Social anxiety is often evident early in life and may be diagnosed in children as young as eight years old (Beidel & Turner, 1998). Furthermore, when the social fears of children continue to be expressed through late adolescence they are more likely to be associated with a poor prognosis for recovery (Davidson et al., 1993; Mannuzza et al., 1995). The clinical presentation of social anxiety in children is similar to that of adults, with comparable somatic symptoms and feared situations. However, because of the limited cognitive development of younger children, they may not report specific negative cognitions (Beidel & Turner, 1998). Social anxiety in children is also associated with significant distress and impairment, including poor school achievement, greater loneliness, and difficulties with social relationships (Albano, Chorpita & Barlow, 1996a). Socially anxious children and adolescents may also suffer from elevated rates of general anxiety, depression, and secondary alcohol abuse (Beidel, Turner & Morris, 1999). Although social anxiety is one of the more common principal diagnoses in children who present for treatment (Albano et al., 1996b; Chapman et al., 1995; Last et al., 1992; Vasey, 1995), developmentally sensitive treatment programmes have only recently become a focus of empirical investigations.
An intervention called Social Effectiveness Therapy for children (SET-C) has been developed to treat socially anxious preadolescent children (ages 8 to 12) (Beidel, Turner & Morris, 1996). It was adapted from the adult SET programme (Turner et al., 1994b) and comprises separate group social skills training and individual exposure sessions for 12 weeks. A unique aspect of this treatment is that each child is paired with a non-anxious peer helper to assist in interactions in age-appropriate social outings. Parent involvement is limited to assistance with conducting the structured interaction homework assignments. Cognitive restructuring is not a fixed component of SET-C because the authors believe that children in Piaget's concrete operational stage may not endorse catastrophic negative thoughts during socially stressful situations.
A recent study compared SET-C with a nonspecific control intervention in 67 children (ages 8 to 12) with social anxiety (Beidel, Turner & Morris, 2000). Following 12 weeks of treatment, the SET-C group was significantly more improved than the control group on self-report and parent ratings of anxiety, as well as independent observers' ratings of skill and anxiety during behavioural tasks. Furthermore, 67 % of the children in the SET-C condition no longer met diagnostic criteria for social phobia at post-assessment compared with 5 % of those in the control group. Treatment gains were maintained at a six-month follow-up assessment of 73 % of the original SET-C group. Further, at three-year follow-up, post-treatment responders largely maintained their treatment gains and 72 % of children in the treatment condition no longer met diagnostic criteria (Beidel et al., 2005).
Cognitive-Behavioural Group Treatment for Adolescents
Cognitive-behavioural group treatment for adolescents with social anxiety disorder (CBGT-A) (Albano et al., 1995a) was first pursued with an adaptation of Heimberg's CBGT for adults. In addition to psychoeducation, cognitive restructuring, and exposure, CBGT-A incorporates social skills and problem-solving skills training to address specific concerns of socially anxious youth (Albano, 1995). Parents attend four key sessions involving psychoeducation, assessment of family interactions, exposure planning and the use of skills following treatment. Albano et al. (1995b) present data on the treatment of five adolescents who completed 16 sessions of CBGT-A. Three months after treatment, the social anxiety of four participants was reduced to subclinical levels. At a one-year follow-up the four adolescents showed no social anxiety or other mental disorder; the remaining adolescent reported subclinical social anxiety.
Hayward et al. (2000) compared CBGT-A with a no-treatment control condition for female adolescents with social anxiety (mean age = 15.8 years). Eleven participants who completed 16 weeks of CBGT-A showed greater reductions on self- and parent ratings of interference and on self-reported social anxiety than the 22 participants in the control condition. At post-treatment, 46 % (5/11) of the CBGT-A group no longer met criteria for social anxiety, compared to only 4.5 % (1/22) of the control group. However, at a one-year follow-up assessment, these differences were no longer significant. Additional analyses suggest that CBGT-A may reduce the frequency of major depression in participants with a previous history of major depression, with 17 % relapse in depression among CBGT-A participants with this history, compared to 64 % in the control group, over the course of the study.
Other existing controlled trials examining the efficacy of cognitive restructuring and exposure therapy for anxious children have included mixed diagnostic samples, limiting the specificity of the results for social anxiety disorder. In the following studies, socially anxious children comprised 24 % to 33 % of the total samples. Kendall's (1994) Coping Cat programme combines relaxation training with exposure and cognitive restructuring to alleviate children's fears. This programme provides an age-appropriate format for leading younger children through cognitive restructuring steps. Parental involvement in therapy is mainly in a supportive role and collaboration within session is variable. After 16 sessions, this intervention was superior to a wait-list condition for children (ages 9 to 13) with either overanxious disorder, separation anxiety disorder or DSM-III-R (American Psychiatric Association, 1987) avoidant disorder of childhood, which was later subsumed under social anxiety disorder in the DSM-IV (American Psychiatric Association, 1994). Improvements were found on child self-report measures, parent ratings of their children's anxiety and social competence as well as observer ratings from a videotaped behavioural task. However, no changes were found on teacher ratings. Sixty-four per cent of the treated group no longer met criteria for their principal diagnosis at post-treatment. Results from a two- to five-year follow-up showed that treatment gains were maintained (Kendall & Southam-Gerow, 1996). Kendall et al. (1997) replicated these findings in another sample of 60 children (ages 9 to 13) with various anxiety disorders. More than half (53 %) of the treated children no longer met diagnostic criteria for their primary anxiety disorder compared with 6 % of the wait-list control group. Treatment gains were maintained at a one-year follow-up. There were no outcome differences by diagnostic group.
Because one of the hypothesized mechanisms of transmission for anxiety is observational learning and modelling within the family (Bruch, 1989; Bruch & Heimberg, 1994), additional involvement of the family in treatment may add to the efficacy of CBT. Barrett, Dadds & Rapee (1996) examined the efficacy of Kendall's intervention, alone or in combination with family anxiety management treatment (FAM), for 79 children with separation anxiety, overanxious disorder, or social anxiety disorder. FAM comprises strategies to support and encourage adaptive behaviour and to extinguish maladaptive behaviour, a component for the management of parental anxiety and training in problem-solving skills to extend the child's progress in treatment. The combined treatment was superior to child treatment alone on several clinical and self-report measures after treatment and at 12-month follow-up. Again, no differential response based on diagnosis was noted.
Since none of the studies of Kendall's treatment included specific measures of social anxiety, it is difficult to draw conclusions regarding its efficacy for children with social anxiety disorder. However, they seemed to fare as well as children with other diagnoses, calling into question the need for specialized social anxiety treatments for children. Further evaluation of the outcomes of this treatment for children with social anxiety disorder, in comparison to treatments focused specifically on social anxiety, in studies including specific measurement of social anxiety, appears to be warranted.
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