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Pediatr (Rio J). 2017;93(5):442---451

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EVIEW ARTICLE

actors related to the association of social anxiety isorder and alcohol use among adolescents:

systematic review�

lisabeth Lima Dias da Cruz a,∗, Priscila Diniz de Carvalho Martins b, aula Rejane Beserra Diniz a

Universidade Federal de Pernambuco (UFPE), Pós-graduação em Neuropsiquiatria e Ciência do Comportamento, Recife, PE, razil Universidade Federal de Pernambuco (UFPE), Pós-graduação em Saúde da Criança e do Adolescente, Recife, PE, Brazil

eceived 20 October 2016; accepted 9 January 2017 vailable online 1 June 2017

KEYWORDS Phobic disorders; Adolescent; Behavior; Ethanol; Risk factors

Abstract Objective: To identify the risk factors related to the association between social anxiety disorder and alcohol use in adolescents. Source of data: The PICO research strategy was used to perform a systematic review in Medline, LILACS, Pubmed, IBECS and Cochrane Library databases. DeCS/MeSH: Phobic Disorders, Adoles- cent, Behavior, Ethanol, Risk Factors, and the Boolean operator ‘‘AND’’ were used. Inclusion criteria were: cross-sectional, prospective/retrospective cohort, and case-control studies, car- ried out in adolescents (10---19 years), original articles on social anxiety disorder and alcohol use published between 2010 and 2015. Studies that did not report the terms ‘‘anxiety disorder’’ and ‘‘alcohol use’’ in the title and abstract were excluded. Synthesis of data: 409 articles were retrieved; after the exclusion of 277 repeated articles, the following were eligible: 94 in MEDLINE, 68 in Pubmed, 12 in IBCS, and three in LILACS. Titles and abstracts were independently read by two examiners, which resulted in the selection of eight articles for the analysis. Risk factors associated to the two disorders were female gender, age, peer approval and affective problems for alcohol use, confrontation situations and/or compliance reasons, frequency of alcohol use, and secondary comorbidities, such as depression and generalized anxiety. Conclusions: It is necessary to assess the period of social anxiety disorders first symptom onset, as well as the risks for alcohol use in order to establish corrective intervention guidelines,

especially for socially anxious students. © 2017 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Pediatria. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).

� Please cite this article as: Cruz EL, Martins PD, Diniz PR. Factors related to the association of social anxiety disorder and alcohol use mong adolescents: a systematic review. J Pediatr (Rio J). 2017;93:442---51. ∗ Corresponding author.

E-mail: [email protected] (E.L. Cruz).

ttp://dx.doi.org/10.1016/j.jped.2017.05.001 021-7557/© 2017 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Pediatria. This is an open access article under he CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Social anxiety and alcohol use among adolescents 443

PALAVRAS-CHAVE Transtornos fóbicos; Adolescente; Comportamento; Etanol; Fatores de risco

Fatores relacionados à associação de transtorno de ansiedade social e uso de álcool entre adolescentes: uma revisão sistemática

Resumo Objetivo: Identificar os fatores de risco relacionados a associação entre o transtorno de ansiedade social e uso de álcool entre adolescentes. Fontes dos dados: Utilizou-se a estratégia de pesquisa PICO para realizar a revisão sis- temática nas bases Medline, LILACS, Pubmed, IBECS e Biblioteca Cochrane. Foi utilizado os DeCS/MeSH: Transtornos Fóbicos, Adolescente, Comportamento, Etanol, Fatores de Risco e o operador boleano ‘‘AND’’. Os critérios de inclusão foram: estudo transversal, coorte prospec- tiva/retrospectiva e caso-controle, realizados em adolescentes (10 a 19 anos), artigos originais sobre transtorno de ansiedade social e uso de álcool publicado entre 2010 a 2015. Excluíram-se os estudos que não referiam transtorno de ansiedade e uso de álcool no título e no resumo. Síntese dos dados: 409 artigos foram identificados e após exclusão repetidos 277 estudos foram elegíveis: 94 no MEDLINE, 68 em Pubmed, 12 IBCS e 3 LILACS. Foi realizada a leitura dos títulos e resumos de forma independente por dois examinadores, que resultou na seleção de 8 artigos para análise. Fatores de riscos associados aos dois transtornos: predominância do gênero fem- inino, idade, aprovações pelos pares e problemas afetivos para o uso de álcool, situações de enfrentamentos e/ou motivos de conformidades, frequência de uso do álcool e comorbidades secundárias como depressão e ansiedade generalizada. Conclusões: É necessário avaliar o período de surgimento dos primeiros sintomas de transtorno de ansiedade social e dos riscos para o uso de álcool e instituir normas corretivas de intervenções, principalmente para os alunos socialmente ansiosos. © 2017 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de Pediatria. Este é um artigo Open Access sob uma licença CC BY-NC-ND (http://creativecommons.org/licenses/ by-nc-nd/4.0/).

