Emotion regulation in children with social anxiety: A systematic review and meta-analysis

Social anxiety disorder (SAD) is among the most common and impairing disorders in childhood and adolescence, with emotion regulation (ER) difficulties proposed as a key mechanism in its onset and maintenance. While both behavioral and physiological aspects of ER have been investigated, findings remain fragmented and partly inconsistent.

We conducted a systematic review of studies published between 2000 and 2025 examining ER in children and adolescents (mean age ≤ 18). Thirty-seven studies (14 clinical, 23 community) met inclusion criteria. Where sufficient and comparable data were available, random-effects meta-analyses were conducted.

ER difficulties emerged as a robust feature of both clinically diagnosed SAD and dimensionally assessed social anxiety (SA). Meta-analyses revealed large group differences indicating greater use of maladaptive ER strategies (g = 0.90) and moderately reduced use of adaptive strategies (g = -0.61) in children with SAD compared to healthy controls. In community samples, maladaptive ER strategies prospectively predicted increases in SA symptoms, with evidence for bidirectional associations over time. Narrative and meta-analytic synthesis on physiological data indicated that higher SA was associated with attenuated physiological stress reactivity (r = -.17), alongside reduced parasympathetic flexibility and impaired recovery, particularly in older children and adolescents.

ER difficulties represent a core characteristic of both clinically diagnosed SAD and subclinical SA in youth. Rather than uniform hyper- or hypo-arousal, findings point to inflexible and context-insensitive regulation patterns. These patterns may function both as early vulnerability markers and as maintaining factors in SA. Interventions that explicitly target regulatory flexibility across contexts may therefore hold promise for prevention and treatment.