An Interview with Psychologist Andres De Los Reyes
Andres De Los Reyes, Ph.D. is a Professor of Psychology at the University of Maryland. He's an expert in the field of adolescent psychology, social anxiety and ADHD.
Tori Steffen: Hi, everybody. Thanks for joining us today for this installment of the Seattle Psychiatrist interview series. I'm Tori Steffen, research intern at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
I liked to welcome with us today, Psychologist Andres De Los Reyes. Dr. De Los Reyes is a professor of psychology at the University of Maryland in College Park, as well as the Director of the Comprehensive Assessment and Intervention Program. Dr. De Los Reyes is an expert in the field of clinical psychology. He's published over 100 articles, including “When Adolescents Experience Co-occurring Social Anxiety and ADHD Symptoms,” “Links with Social Skills when Interacting with Unfamiliar Peer Confederates,” and “Multi Informant Reports of Depressive Symptoms and Suicidal Ideation Among Adolescent Inpatients.”
Before we get started today, Dr. De Los Reyes, could you please let us know a little bit more about yourself and what made you interested in studying social anxiety, ADHD, and other mental health issues among adolescents?
Andres De Los Reyes: As you mentioned, I've been at the University of Maryland for some time now, about 15 years. In that work, I spent a lot of time thinking about the most accurate ways of assessing various kinds of mental health concerns with a particular emphasis on those concerns, where when we try to get a sense of symptoms and associated impairments... Obviously, because we're often assessing children and adolescents, we're seeking input from not only the clients themselves but also significant others in their lives, like parents and teachers and sometimes peers. We focus our attention a great deal on those domains, where when we ask these questions, we oftentimes get very different responses depending on who we ask. That's a common byproduct of assessments of social anxiety, of ADHD.
The work our group has conducted, and the work of many other labs all over the world, really have led us to believe that although there may be some circumstances where these assessments are telling us different things because perhaps one or more of the informants aren't nearly as useful reporters as they might be, under the grand majority of circumstances, when we administer assessments to understand things like ADHD and social anxiety, we're often using well-established instruments, and we're also often asking people, informants, who mental health professionals have relied on for decades to assess behaviors. So under a variety of circumstances, there may very well be reason to believe that rather than these differences in results reflecting something artifactual about the measures we administer and the scores we obtain from these informants, it might be actually something really important. In particular, the specific contexts where adolescents, children might be experiencing concerns like social anxiety and ADHD.
It turns out that in both of these circumstances, in both of these domains, social anxiety and ADHD, the symptoms and associated impairments can move around considerably across various social environments that impact the lives of those we assess, the peers with whom they interact, the teachers who are serving as instructors in their classes, the parents who look after them and in fact are often initiating their services. So, I tend to choose domains like ADHD, like social anxiety because I think not only are they places where these discrepancies and results happen often, but if we learn more about these discrepant results, then we also learn more about the actual domains themselves.
Tori Steffen: Right. Wow. That's really profound. I can definitely agree with you there how it's important to understand the differences, especially when assessing for the two of those domains. So, thank you for explaining that for us.
Well, getting down into basics about our topic, what age range describes an adolescent?
Andres De Los Reyes: A very wide one. Even just a definition of what counts as an adolescent is a topic of considerable debate among mental health professionals, among developmental scientists. Adolescence can begin within some definitions as early as 12 or 11, and can stretch out as far as, within some definitions, the early adulthood years. There may be various factors that one might consider when thinking about where adolescence as a developmental period begins and ends.
But germane to the work that we do, we tend to focus on what some scholars might consider the mid- to late-adolescence period, so that period between the ages of about 14, 15, 16, 17, where developmental research and theory would posit that the people we're trying to assess are undergoing significant amount of changes in their biology, in their social environments. They see a lot of new environments, novel environments they oftentimes are not necessarily accustomed to encountering earlier on in development, like the development of romantic attachments, the development of time spent outside the home, outside of the immediate observation of caregivers who, as I mentioned previously, are often initiating care.
So we think of, like I mentioned before, social anxiety and ADHD as a great place where the assessment issues we care about happen. On top of that, the developmental peer that we focus these assessments on will oftentimes create additional complexities that require further elaboration and interpretation. That's where a lot of our work essentially seeps from, is trying to figure out within the traditional approaches we use to measure domains like social anxiety and ADHD, what additional things must we think about and be developmentally sensitive to when we're trying to apply our traditional assessment tools to assessing these specific domains in this particularly complex period of development?
Tori Steffen: Right. Yeah. Definitely a lot to consider when defining an adolescent. So, that all is very important. Could you explain for our audience what social anxiety is?