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Introduction

Social anxiety disorder (SAD) is a condition that starts in childhood/adolescence and is characterized by exces- sive fear or intense anxiety when the individual is faced with social exposure situations in public or meeting new people. It is estimated that between 5% and 13% of the population have this problem. It is considered as a chronic pathology, capable of incapacitating the indi- vidual and promoting the development of high rates of psychiatric comorbidities, such as depression, generalized anxiety disorder, and agoraphobia, being the most common anxiety disorder and the third most frequent psychiatric disorder.1---4

These individuals have difficulties in interpersonal rela- tionships (family and social interactions), low self-esteem, low school performance, school dropout, and impairment in memory, perception, and thinking processes. It is note- worthy that SAD usually precedes abuse and dependence of alcohol and other illicit substances, which aggravates symptoms.5

Considered a public health problem, alcohol experimen- tation typically begins in adolescence, between the ages of 12 and 15 years, regardless of social context; individuals with early onset of SAD are at risk for developing depres- sion or alcoholism.2,6,7 This diagnosis occurs shortly before or concurrently with the onset of substance use, which sug-

gests an association between these two health problems and that, even in the face of this evidence, this type of disorder in adolescence has shown a conflicting association with the use of alcohol.

t o b w

The present systematic review aimed to identify the risk actors related to the association between SAD and alcohol se among adolescents.

ethod

systematic review of the literature was carried out based n a search in the Medical Literature Analyses and Retrieval nline (Medline), Latin American and Caribbean Literature

n Health Sciences (LILACS), PubMed, Indice Bibliográfico spañol de Ciencias de la Salud (IBECS), and the Cochrane ibrary databases.

For each research portal, a specific strategy was devel- ped for crossing Descriptors in Health Sciences (DeCS, a razilian database of medical keywords) or Medical Subject eadings (MeSH). The keywords used for the study selection ere: Phobic Disorders, Adolescents, Behavior, Ethanol, Risk actors, and the corresponding terms in Portuguese. The oolean operator ‘‘AND’’ was used to combine keywords and erms for searches. The selection was limited to studies pub- ished in Portuguese, English, or Spanish between 2010 and 015.

After the articles were identified, eligibility, selection, nd exclusion criteria were applied. Original articles that ad alcohol use as a risk factor for SADs were consid- red eligible. The Population, Intervention, Comparison, utcome, Study Design (PICO) research strategy was used

o construct the research question, in order to carry ut the search for clinical evidence of the association etween social phobia and alcohol use.8,9 The following ere selected: cross-sectional, prospective/retrospective,

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nd case---control studies, carried out in humans aged 10---19 ears10; original studies; with alcoholism as a risk factor for hobic disorders. Studies that did not mention alcoholism nd phobic disorders in the article title were excluded, as ell as those with a population of young adults aged 20---24 ears.

Article selection was carried out in three steps, follow- ng the Transparent Reporting of Systematic Reviews and eta-Analyses (PRISMA) method.11 In the first step, two inde- endent researchers read the titles without knowledge of he authors and the journal where they were published. fter the exclusion of the repeated articles, the second tep began, in which the abstracts of the selected studies ere read and, likewise, those that did not meet the inclu-

ion criteria were excluded. Disagreements were resolved by onsensus. In the third step, all studies not excluded in the revious steps were read in full to select those that would e included in this review (Fig. 1).

esults

fter exclusion of the repeated articles, 277 studies were ligible: 94 in MEDLINE, 68 in Pubmed, 12 in IBCS, and three n LILACS. The titles and abstracts were independently read y two examiners, totaling eight articles for analysis in this eview.

