with SAD (Warnock-Parkes
et al., 2017), that has recently shown promise for adolescents (Leigh & Clark, 2018). Furthermore, chil-
dren that are concerned about exhibiting flaws in social competence and coming across as anxious may
benefit from treatment interventions that target such concerns and have been found to be helpful for
adults with SAD (see Moscovitch, 2009). In contrast, for those children who appeared less aware of their
cognitions, persisting with questioning them about their negative thoughts may be disheartening and
unhelpful, whereas focusing mainly on behavioural exposure may be more appropriate. However, there
may also be additional (yet unknown) processes contributing to the maintenance of social anxiety in these
children and this warrants further examination.
One of the significant strengths of qualitative studies is that they encourage theory development
from the lived experiences of study participants (Braun & Clarke, 2013). Indeed, findings from qualitative
studies investigating the lived experiences of adults with SAD have resulted in a better understanding
of the nature and maintenance of social anxiety in adult populations and supported the development
of effective treatment interventions (e.g., Hackmann et al., 2000). That so many participants were able
to give detailed descriptions of their experiences suggests that, despite their social anxiety, there is merit
in sensitively using social stress tasks to explore how children with SAD experience and interpret social
events. Nonetheless, our findings should be considered in light of their limitations. First, interviewing
children presents several challenges including communicating about concepts in age-appropriate ways and
making sure they can express their views and ideas (Gibson, 2012). Despite careful use of language and
the use of several items and prompts to make it easier for study participant's (who, given their presenting
problem, find social interactions particularly difficult) to express themselves, not all children were able to
provide in depth, rich responses in the interviews. It is also important to note that some participants may
have found the dual nature of the social stress task (i.e., watching a video whilst also answering questions)
complex and difficult to process, which may have had an impact on their ability to answer the study's
questions. This was a novel procedure and further examination is required, however, that so many chil-
dren were able to give detailed descriptions of their experiences, provides evidence of ecological validity
and, demonstrates that, despite the difficulties, there is merit in asking children with SAD to participate
in research of this kind. Second, the study is qualitative and so statistical-probabilistic generalization to
the population is not possible. Instead, the goal of qualitative research is to provide a rich, contextualized
understanding of children's experience of social anxiety disorder in order to extend the transferability of
the findings beyond the study sample and make analytic generalizations to theory (Polit & Beck, 2010).
Third, it is likely that there may be other potential maintenance mechanisms that we did not identify and
explore within this study. For example, peer interactions, such as low peer acceptance and/or victimiza-
tion, and particular parental practices may play a role in maintaining social anxiety in children (Halldors-
son & Creswell, 2017). Furthermore, although the topic guide was modified iteratively to incorporate new
information and focus progressively on themes, it was influenced by two particular cognitive models of
adult SAD (Clark & Wells, 1995; Rapee & Heimberg, 1997). It is important to note that other models
of adult SAD have been published over recent decades that include distinct components. For example,
Hofmann (2007) emphasizes the role of ‘low perceived emotional control’ and ‘poorly defined social
goals’, and Moscovitch (2009) argues that particular self-relevant concerns play a role in maintaining
social anxiety (i.e., individuals with social anxiety are concerned about exhibiting flaws in social compe-
tence, showing visible signs of anxiety and exhibiting flaws in physical appearance). Future studies would
benefit from examining whether these factors also play a role in maintaining childhood social anxiety.
Notably, in support of Moscovitch (2009) model, some children in this study expressed concerns about
their social competence and (to some extent) coming across as anxious; although notably they did not
specifically describe concerns about their physical appearance. Fourth, although our sample, with its
high levels of comorbidity, is clinically representative (Kendall et al., 2010; Waite & Creswell, 2014), it is
not clear to what extent children's responses reflect their experience of social anxiety disorder specifi-
cally. Another key limitation is that the participants were all White British. Although reflecting the typi-
cal patient receiving treatment/assessment in the setting in which they were recruited, future research
should explore ‘in the moment’ social experiences of children from more diverse backgrounds as there
is evidence to suggest that culture may influence the presentation and expression of anxiety problems in
children (Varela et al., 2019) and adults (Hofmann et al., 2010). Finally, and critically, although the whole
research team took part in shaping the data and comprised researchers from different backgrounds, three
authors have expertise in CBT, and this experience is likely to have had an effect on the interpretation of
the data in this study.
CONCLUSIONS
This analysis of the ‘in the moment’ social experiences of children with SAD highlights the varied pres-
entation of childhood SAD which should be considered when undertaking clinical work with children
with SAD. There appear to be differences in which maintenance mechanisms children with SAD endorse
and developmental factors are likely to influence when specific mechanisms come ‘online’. In line with
SAD treatment development procedures within the adult field (Clark, 2004), further studies are now
needed to (i) experimentally manipulate the psychological factors identified in the current study to exam-
ine which factors truly play a role in maintaining childhood SAD; (ii) use those findings to develop specific
treatment strategies to target the identified maintenance mechanisms; and (iii) develop instruments that
allow us to identify which mechanism (individual) children with SAD express and use the same instru-
ments to guide the focus of treatment.
AUTHOR CONTRIBUTIONS
Brynjar Halldorsson: Conceptualization; data curation; formal analysis; investigation; methodology;
project administration; resources; writing – original draft; writing – review and editing. Polly Waite:
Formal analysis; writing – original draft; writing – review and editing. Kate Harvey: Formal analysis;
writing – original draft; writing – review and editing. Samantha Pearcey: Data curation; writing – original
draft; writing – review and editing. Cathy Creswell: Conceptualization; formal analysis; investigation;
methodology; supervision; writing – original draft; writing – review and editing.
ACKNOWLEDGEMENTS
Brynjar Halldorsson is funded by the Oxford and Thames Valley NIHR Applied Research Collaboration.
Polly Waite is funded by an NIHR Postdoctoral Research Fellowship (PDF-2016-09-092). Cathy Creswell
was supported by an NIHR Research Professorship (NIHR-RP-2014-04-018) until 30.9.19. The views
expressed in this publication are those of the authors and not necessarily those of the NIHR or the
Department of Health and Social Care.
CONFLICT OF INTEREST
All authors declare no conflict of interest.
DATA AVAILABILITY STATEME NT