Andres De Los Reyes: The typical definitions of social anxiety revolve around several different kinds of core features of the condition. One of the big core features is an intense fear or apprehension. Under some circumstances, when the fears are really high in avoidance of social situations of various kinds, interacting one-on-one with somebody, even just going up to somebody and asking them for information or directions, like if you're going somewhere you don't really know where to go, giving presentations in a structured setting like a classroom or an adulthood in a workplace... But one of the common, core denominators that cut across all those situations is that among individuals who experience social anxiety, there tends to be a particular fear, apprehension, avoidance, of unfamiliar scenarios, scenarios that appear novel that haven't been encountered all that frequently, and where people might not have a lot of practice in navigating those situations effectively.
That's one of the big things that we think about when it comes to assessing and understanding social anxiety within adolescence, because like I mentioned before, you have these situations, these scenarios that as you enter the adolescence period you don't have a lot of practice in. One of the big ones that we focus on is in those scenarios where adolescents feel like it's one of their tasks to engage with people they don't know very well, particularly their own age, and try to develop bonds of some kind: friendships, romantic attachments, and then in both those places that unfamiliarity is something new to them, especially when you consider the fact that a lot of these unfamiliar interactions with people your own age are happening where your caregiver, somebody older than you isn't looking over your shoulder to see how things are going. You're doing a lot of this by yourself.
Tori Steffen: Mm-hmm. Right. Okay. That definitely makes sense, that a lot of uncertainty and fear might be present.
Could you explain for us how adolescents typically experience social anxiety, and would you say that there's any big differences in symptoms among adolescents compared to adults with social anxiety?
Andres De Los Reyes: This is something we've struggled with a great deal, and it bears some relation or implication to how we diagnose the condition among adolescents, children, and adults. I can focus specifically on the sort of diagnostic considerations you have within one of our predominant systems, the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition.
In the current edition, there's a distinction between the kind of social anxiety that manifests consistently across situations across contexts. So, for many clients there's this sense that the symptoms and their impairments: fears, the avoidance, the apprehensions, are there when you are ordering food at a restaurant and interacting with coworkers and trying to meet new people. You see it everywhere. That can be contracted with at least one other form of social anxiety that we tend to see in clients, and that is those scenarios, those instances in which clients appear to be experiencing symptoms and impairments that manifest in a specific kind of context.
In the Diagnostic and Statistical Manual of Mental Disorders, the DM, that context is typically characterized as a performance-based context, some kind of place where there's a lot of structure and you have a sense of what it's like to give a presentation in front of a group, you know what the rules of engagement are: You have to make eye contact; you have to enunciate; you have to be able to answer questions effectively. What we've been learning in our work is that although adolescents can experience that kind of context specificity that has a look and feel of what you see in adults, we also see at least one other kind of specific form of impairment and where symptoms arise. And that's when adolescents are engaging in the social scenario where the rules of engagement are kind of stripped away. There's no manual to figure out how to navigate parties effectively. There's no how-to guide on the right thing to say when you sit down next to someone on the first day of school. You probably think that you should be friendly, maybe say hi, but what else do you do after that?
So, that lack of structure in our work leads us to believe that although adolescents can experience those kinds of patterns that we tend to see in adults, the symptoms and impairments can manifest in lots of places or in one specific place, we have reason to believe that maybe it's worth considering the notion that because of the novelty inherent in the social experiences that adolescents often have, that even just being placed in a situation where you don't know the rules of engagement can produce the same kinds of symptoms and impairments that we see in that context-specific subcategory that you said that we already have in our diagnostic manuals.
Tori Steffen: Right. Okay. That's good information to know, the importance of novelty, especially for adolescents. So, that's really interesting.
How are the issues of social anxiety and ADHD and adolescence connected? If the two issues, let's say, that they're co-occurring in an adolescent, does that have more of a negative impact?
Andres De Los Reyes: In our work, we tend to see that it does. It's a phenomenon that fascinates us. The reason why is because there are a lot of different kinds of features of all of our disorders, all of our diagnostic categories. They all have their own lists of symptoms. What they also have are what we call associated features, or there could even be risk factors depending on whether or not their presence brings about the condition. But many times, when we're thinking about treatment, we're thinking about those aspects of functioning that might not be symptoms, but they could be implicated in how conditions are maintained. It's kind of like whatever started the engine, an associated feature might might keep it going.
One of those features that cuts across many conditions, but in particular social anxiety and ADHD, is a concept or domain that we call social skills: those behaviors, those elements of how you engage in social situations and make a difference in whether or not you're able to make friends and influence people, and not only make friends, but also maintain those friendships over time. We know that in both ADHD and in social anxiety, one of the key areas of impairment is in friendships, in how many friendships you've initiated or developed, and the maintenance of those relationships over time.