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132 duplicate articles subse removed

277 selected article

19 full-text articles evalua for readability

Studies included fo quantitative synthes

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Figure 1 Flowchart representing the selection steps of articles a Source: ‘‘Prisma: Transparent Reporting of Systematic Reviews and

Cruz EL et al.

Table 1 shows the characteristics of the eight studies and he type of protocols used; one study was carried out in inland and seven in the United States. A total of 4579 ado- escents, aged 10---19 years, who had symptoms of SAD and ho consumed alcohol were investigated. In 62.5% of the

tudies, the female gender predominated, accounting for 4% of the total sample.

The association between social anxiety symptoms and lcohol use was confirmed in six studies, two of which ere carried out in a group of adolescents with mean age etween 10 and 11 years, whereas the others evaluated ado- escents older than 15 years. The risk factors attributed by he studies for this association were female gender, peer cceptance, and affective problems for alcohol use, as well s the presence of secondary comorbidities, such as depres- ion, generalized anxiety, agoraphobia, separation anxiety, nd obsessive---compulsive disorder. Other factors such as ultural aspects, frequency of alcohol use, and frequency f intoxication investigated by the studies did not appear to e related to this association (Table 2).

iscussion

he findings show that the evaluated association is still nclear, due to the small number of studies retrieved; how- ver, 75% of the studies showed positive evidence between he association of SAD and alcohol use.

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s 258 excluded articles

ted Full text articles excluded

Six did not have alcohol in title or abstract

Two included adults in the sample

Three included late adolescents in the sample

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bout social anxiety disorder and alcohol abuse in adolescents. Meta-Analyses’’.

Social anxiety and alcohol use among adolescents 445

Table 1 Characteristics of the studies and types of protocols used.

Authors, year, and impact factor (IF)

Country Study duration and sample

Gender and age Type of study Research tool

Fröjd et al. (2011) IF: 1.09

Finland 48 months Sample: 2070

Boys: 903 Girls: 1167 Mean age: 17.6 (SD = 0.41)

Longitudinal study

Social Phobia Inventory (SPIN)

Terlecki et al. (2012) IF: 1.36

USA Sample: 52 Boys: 35 Girls: 17 Mean age: 20.38 (SD = 1.46)

Longitudinal study

Alcohol Use Disorder Identification Test (AUDIT) Brief Alcohol Screening and Intervention for College Students (BASICS) Quantity/Frequency/Peak Index (QFI) Drinking Norms Rating Form (DNRF) Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) Spielberger Trait Anxiety Inventory

Dahne et al. (2014) IF: 1.41

USA 48 months Sample: 277

Boys: 156 Girls: 121 Mean age de 11 (SD = 0.81)

Longitudinal study

Generalized estimating equations (GEE) The Revised Child Anxiety and Depression Scale (RCADS) Youth Risk Behavior Surveillance System

Zehe et al. (2013) IF: 1.4

USA 12 months Sample: 387

Boys: 174 Girls: 213 Mean age: 12.1

Longitudinal study

Social Anxiety Scale For Children --- Revised (SASC-R) Youth Self-Report Survey (YSR)

Terlecki and Buckner (2015) IF: 1.4

USA Sample: 232 Boys: 71 Girls: 161 Mean age: 19.32 (SD = 1.34)

Cross-sectional study

Social Phobia Scale (SPS) Social Interaction Anxiety Scale (SIAS) Drinking Motives Questionnaire Revised (DMQR) Drinking Context Scale-Revised (DCS-R)

Blumenthal et al. (2010) IF: 1.36

USA Sample: 50 Boys: 24 Girls: 26 Mean age 16.35 (SD = 1.10)

Cross-sectional study

Adolescent Alcohol and Drug Involvement Scale (AADIS) Youth Self Report (YSR) Drinking Motives Questionnaire Revised (DMQ-R) Revised Child Anxiety and Depression Scale --- Social phobia subscale (RCADSSP)

Wu et al. (2010) IF: 1.47

USA Sample: 781 Boys: 412 Girls: 369

Cross-sectional study

Diagnostic Interview Schedule for Children

Mean ag

e: 15 (DISC)

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Table 1 (Continued)

Authors, year, and impact factor (IF)

Country Study duration and sample

Gender and age Type of study Research tool

Clerkin. Barnett (2012) IF: 1.4

USA 12 months Sample: 730

Boys: 295 Girls: 435 Mean age 18.35 (SD = 0.47)

