School Closures and Social Anxiety During the COVID-19 Pandemic.

In their recent systematic review, Loades et al.1 reported on the effects that social isolation and loneliness may have on children and adolescents during the global 2019 novel coronavirus disease (COVID-19) pandemic, with their findings suggesting associations between social anxiety and loneliness/social isolation. While this is undoubtedly true for many children and adolescents, it is also worth commenting on the subset of children and youths with social phobia for whom a temporary lessening of distress may be observed while schools are closed owing to a lack of exposure to anxiety-provoking situations in the school environment.

To the Editor:

In their recent systematic review, Loades et al. reported on the effects that social isolation and loneliness may have on children and adolescents during the global 2019 novel coronavirus disease (COVID-19) pandemic, with their findings suggesting associations between social anxiety and loneliness/social isolation. While this is undoubtedly true for many children and adolescents, it is also worth commenting on the subset of children and youths with social phobia for whom a temporary lessening of distress may be observed while schools are closed owing to a lack of exposure to anxiety-provoking situations in the school environment.

Exposure to feared situations is generally regarded as an essential component of anxiety treatment. School environments typically provide a plethora of opportunities for social exposure. Needless to say, opportunities for exposure to social situations have been exceedingly limited for many children and youths during the COVID-19 outbreak. Furthermore, in many jurisdictions, citizens are being commended by politicians and public health officials for engaging in practices aimed at mitigating viral spread, including physical distancing and avoiding nonessential travel outside of their homes. As a result, people with social anxiety disorder are receiving positive reinforcement for avoiding the very situations to which psychological treatment would encourage exposure. In addition, avoidance begets further avoidance by way of negative reinforcement, and acute destabilization for socially anxious children and youths is foreseeable when schools reopen and attendance is expected. Loades et al. aptly acknowledged the limitations of extrapolating existing evidence to the current context. Indeed, the mixture of limited opportunities for social exposure combined with aspects of both positive and negative reinforcement for avoidance of exposure highlights the uniqueness of circumstances resulting from the COVID-19 pandemic.

Despite pragmatic challenges imposed by the COVID-19 outbreak, it is imperative that treatment of social anxiety disorder continue during the pandemic. Clinicians employing cognitive-behavioral therapy may consider shifting their interventions to address negative beliefs and processing of events, rather than emphasizing exposure. Creative and innovative treatment strategies are also called for. Loades et al. suggested that digital interventions may facilitate treatment for children and adolescents during times of social isolation. Indeed, health care providers in various fields are increasingly turning to virtual care technologies to limit physical meetings between patients and clinicians to mitigate viral spread. In treating social anxiety, clinicians should consider exposure to social and performance situations using virtual means.

Clinicians may be lulled into a false sense of security when socially anxious children and adolescents report improvement concurrent with school closures. However, this does not obviate the need for continued treatment during the pandemic. Such improvement is likely to be short-lived, and children and youths with social anxiety disorder will face significant challenges when schools reopen, highlighting the need for continued treatment during the pandemic.