Social anxiety disorder (SAD) is quite common among young people, with a lifetime prevalence rate ranging from 3.5 to 9.1% aged 10-24 in western countries such as the United State, Germany and Austria (Stein et al., 2001; Burstein et al., 2011; Knappe et al., 2011; Wagner et al., 2017). The core features of SAD are excessive fear of scrutiny by others and avoidance of social situations in which embarrassment or humiliation might occur (American Psychiatric Association., 2013). Social anxiety brings a series of problems such as impaired academic and global functioning (Ranta et al., 2009; Edlund et al., 2018; Finsaas et al., 2020), loneliness (Bernstein et al., 2008; Eres et al., 2021), low level of social support from classmates (Coyle and Malecki, 2018), poor social skills (Scharfstein et al., 2011; Lau et al., 2022), and high rates of sickness absence and unemployment (Amin et al., 2019). The onset of SAD is early, with a median age of 13 years in epidemiological studies (Kessler et al., 2005), and there are few new cases after 25 years of age (Wittchen and Fehm, 2003; Stein et al., 2017). In clinical samples, SAD is the most chronic anxiety disorder, with a 37–56% remission rate (Bruce et al., 2005; Springer et al., 2018).

Due to its significant negative consequences, SAD has received much research and clinical attention. However, significant social anxiety symptoms (SAS) should not be ignored because social anxiety is on a continuous spectrum from absence of social fear through normal anxiety and shyness to SAD (McNeil, 2001). Studies have shown that even subthreshold social anxiety (≥one social phobia symptoms in DSM-IV plus avoidance) brings significant psychosocial impairment and elevated rates of other psychiatric disorders (Crum and Pratt, 2001; Merikangas et al., 2002; Filho et al., 2010). In the present study, SAD refers to a type of an anxiety disorder that meet the DSM-5 or ICD-11 diagnosis. SAS, on the other hand, refers to the symptoms and manifestations of social anxiety which is measured by valid self-report scales.

Epidemiological surveys revealed significant cultural differences in the prevalence of social anxiety symptoms and disorder. A review shows that the prevalence of SAD among adults in Asian countries is significantly lower than that in Europe and the United States (Hofmann et al., 2010). For example, Asian countries such as China, South Korea, and Japan had 12-month prevalence rates of 0.2% (Shen et al., 2006), 0.2% (Cho et al., 2007), and 0.8% (Kawakami et al., 2005), respectively. Meanwhile, the prevalence of SAD in some European and American countries such as the United States, the Netherlands, and Australia ranged between 4.2 and 7.1% (Bijl et al., 1998; Ruscio et al., 2008; Crome et al., 2015). Interestingly, the phenomenon is reversed in self-report measurement. A meta-analysis found that individuals of Asian heritage had higher self-reported social anxiety scores than those of European heritage in 28 out of 32 independent studies and yielded a mean effect size of d = 0.36 (Krieg and Xu, 2015). One possible reason for this difference is that Asian individuals belong to collectivism and are more likely to feel embarrassment and anxiety in social interactions, and therefore have higher social anxiety symptoms. However, Asian culture acquiesces or even appreciates social shyness and anxiety. Individuals with high social anxiety symptoms do not necessarily bring about impairment in social functioning in Asian societies, and therefore exhibit lower prevalence of social anxiety disorder (Heinrichs et al., 2006).

It is not clear whether a similar phenomenon exists in children and adolescent populations. There is a lack of large-scale epidemiological surveys or meta-analyses to report the prevalence of SAD or SAS among Chinese children, adolescents, and young adults (CAYA). Some studies found that the point prevalence of SAD in primary and secondary schools was as low as 0.6% (Ye et al., 2013), while others reported a prevalence rate of 2.7% (Su et al., 2006). The findings of SAS prevalence were also inconsistent. One previous study found that 6.9% of Chinese primary school students experienced severe social anxiety symptoms as measured by the Social Anxiety Scale for Children (SASC; Cai, 1998). However, with the same assessment tool and cutoff point, one more recent study reported a rate of 26.3% in a similar population (Gao et al., 2013). These inconsistencies might be due to the use of different age groups of CAYA, sampling frames, sampling methods, and other factors.

Compared with depression, PTSD, and other mental health issues, people have less knowledge and poorer recognition of social anxiety (Katzelnick et al., 2001; Coles et al., 2016). The public's underestimate of the severity of social anxiety could be due to the inaccurate estimates of the prevalence of social anxiety, which might further hinder the clinicians' detection and recognition of social anxiety and provide treatment to people who are in need.