Cross-sectional study

Social Avoidance and Distress Scale (SADS) Drinking Motives Questionnaire --- Revised The Graduated Frequency for Alcohol Questionnaire Young Adult Alcohol

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ontextualization of study location

his review identified a predominance of studies carried out n developed countries, primarily in the United States, which ay be related to greater epidemiological surveillance in ental health for children and adolescents. It is important to remember that approximately one in

ve adolescents in that country suffer from a mental disor- er severe enough to have an impact on their activities of aily living, and these are relevant data for the increase in he investigations.12

In Brazil, population-based studies have shown that the nset of anxiety disorders occurs at the mean age of 13 years nd the use of alcohol between 12 and 15 years, while sub- tance abuse begins later, at the age of 24 years. This may e an indication that the resources available for the treat- ent of mental disorders in children and adolescents might e deficient, consequently increasing the rates of comorbid- ty in early adult life.13,14 This review did not retrieve any razilian publication that could clarify the national reality bout the association between SAD and alcohol use.

These data are important to emphasize the need to iagnose and follow-up adolescents who are predisposed o developing mental disorders and to initially establish reventive actions in schools and healthcare services, thus educing the long-term associated burden on the individual, amily, and community.

AD and alcohol use

iven that SAD is one of the most prevalent psychiatric con- itions in the world’s population, second only to depression,6

nd that its development precedes the onset of alcohol use isorders, it is important to carry out alcohol intervention ctivities,15 as young individuals with SAD are five times ore likely to develop alcohol dependence than those with-

ut the disorder.14,16---20

Studies that failed to show a significant association etween SAD and alcohol use in adolescents,15,21 still indi- ated the possibility of reaching different results when

ultural differences were observed, such as free access to lcohol by adolescents. Another observed risk was the devel- pment of this association with depression, which may occur n late adolescence or take more than two years to develop.

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Problems Screening Test

It is worth emphasizing the importance of recognizing and reating anxiety disorders in childhood, especially among irls, aiming to help them prevent the development of sub- tance use disorders and secondary comorbidities.22

According to the Differential Diagnostic Guidelines for ocial Anxiety Disorder, the age of SAD onset tends to occur arlier and the distribution between the genders is more omogeneous.3 When analyzing gender in association with lcohol consumption among Brazilian adolescents in the ational School Health Survey (PeNSE 2012), a higher preva-

ence of the female gender (51.7%; 95%CI: 50.8---52.6) was bserved.23 When assessing the influence of gender on the ssociation between illicit substance use and social anxi- ty, it was observed that women with higher levels of social nxiety had a higher number of friends who use drugs and lcohol.24

However, there are differences between the patterns bserved in adolescents and the results of studies with dults, i.e., the association between anxiety disorders and ubstance use can change from adolescence to adulthood.22

hat is initially used as an anxiety coping tool, attenuat- ng inhibition and making them feel safe while alleviating he fear in social situations throughout life, can lead to mbarrassing situations and dependence, as well as the per- istence of phobic symptoms.25

In the study carried out at schools, libraries, and dolescent clubs in the Washington, DC, United States etropolitan area, the rates of alcohol use were relatively

ow; however, the results indicated that young individuals ere more likely to have problems with alcohol consumption ver time.26

In the study that investigated social anxiety, general- zed anxiety, and substance use (cigarettes and alcohol) in he early adolescence phase, it was observed that for the emale gender, social anxiety is a risk factor when alco- ol use approval use by peers is high (high levels of peer pproval and high levels of social anxiety were associated ith a high likelihood of substance use), whereas for gener- lized anxiety, it is considered a risk factor when the use by eers is low.27

However, gender was not significantly associated with ocial anxiety and alcohol use, emphasizing age, frequency

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f alcohol use, and affective problems. Nevertheless, this ssociation was associated with affective problems, as well s reasons for survival and coping, so that young individ- als who had elevated symptoms of the disorder reported

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Table 2 Summary of studies and risk factors associated with social anxiety disorder and alcohol use in adolescents.

Authors, year and impact factor (IF)

Objective Analyzed risk factors Results Conclusions

Fröjd et al. (2011) IF: 1.09

To investigate whether the association between anxiety and alcohol and other substances are already evident in the middle adolescence, and whether the general anxiety or social phobia symptoms affects the continuity of frequent use of alcohol, frequent drunkenness, and marijuana use.

