According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), avoidant personality disorder (APD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Children who meet the criteria for APD are often described as being extremely shy, inhibited in new situations, and fearful of disapproval and social rejection. The degree of the symptoms and impairment is well beyond the trait of shyness that is present in as many as 40% of the population. Similar to other personality disorders, the condition becomes a major component of a person’s overall character and a central theme in an individual’s pattern of relating to others. Like other personality disorders, the diagnosis is rarely made in individuals younger than 18 years, even if the criteria are met. The literature regarding childhood APD is extremely limited. More information is known about social phobia (also known as social anxiety disorder) in children, which has many overlapping features with APD.
APD is closely linked to a person’s temperament. Approximately 10% of toddlers have been found to be habitually fearful and withdrawn when exposed to new people and situations. This trait appears to be stable over time. Social anxiety is hypothesized to involve the amygdala and other areas of the brain’s limbic system, which, in affected individuals, is postulated to have a lower threshold of arousal and a more pronounced response when activated. Dysregulation in the brain’s dopamine system has also been found to be associated with adult social anxiety disorder.
The frequency of APD in children is unknown because current psychiatric practice is to avoid labeling children and adolescents with personality disorders and to describe their traits instead. However, in the adult general population, the prevalence is estimated to be 2.1–2.6%.2 Among adults receiving outpatient psychiatry treatment, the rate of APD is reported to be 14.7%.
The international frequency has not been studied in children, although a twin study of young adults found an APD rate of 1.4% in men and 2.5% in women.
- School refusal and poor performance: As many as one third of children who refuse to go to school may have significant social anxiety.
- Conduct problems and oppositional behavior: Many children with severe social anxiety refuse to participate in social activities and may have behavioral outbursts or panic attacks when placed in a social situation.
- Poor peer relations: Patients with APD often have few friends and often refuse social overtures as children, behavior patterns that persist through adolescence and adulthood.
- Lack of involvement in social and nonsocial activities: Patients with APD demonstrate lower levels of participation in athletics, extracurricular activities, and hobbies than children with depression or other personality disorders.
APD is estimated to be equally common in males and females.
APD is not usually diagnosed in individuals younger than 18 years; however, most patients report an onset in childhood or adolescence, and many report continued social anxiety throughout their lives.
- Avoidant personality disorder (APD) is a clinical diagnosis based on history provided by the child and caretakers combined with direct behavioral observation and mental status examination. According to the DSM-IV, criteria for diagnosis of APD in adults are met when a patient exhibits 4 or more of the behaviors below. No formal modification has been made for children. However, physicians should use caution when applying DSM-IV criteria, because over diagnosis is a risk in adolescents.
- Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection (For children, the DSM-IV reference to occupational activities can apply to school. Children with APD often have marked difficulty, especially with new classes, presentations in front of the class, and less-structured times such as recess or lunch.)
- Is unwilling to get involved with people unless certain of being liked
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
- Is preoccupied with being criticized or rejected in social situations
- Is inhibited in new interpersonal situations because of feelings of inadequacy
- Views self as socially inept, personally unappealing, or inferior to others
- Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
- In the Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version (DSM-PC), the diagnosis of APD is not used; however, social phobia is mentioned.
- For patients with a suspected diagnosis of APD, evaluating for the presence of other psychiatric disorders, particularly major depression, substance abuse, and other anxiety disorders, is extremely important. The possibility that a fear of involvement with people is based on a history of child abuse and neglect should be investigated.
- Because social anxiety disorders are often found in other family members, a family psychiatric history is beneficial. Treatment of parents and caretakers for their own psychiatric conditions may improve the outcome in the referred child.
- Unlike milder forms of developmental shyness, children with APD or social anxiety disorder do not easily adjust to people in new situations.
- No specific physical examination findings are associated with APD.
- Assess the patient’s hearing acuity as part of a general screening.
- ADP may be more common in patients who have disfiguring physical conditions or limiting chronic illnesses.
- There may be an association between APD and motor impairment in children.
- In adults, a link has been found between APD and obesity.
- The exact cause of APD is unknown.
- The disorder may be related to temperamental factors that are inherited. Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful, and withdrawn in new situations. Components of this temperament have been identified in infants as young as 4 months.
- Genetic factors have been hypothesized to cause APD and social phobia because both conditions are found more frequently in certain families. A recent twin study of Norwegian young adults found a 35% genetic effect for APD; the majority (83%) of these genes are also related to other personality disorders.3
- Environmental factors also play in role in APD. Parenting behaviors, such as low parental affection or nurturing, were associated with an elevated risk of APD when these children reached adulthood.4
- Retrospective studies of adults with APD report high levels of childhood emotional abuse (61%).5 However, physical abuse may be more closely linked with a diagnosis of another personality disorder or posttraumatic stress disorder (PTSD).
- A multifactorial model of causation is likely, with genetic and environmental factors interacting from infancy in various combinations.
Author: David C Rettew, MD, Director, Pediatric Psychiatry Clinic, Assistant Professor of Psychiatry and Pediatrics, University of Vermont College of Medicine
Dr. Gnap is a family practice physician and behavioral medicine specialist in suburban Chicago. Dr. Gnap developed the Inner Control™ Program in 1970 and has worked with thousands of people to improve and correct medical, emotional, behavioral and learning problems including performance. He started the Inner Control program because so many patients asked, “what more can be done along with traditional treatment methods?”