This century's increase in addiction issues among U.S. youth may be related to their developmental need to fit in, particularly youth with social anxiety disorder (SAD), which could exacerbate the drink/trouble cycle. In addition, socially anxious youths may avoid participating in therapeutic activities during treatment for fear of negative peer appraisal. A study of the influence of SAD on clinical severity at intake, peer helping in Alcoholics Anonymous (AA) during treatment, and subsequent outcomes has found that almost half of the patients entering treatment had a persistent fear of social humiliation, however, helping others through service activities greatly aided their recovery.
Results will be published in the May 2015 online-only issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.
"Socially anxious adolescents quickly figure out that alcohol and drugs can provide ease and comfort in social situations that are anxiety provoking," explained Maria E. Pagano, associate professor in the department of Psychiatry at Case Western Reserve University and corresponding author for the study. "Reaching for a substance to change how you feel can quickly become a knee-jerk reaction, develop into an addiction, and rob youth of learning how to tolerate interpersonal differences and uncomfortable feelings, develop emotional maturity, and cultivate self acceptance."
John F. Kelly, associate director of the Center for Addiction Medicine at Massachusetts General Hospital, and associate professor of psychiatry at Harvard Medical School, agreed. "SAD, in particular, is a predictor of alcohol and other drug use and related problems," he said. "If adolescents do not know about other forms of help for their social anxiety or if they are not made available to them, then alcohol can become a predominant form of coping, which can lead to increased risk for alcohol-related problems, especially when there are shared genetic or other biological vulnerabilities present for alcohol use disorder and SAD."
Furthermore, added Pagano, adolescents who fear being criticized by their peers will likely not speak up in group therapies during treatment, which can limit their benefit from treatment. "There is a lot of healing that comes from sharing your insides with others," she said. "Socially anxious patients may not get this healing, nor let others really get to know who they are and give input to their lives."
Researchers examined a large sample of adolescents court-referred to residential treatment. The adolescents (n=195; 102 females, 93 males; 30% Black), ages 14 to 18 years, were prospectively assessed at treatment admission, treatment discharge, and six months after treatment discharge. Data were collected using rater-administered assessments, youth reports, clinician reports, medical charts, and electronic court records. The influence of SAD on peer helping and outcomes was also examined.
"We found that almost half of patients entering adolescent residential treatment suffer from a persistent fear of social humiliation that began years before they started to experiment with alcohol and other drugs," said Pagano.
"During residential treatment, in general, SAD and non-SAD youths did not differ on the degree to which they engaged in other 12-step activities or treatment duration, however, SAD youth were more likely to be involved in 12-step service activities," added Kelly. "At six months after treatment, those with SAD and those engaging in 12-step service work were associated with better outcomes - with evidence of 12-step service work partially explaining the effect of SAD's positive relationship to abstinence."
Pagano explained that service or higher peer helping during AA meetings refers to low-intensity tasks like putting away chairs, or making coffee. "It is less about needing peer assistance or expecting praise or recognition from giving service," she said. "It is more about adopting the attitude of 'how can I be helpful?'"
Both Pagano and Kelly called for greater service participation during all stages of treatment in order to help youth overcome their social anxiety and further aid in their recovery efforts.
"There are many real-world applications for the findings from this study," said Pagano. "Adolescents could benefit from knowing that most people feel like they do not fit in and that it is a lifelong journey to become comfortable in your own skin. Parents, teachers, and other positive adults in the lives of adolescents can provide education about this and the role and long-term costs that alcohol and other drugs might have in the pursuit of short-term relief. While learning to tolerate feeling different and letting other people have their opinions about you takes practice, it gets easier."
"Although the impulse may be to protect socially anxious kids from situations in which they may experience social scrutiny," added Kelly, "when exposure is thoughtfully done, it may help young people with alcohol/drug problems to adapt successfully in the transition to young adulthood."
Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. Co-authors of the ACER paper, "Social Anxiety and Peer-Helping in Adolescent Addiction Treatment," were: Alexandra R. Wang of the Case Western Reserve University School of Medicine; Brieana M. Rowles of the Department of Psychiatry in the Division of Child Psychiatry at Case Western Reserve University; Matthew T. Lee of the?Department of Sociology at the University of Akron; and Byron R. Johnson of the Institute for Studies on Religion at Baylor University. The study was funded by the National Institute on Alcohol Abuse and Alcoholism, and the John Templeton Foundation.
Contact: Maria E. Pagano, Ph.D.
Case Western Reserve University
Add'l contact: John F. Kelly, Ph.D.
Harvard Medical School