Generalized anxiety Social phobia Substance use Frequency of use Drunkenness frequency Use of marijuana

Anxiety preceded the use of the substance, while no reciprocal associations were observed. Depression-mediated associations between anxiety and substance use. Symptoms of social phobia did not increase the incidence of substance use, but overall anxiety. General anxiety increased the persistence of frequent alcohol use, while co-morbid social phobia decreased its persistence.

General anxiety in adolescence puts adolescents at risk for substance use. The risk may, however, be associated with depression. Social phobia in middle adolescence may protect against substance use. Adolescents with symptoms of internalization may need guidance in coping with symptoms, even though the symptoms did not meet the criteria of mood or anxiety disorder.

Terlecki et al. (2012) IF: 1.36

To evaluate whether socially anxious students showed less change in alcohol use behavior among college students.

Social anxiety Typical drinks Rules for drinking

Among students with minor changes in rules, being a member of a group with social anxiety was associated with heavier drinking of typical drinks. Among students with major changes in rules, being a member of a social anxiety group was not significant.

Generalized anxiety in middle adolescence puts adolescents at risk for concomitant substance use and subsequently in late adolescence. The risk may, however, be associated with depression. Social anxiety and use of alcohol or substance was not observed in middle and late adolescence.

Dahne et al. (2014) IF: 1.41

To assess whether social phobia symptoms predicted increased likelihood of alcohol use over time.

Demographic data Psychopathology Alcohol use

There were correlations between the baseline predictors (child’s age, child’s gender, baseline alcohol use, social phobia symptoms) and waves 1---5 alcohol use In general, the concurrent associations were low to moderate.

It highlights the importance of social phobia symptoms in predicting alcohol use over time among young adolescents. Several future directions within this line of research would be valuable, including expanding the assessed age range to younger children and adolescents/older young adults.

Zehe et al. (2013) IF: 1.4

To assess the association between social and generalized anxiety symptoms and alcohol and cigarette use in early adolescence and as a precautionary measure (perceived peer use approval) and (perceived use point) descriptive rules may moderate the association.

Peer norms Gender differences

Peer norms were moderated for the association between social anxiety symptoms, generalized anxiety, and the likelihood of alcohol and cigarette use by girls, but not for boys.

Girls with high levels of social anxiety symptoms were at risk for use when perceived peer approval of use was high, and protected from use when perceived peer approval of use was low. Profiles of anxiety symptoms and perceived peer approval of use may help identify girls who are potential targets for intervention, but the nature of these interventions is still unclear, since this study did not assess the potential risk mechanisms.

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Table 2 (Continued)

Authors, year and impact factor (IF)

Objective Analyzed risk factors Results Conclusions

Terlecki and Buckner (2015) IF: 1.4

Identify cognitive/motivational factors related to drinking in high-risk situations.

Demographic data Social anxiety and Reasons to drink

High social anxiety was associated with greater coping and compliance reasons. Both coping and compliance motives were mediated, the association between social anxiety to heavy alcohol consumption to negative emotional and personal/intimate contexts.

Multiple mediation analysis has indicated that to mediate anxiety situations university students drink socially, such that heavy drinking among college students with clinically elevated social anxiety can be attributed jointly to the desire to deal with negative affect and to avoid social scrutiny.

Blumenthal et al. (2010) IF: 1.36

To assess the reasons for alcohol use among young individuals as a function of social anxiety, associated variables (age, gender, frequency of alcohol use, affective problems)

Age Frequency of alcohol use Affective problems

High social anxiety was significantly associated with a high level of affective problems, as well as with coping reasons. Social anxiety was significantly associated with coping motives, so that young individuals who had high social anxiety reported greater motivation to drink for coping-related purposes.

Socially anxious young individuals endorse higher consumption motives, related to coping issues, a characteristic that may put them at risk for developing alcoholism problems. Prospective studies focused on clarifying associations between adolescent social anxiety, dealing with reasons for drinking and problematic use of alcohol, with the ultimate goal of designing prevention programs targeting young individuals at risk for social anxiety.

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Table 2 (Continued)

Authors, year and impact factor (IF)

Objective Analyzed risk factors Results Conclusions

Wu et al. (2010) IF: 1.47

To assess the use of three substance categories by adolescents (frequent smoking, frequent drinking/heavy use, and use of illicit drugs) in relation to each of the six anxiety disorders (social phobia, agoraphobia, high anxiety disorder/generalized anxiety disorder, separation anxiety, and obsessive-compulsive disorder).