Therefore, a meta-analysis focusing on the prevalence of social anxiety among Chinese CAYA is warranted. The purpose of the current study was to combine the prevalence rates in existing surveys to provide a more reliable prevalence estimate of SAD and its symptoms in Chinese CAYA. For social anxiety disorder, the prevalence refers to the proportion of individuals who are positive on a certain diagnostic tool. For social anxiety symptoms, the prevalence is the proportion of individuals who exceed a cutoff on a self-rated scale. The most appropriate test cutoff value is determined with a compromise between sensitivity and specificity based on receiver operating characteristic (ROC) analysis (Habibzadeh et al., 2016). Although there are some drawbacks to using a dichotomous approach for a psychological disorder which lies on a continuum, this approach is simple to understand and can be of great value to the public and to clinical practice, especially in China where relevant data are lacking.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Liberati et al., 2009) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE; Stroup et al., 2000) guidelines throughout this meta-analysis. This review has been registered at PROSPERO (Registration Number: CRD42020149591).

To our knowledge, this review is the first meta-analysis that provides prevalence estimates of SAD and its symptoms in Chinese CAYA.

The review showed that the point prevalence of SAD among Chinese CAYA was 2.1%. Direct comparisons are difficult to conduct because most studies in other countries tend to report 12-month or lifetime prevalence (Burstein et al., 2011; Knappe et al., 2011; Jefferies and Ungar, 2020; Mohammadi et al., 2020). However, there are some studies providing point prevalence rates in countries such as Spain (3.4%; Canals et al., 2019) and Austria (3.5%; Wagner et al., 2017), which had a higher prevalence than Chinese CAYA. This observation is consistent with Hofmann's review, which found that the prevalence of SAD is lower in Asian cultures than in European cultures (Hofmann et al., 2010). Meanwhile, the current study showed that the proportion of Chinese CAYA experiencing SAS was 23.5%. This prevalence estimate is comparable to the prevalence of CAYA in many other countries such as the United Kingdom (28.5%; Fahy et al., 2016), Italy (23.5%; Di Blasi et al., 2015), Spain (25.8%; Calvete, 2014), India (22.9%; Yuvaraj et al., 2018), and Saudi Arabia (25.8%; Hakami et al., 2017).

Our review was partially consistent with the findings of Krieg and Xu (2015)—that is, Chinese CAYA have a lower prevalence of SAD than their western counterparts, however, the prevalence of SAS is similar to their western counterparts.

The similar prevalence of SAS may be due to the fact that Chinese and Western CAYA are exposed to the same risk factors, such as low self-acceptance, negative self-evaluation, and fear of negative evaluation (Li et al., 2019; Peng et al., 2019; Liu et al., 2020). On the other hand, factors specific to Chinese culture, such as shame, may only provoke more social anxiety in early adulthood or in an older population (Zhong et al., 2008; Lau et al., 2009), with no additional effect in social anxiety in younger groups.

It might be true that Chinese CAYA experience a considerable amount of SAS, but this does not necessarily imply that they have a corresponding rate of SAD as their western counterparts did. A criterion of SAD is impairment in social functioning (American Psychiatric Association., 2013). Several cultural factors might reduce the possibility of social dysfunction in the Chinese population. First, in many individualistic cultures, fear and avoidance of social situations are regarded as problematic and might impair social functioning. However, collectivist cultures have greater acceptance of socially reticent behavior (Schreier et al., 2010). Studies have found that in Canadian children, reticent behavior was associated with peer rejection such as overt refusal and disagreement, but the same behavior was associated with positive responses such as approval in a Chinese sample (Chen et al., 2006). In addition, life interference was found to have a stronger relationship with social anxiety in Western youths than in East Asia (Rapee et al., 2011). Second, interpersonal harmony is highly valued in East Asian countries, especially in China (Zhang et al., 2005; Wei and Li, 2013). People might even maintain interpersonal harmony by suppressing their negative emotions (Wei et al., 2013). It is likely for individuals in western cultures to “express appropriate disagreement or disapproval to people they don't know very well” as listed in the LSAS scale (Fresco et al., 2001), whereas Chinese youth might display more fear and avoidance, which reduce the occurrence of social conflicts or dysfunction. Some studies have provided indirect support for this argument. Although Chinese youths feel relatively high levels of anxiety in social situations, they tend not to undermine social norms and interpersonal harmony. It is therefore less likely for them to experience social dysfunction, which is a necessary diagnostic criterion for SAD. However, the cultural factors need to be interpreted with caution. For example, interpersonal harmony may also put more social stress on the individual. In order to maintain interpersonal harmony, individuals may need to compromise and be more attentive to the impact of their behavior on others, which may in turn be a risk factor for social anxiety. More cross-cultural studies may need to be done in the future to explore the reasons for the manifestation of SAS and SAD in China.