The key distinction that many of us encounter when it comes to social anxiety and ADHD is that although there's those associated features of social skills and friendships in both of the conditions, there's reason to believe that those features might arise in these conditions for very different reasons. So, for adolescents who experience social anxiety, they might experience social skills issues in part because of the avoidance. They experience apprehension, fears about engaging situations. They might not engage in situations where they could get opportunities to make friends nearly as much as other kids who don't experience social anxiety. The consequence of that might be kind of the same thing as you missing out on going to the gym for a few months, a muscle here or there atrophies, and then you get back to the gym and you say to yourself, "I can't lift nearly as much as I used to."
That avoidance might have the effect of perhaps overall reducing fears, so if you don't enter into a situation that you find stressful, you're going to experience less stress maybe, but at the cost of not being able to have opportunities to do positive things that might actually even help the anxiety down the line. So, that avoidance makes a big deal when it comes to social skills and associated impairments in developing and maintaining friendships.
With ADHD, there's reason to believe that within that condition, the social skills issues associated impairments of friendships have less to do with avoidance and perhaps a bit more to do with the fact that among many children and adolescents who experience ADHD, the hyperactivity they might experience might be seen by peers as aversive and perhaps make it less likely that they might want to engage with them in the future.
Now, if it's the case that someone's experiencing both social anxiety and ADHD, are perhaps experiencing social skills issues and associated impairments with building and maintaining friendships for different reasons, and those two different reasons are encapsulated in the same individual, so not just the avoidance, but on occasion, the hyperactivity kicks in; you create some kind of aversive interaction with somebody, maybe they don't want to associate with you as a friend. That might be one of the reasons why we're seeing what we're seeing, at least in our own data, that when adolescents experience heightened levels of both of these conditions at the same time, they tend to be experiencing more of these social skills issues in direct observations of how they interact with same-age adolescents.
That's the neat feature of the work that we do. We collect the symptom data the old-fashioned way by asking a bunch of people about what's going on with the adolescent or how they are thinking, feeling, and behaving, and whether or not those symptoms tell us that somebody's elevated in social anxiety and ADHD. But we're looking at those combinations in relation to how the adolescent actually behaves in our laboratory when we create scenarios that have the look and feel of everyday social interactions between themselves and somebody that we lead them to believe is a same-age peer.
Tori Steffen: Okay. Yeah. That definitely makes sense. It sounds like really interesting work that you guys are doing to figure that out.
Well, one of your articles mentions that the presence of social anxiety and ADHD can have a negative impact on adolescent social skills. I know that you kind of explained how they might show up symptom-wise. Could you explain for us the impact on social skills in an adolescent?
Andres De Los Reyes: Going back to this notion that adolescents experience social anxiety might have fewer opportunities to engage socially with people, typically their own age or other people. If they avoid those scenarios, then by construction, they're going to get less practice building the kinds of competencies that we know are instrumental in being able to have healthy relationships with other people. When's it appropriate to make eye contact? When is it appropriate to avert your eye contact? When is it appropriate to initiate a conversation? Is it okay to say hello to somebody when you're having a very deep conversation with somebody else? When is it appropriate to end the conversation and maybe go somewhere else, interact with somebody else? All these kinds of skills, we develop them whether we know it or not, oftentimes through trial and error. Most of us don't read a guide about how to be socially skilled before we go to a party. That's just not what we typically do.
Over time, we figure out what's worked and hasn't, and in that respect, among many of us who can be considered as socially skilled, those kinds of skills are kind of like a really good app on your phone. They fit into the background after they all make sense. So oftentimes, in our interventions for both social anxiety and ADHD, although the approaches we might take to improving social skills might differ, the outcomes have the similar kind of look and feel. We're trying to build up your competencies to be able to make friends and influence people, but the routes you might get there might be quite different.
Tori Steffen: Okay. Yeah. That definitely makes sense, how it could have an impact there.
Have any significant differences been found in your lab work for prevalence of social anxiety and/or ADHD among girls versus boys?
Andres De Los Reyes: We don't tend to see too many big differences in our work as a function of gender, but it is just one sample. One thing I can say is that some of the gender and the gender-related issues and how we diagnose these two conditions, depending on the condition, reflect either variations in rates as a function of gender or in features. So as an example, when you assess ADHD in the general population, so outside of a clinic, you tend to see a bit higher rate, 2-to-1 in children, maybe 1.5-to-1 in adults in the direction of males tend to be diagnosed more often than females. But in ADHD, you also tend to see that females are more likely than males to experience symptoms that have more to do with inattention, so difficulty in maintaining attention relative to males. Again, big average differences that we tend to see in research.