Substance use Anxiety disorder Demographics and family factors Depression

Social phobia was associated with smoking only among boys. For girls, social phobia appeared to be negatively associated with drug use. For the other anxiety disorders, associations with substance use tend to be stronger among girls. There was an association between social anxiety symptoms and alcohol use only in girls. Frequent or heavy drinking was more common among boys than girls, but this difference was only marginally significant.

The differences between the patterns observed in the study sample of adolescents and the results of studies with adults regarding social phobia to some extent indicate that the association between anxiety disorders and substance use may change from adolescence to adulthood.

Clerkin and Barnett (2012) IF: 1.4

To test the separate and interactive effects of drinking motives and social anxiety symptoms in predicting drinking and drinking-related problems.

Social anxiety symptoms Reasons to drink Alcohol consumption Problems with alcohol

Increased social anxiety symptoms were significantly associated with less alcohol consumption, and there was some evidence that greater social anxiety symptoms were also associated with greater problems with alcohol.

The main effects of social anxiety symptoms and consumption motives were more influential in predicting consumption outcomes. Greater social anxiety was associated with greater endorsement of coping and compliance motives, and less endorsement of reasons for enhancement. Symptoms of social anxiety were associated to lower alcohol consumption, and also with more problems with drinking.

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ncreased motivation to drink associated with coping pur- oses. This was also demonstrated in the three models used o assess the groups of people with social anxiety who used lcohol in situations of confrontation and/or compliance easons.29

Adolescents with elevated social anxiety symptoms con- ume less alcohol, but show a higher association when it is elated with coping endorsement and compliance motives.30

uture perspectives

he limitations of the analyzed studies are based on sample ize; on the short period of follow-up of the adolescents; n the fact that, as it was not possible to observe the tudents’ behavior during the transition period from elemen- ary to high school,15,26,28 the results cannot be generalized or all phases of adolescence or for all regions (rural and rban areas), since each phase has different characteris- ics and behaviors regarding the decision-making for use f alcohol according to the place of residence27; and on he use of a combination of variables regarding the use of lcohol, cigarettes, marijuana, and other substances, which as implications for their association with anxiety, as each ubstance has unique properties and distinct physiological ffects.21,22,27

Regarding future investigations, it is necessary to assess he individuals at the initial, middle, and late adolescence hases, as well as to expand racial and ethnic groups; o use both the descriptive analysis (perceptions of the rinking behavior) and the analysis of precautionary norms approval/disapproval of the drinking behavior); to evalu- te the treatment and its effects on the adolescent; and to ssess the coping reasons for drinking and problematic use f alcohol, with the ultimate goal of developing prevention rograms aimed at young individuals at risk.

imitations

he present systematic review study had as limitations: a) non-use of the Web of Science and Pschynfo scientific atabases, with the latter being the database specialized in ehavioral and social science research; (b) scarcity of stud- es published in Portuguese, English, or Spanish; and (c) the mall number of articles included in the analysis.

Despite the limitations, this review becomes relevant, as t allowed the identification and understanding of the main isk factors associated with SAD and alcohol use in adoles- ents, in addition to broadening the knowledge about the ubject.

onclusions

he association between SAD and alcohol use in adolescents ppears to be unclear, due to the few identified studies, he methodological heterogeneity, and their regionaliza- ion. Nevertheless, this review raised interesting evidence

n the existence of this association and identified the main isk factors related to the association between SAD and alco- ol use among adolescents, such as female gender, peer cceptance, and affective problems regarding alcohol use,

Cruz EL et al.

s well as the presence of secondary comorbidities, such as epression and anxiety disorders. Therefore, studies with epresentative samples, with an increase in the racial and thnic groups and that contemplate the initial, middle, and ate phases of adolescence are still necessary.

Some authors also suggest that prospective studies be arried out to observe students’ behavior during the tran- ition period from elementary to high school, as well as valuate the onset period of the first symptoms of SAD and he risks for alcohol use; assess the reasons for alcohol use; valuate treatment and its effects on adolescents; and to mplement corrective intervention guidelines for alcohol use mong socially anxious students.

onflicts of interest

he authors declare no conflicts of interest.

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