The study showed that the prevalence of social anxiety disorder in older CAYA (i.e., aged 15–25) was significantly higher than that of younger CAYA (i.e., 6–15), whereas there was no difference in the prevalence of social anxiety symptoms between the two groups. These finding about the SAD aligns with the existing literature, which suggests that prevalence of SAD is still at a relatively low level in childhood and has a significant increase after early adolescence (Kim et al., 2010; Burstein et al., 2011; Spence et al., 2018). In contrast, the prevalence of SAS remains stable or even decrease from early adolescence to late adolescence (Inderbitzen-Nolan and Walters, 2000; Ranta et al., 2009, 2012). Rapee and Spence (2004) provided a possible explanation that the transition from high social anxiety symptoms to social anxiety disorder depends on the age at which the individual encounters social impairment. From childhood to young adulthood, their perceived social anxiety distress remains unchanged or even decreases, but their social functioning impairment increases when they enter the adolescence. Adolescents usually have to be faced with changes in school environments, physical development, and peer relationships (Simmons, 2017). They might confront more challenges in social aspects, tend to experience impairment in social functioning and therefore are more likely to suffer from SAD.

Although the study showed that the prevalence of SAS and SAD were slightly higher in girls than boys (SAS: 20.7% vs. 18.9; SAD: 5 vs. 4.6%), the differences were not significant (p >0.05). This result was in contrast with most of the existing literature, which suggests that females have a higher prevalence of social anxiety than males worldwide and that gender differences are larger in adolescents (Caballo et al., 2014; Asher et al., 2017; Asher and Aderka, 2018). Self-construal, again, might be one reason that explains the non-significant gender differences in the Chinese population. In western culture, men tend to construct and maintain an independent self-construal, whereas women tend to construct and keep an interdependent self-construal (Cross and Madson, 1997). Women's sense of self being more dependent on relationships with others could make them more prone to social anxiety. However, as mentioned above, all individuals in East Asian culture generally have a higher interdependent social construal (Krieg and Xu, 2018). This could make the gender difference in social anxiety among Chinese CAYA relatively small or non-significant. However, the lack of significant gender differences may be due to the broad age range of the study. Research showed that gender differences in social anxiety were more pronounced in mid- and late-adolescence than in childhood and early adolescence (Beesdo et al., 2009). As age increases into adulthood, the gender differences gradually decline (Espinosa et al., 2008). Therefore, combining data from these different age groups may have resulted in an insignificant gender difference.

It is worth noting that there are significant differences in the prevalence estimates between different self-report scales as well as diagnostic tools. For example, the pooled prevalence of SAS assessed by LSAS-SR is significantly higher than SASC, and the prevalence of SAD diagnosed by SCID is significantly higher than MINI-KID. The difference in diagnostic algorithms and the stringency with which these criteria are applied between measurement tools might be one possible factor that leads to differences in the pooled prevalence estimates (Pélissolo et al., 2000).

Strengths of the current meta-analysis include performing a thorough literature search in both English and Chinese databases and estimating prevalence for both SAS and SAD. However, the study has several limitations. First, there is high heterogeneity between studies that has not yet been explained by the hypothesized moderators (e.g., gender, sampling methods, measures). Second, relative to the large population of China, the numbers of studies and participants included in this meta-analysis are still inadequate and underrepresented. The results of this study could provide a reference for researchers and practitioners and cannot replace national, large-scale epidemiological surveys. Third, there was significant heterogeneity across the included studies. One important reason is that different studies used different measurement tools, that is, the prevalence estimates of SAS and SAD assessed by different self-report scales and diagnostic tools significantly differ. Other possible sources of heterogeneity may include differences in the geographic location of the sample, age, and sex ratio. Fourth, the present study included a wide age range (e.g., 6–25). There may be considerable heterogeneity in the prevalence of social anxiety across age groups and a combination of them may be misleading. In addition, studies on children (mean age between 6 and 10 years old) are very few in this meta-analysis, so the findings may be problematic when generalizing to this population. In sum, we need to be cautious when interpreting and applying these results.

Overall, our findings revealed that Chinese CAYA frequently experience SAS and SAD. It is hoped that more large-scale epidemiological surveys that use consistent screening and diagnostic tools will be conducted in the future to identify the accurate prevalence of social anxiety in this population. In addition, more culturally sensitive screening and diagnostic tools might need to be developed to identify SAS and SAD. If SAS constantly lead to psychological distress in the Chinese population, the criteria of SAD might need further revision. Finally, prevention and intervention programs to reduce social anxiety in Chinese CAYA are still scarce, and more rigorous randomized controlled trials are needed in the future.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

XT and ST contributed to the conception and design of the meta-analysis, contributed to the manuscript writing, revision, and approved the submitted version. QL, FC, HT, and XS conducted the coding of studies. All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.

This work was supported by the Renmin University of China New Faculty Start-Up Grant [22XNKJ27], the Guangdong Planning Office of Philosophy and Social Science [Grant Number GD20YSH06], and the Shenzhen University Natural Science Research Grant [Grant Number 860-000002110172].

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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