In social anxiety, historically what we've tended to see is a gender difference that might manifest in the general population, but once you get into the clinical circumstance, it doesn't tend to be much of a difference, much of a gender difference at all. But what you do see is a kind of variation in the other diagnosis, somebody might meet criteria with as a function of gender. Among females who are diagnosed with social anxiety, they tend to experience a greater number of depressive, bipolar, and anxiety sort diagnoses, whereas males who are diagnosed with social anxiety tend to experience diagnosable conditions that are more externalizing sort of in nature, so oppositional-defiant disorder, conflict disorder, alcohol dependence and abuse or dependence and abuse of illicit drugs.
That latter group, people have been interested in that group for a long time, that combination of social anxiety and substance use disorders. One of the hypotheses people have is what they call a self-medicating hypothesis, this notion that perhaps one of the reasons why people might use substances in the context of something like social anxiety is as a coping mechanism, like a means to reduce your arousal or apprehension to then enter situations and manage them more effectively.
Tori Steffen: Okay. Yeah. That's definitely interesting to know, and sounds like maybe there's a few gender differences, but overall as far as diagnoses go, not super significant in the differences.
Well, another area of your study classified participants in groups of low social anxiety or ADHD and then high social anxiety. What might the main differences in the severity of symptoms be between the two groups?
Andres De Los Reyes: The interesting thing about the groups that we observed in our own data is that the group that could be characterized as high social anxiety symptoms, high ADHD symptoms, differed from that other group that could be characterized as low social anxiety, high ADHD, and specifically in those social anxiety symptoms. But where they didn't differ much at all is in the level of ADHD symptoms.
The same is true for that other group that was high social anxiety, high ADHD, and high social anxiety, low ADHD. That group as well might have differed on the level of ADHD symptoms, but not in the level or severity of social anxiety symptoms, which made us pretty excited in that one of the problems or one of the limitations you have to overcome when you do this kind of work is sort of ask yourself, when I think about grouping individuals this way, is the group that's showing concerns on two different domains simply just a more severe form of clinical presentation, or are they just a more severe client when it comes to the symptoms? Is that all I'm looking at that? That it's a 10 to 5 difference on one versus the other? If so, what's the point?
But what made us really excited was that, at least from a symptom severity standpoint, we didn't see differences in those groups that are elevated on one versus another versus elevated on both. What it looked like to us was that these groups are different from each other, from something other than raw symptom count. There's something else going on here, and it might have implications for understanding the phenomenology of the actual clinical presentation.
Tori Steffen: Wow. Yeah. That's a great finding to come by. Yeah. Thanks for explaining that for us. That's definitely an interesting finding.
Well, actually another finding in your study linked social anxiety in ADHD through impairments or behaviors in adolescents. Can you explain that finding for us a bit?
Andres De Los Reyes: Yeah. We thought it was important to do. In a lot of our studies, we make an observation, we might find it interesting, but we want to scrutinize it a little bit more and probe it. One of the things we wanted to probe with regards to the findings of this particular study was this notion that maybe the social skills issues that we're seeing, the differences among these groups, are isolated to just this kind of interaction. Do we have any data that sort of speaks to the possibility that these differences might have implications for impairment issues we might see outside of the peer context?
It turns out that we had a survey, the work and social adjustment scale for youth, that provides us with a broad sort of index of psychosocial impairments germane to mental health functioning or at least behaviors that might be indicative of mental health concerns. We were able to essentially replicate the finding we observed with the behavioral data, that when you look at overall indices of psychosocial impairments, that same group, that high ADHD, a high social anxiety group, tends experience overall more psychosocial impairments than the other groups in our sample.
Tori Steffen: Okay. Definitely good to know as far as what to expect in the experience.
Well, clinically speaking, what psychotherapeutic treatment methods might work best for an adolescent with, let's say, co-occurring social anxiety and ADHD?
Andres De Los Reyes: The good news with regards to both social anxiety and ADHD is that there are well-established interventions for addressing social skills issues in both of these for these conditions. So, social effectiveness therapy, a form of social anxiety behavioral treatment developed by Deborah Beidell and Sam Turner and colleagues, seeks to focus on improving social competence within children and adolescents experiencing social anxiety and for that matter, adults as well. There's a version of social effectiveness therapy that is developmentally modified or tailored for adults experiencing social skills concerns stemming from social anxiety.