The data that support the findings of this study are available on request from the corresponding author.
The data are not publicly available due to privacy or ethical restrictions.
ORCID
Brynjar Halldorsson https://orcid.org/0000-0003-2108-2669
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SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end
of this article.
How to cite this article: Halldorsson, B., Waite, P., Harvey, K., Pearcey, S., & Creswell, C.
(2023). In the moment social experiences and perceptions of children with social anxiety
disorder: A qualitative study. British Journal of Clinical Psychology, 62, 53–69. https://doi.
org/10.1111/bjc.12393

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In the moment social experiences and perceptions

Brynjar Halldorsson1,2,3,4 | Polly Waite1,2,5 | Kate Harvey5 |

Br J Clin Psychol. 2023;62:53–69. wileyonlinelibrary.com/journal/bjc 53

of the association between the factors identified in this study

Structured diagnostic interviews

Social stress task

Indicative topic guide

T A B L E 1 Child characteristics, clinical severity and levels of social anxiety

ADIS Child Parent Child

Theme one: Discomfort being the centre of attention

I will do something wrong

CC (age 11): …I will say something wrong.

HH (age 12): They wouldn't want to make friends with me

Sense of being stared at

Theme two: (Lack of) awareness of cognitions

Knowing what I and others are thinking

BB (age 11): I don't have any thoughts.

Finding it hard to explain

Interviewer: Anything that you are anxious about?

Theme three: Managing social fears

Wanting to get out of here

Trying to come over as likeable

II (age 12): I'm thinking of what I say before I say stuff.

DATA AVAILABILITY STATEME NT

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