There's a variant of that kind of intervention that's broadly thought of or referred to as social skills training that has been tested for many years among children and adolescents experiencing ADHD. My sense, and this is not something that that's been tested formally in a controlled trial or treatment study, is that addressing these co-occurring issues might involve trying to first assess the associated impairments within a client experiencing both of these concerns at once, prioritizing figuring out which one might be more impairing, and then on the basis of understanding where the priorities lie, which of these might be getting in the way of building social skills competencies in most, starting with one of these two intervention protocols, and then moving on to the next protocol if it looks like further addressing these needs is warranted.
The interesting thing, and this is another thing that hasn't been tested yet, what we tend to see in the treatment literature goes like this: If you try to address anxiety or you try to address ADHD and you're successful in doing it, you'll see reductions in the thing you're targeting, reductions in anxiety, reductions in ADHD, but you'll also tend to see reductions in mental health conditions that are related but conceptualized as distinct from those conditions. So, we tend to see that if we see a reduction in anxiety and we targeted anxiety, we also tend to see a reduction in depression; try to address ADHD and successful reducing ADHD, you're also likely to see reductions in oppositional-defiant disorder or conduct problems or what have you.
The interesting thing here that I don't think has been tested is this idea of if you treat social skills in one of these domains, both lying, by the way, in very different spectra ADHD being a more externalizing-related condition versus than a more internalizing condition like anxiety, might in those circumstances, you see the rare occurrence of seeing a reduction in social anxiety and a concomitant reduction in ADHD, specifically because the core feature that cuts across both of them is social skills.
Well, might this be one of those rare circumstances where you would see a reduction in two distinctly conceptualized diagnostic conditions? That's a question that I'd be intrigued to see somebody probe, and maybe they have the data to probe it in one a large-scale data set of sorts. But suffice to say, that the good news is there are these two classes of interventions available to address both of these conditions, and what might be required in a clinical scenario is figuring out which one to target first and then monitor symptom response to intervention across sessions and then figure out at what point might it make sense to transition over to addressing social skills in their domain versus continuing on with that same one.
Tori Steffen: Right. Okay. Yeah. That's really good to know, good information, especially to know that treating one issue might actually help the symptoms of another, which is really good information for a researcher.
Well, while all these treatment options are best and ideally done under the guidance of a licensed mental health professional, what are some things that adolescents can do on their own to potentially reduce or lessen some of those symptoms of social anxiety or ADHD?
Andres De Los Reyes: It's important when you're experiencing these kinds of issues to become a good detective of how you're thinking, feeling, behaving. If you start noticing that it's kind of hard to build the kinds of relationships that you really want to have because it is true, and this is the interesting thing about social anxiety and ADHD for that matter, is that when you avoid these situations or you have difficulty maintaining friends, that doesn't mean that you don't want to be in those situations; you don't want to make friends. Quite the contrary. I mean, the research on social anxiety suggests that avoidance doesn't equal, "I don't care." There's that weird push and pull where you don't want to go into that situation, but you actually do really want to have friends. You actually do really want to maintain a healthy relationship, which is a universal feature. It's the rare person that doesn't want to build these kinds of relationships, because they're healthy and they feel good, and being able to have fun conversations and lean on people when times get tough, those are all things that the majority of us value.
So, if I was experiencing these kinds of concerns, I would sort of start asking myself, “What might be getting in the way? What are the things that I notice about myself when I know I want to go meet that person? I know I want to go. I know I really would love to be friends with that person, but I just can't get there.” What seems to happen before I get there? That isn't to say that you need to become your own therapist, far from it. But I think the interesting thing is to think about what information can I start gathering about myself, that once I get there, once I think I have the information I need, I can reach out to somebody who can help me: my parents, a counselor at school, someone who can guide you towards the people who have the experience, the expertise to help you make a meaningful change in your life.
Tori Steffen: Right. Awesome. Yeah. That's really good advice. So, thank you so much for sharing that.
Do you have any final words of advice for us or maybe anything else that you'd like to share with the listeners today?
Andres De Los Reyes: Do you have any questions about our work or are interested in learning more? I can be reached on Twitter with the handle @JCCAP_Editor, and feel free to reach out to me at my email address adlr@umd.edu. Thanks so much for finding this work interesting enough to listen all the way to the end.
Tori Steffen: Perfect. Yeah. Thank you so much for sharing your knowledge. Definitely a lot of good advice and just good things to know about social anxiety and ADHD in adolescents, so we really appreciate you taking the time to enlighten us.
Andres De Los Reyes: Happy to do it. It was a lot of fun.
Tori Steffen: Yes, definitely. Well, thank you so much again, and thanks everybody for tuning in, and we will see you guys next time.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.