This paper describes the phenomenology and cognitive behavioral treatment of social phobia in youth. Although once a neglected disorder, social phobia is receiving increased attention by investigators within the broad fields of clinical psychology, psychiatry, and developmental psychopathology. Most relevant to this paper is the work of clinical scientists who are actively involved in developing empirically valid treatment approaches for children and adolescents with social phobia and related disorders. This chapter describes recent developments in the cognitive-behavioral treatment of social phobia in youth. In particular, I highlight one specific protocol that holds much promise in alleviating this common and serious anxiety disorder of youth. Cognitive-Behavioral Group Treatment (CBGT-A; Albano, Marten, Holt, Heimberg, & Barlow, 1995; Albano, DiBartolo, Heimberg, & Barlow, 1995) is focused on adolescents with the disorder (ages 13-17), is based on cognitive-behavioral principles, and gives unique attention to the cognitive-developmental level of the intended participants.
Cognitive behavioral therapy involves assisting an individual with accessing corrective information regarding threatening situations and stimuli, such that new and appropriate coping skills and strategies may be employed when confronting novel or potentially challenging situations. As such, cognitive behavioral programs for the range of anxiety disorders are focused on intervening within each of the three components of anxiety, the cognitive, somatic, and behavioral components. Through psychoeducation, the child learns corrective information about the nature of his or her social phobia and the mechanisms by which it is maintained. Cognitive restructuring allows the older child and adolescent to identify and challenge anxious and unrealistic thoughts, and replace these thoughts with coping, proactive reasoning. Exposure is the key to effective treatments of anxiety disorders, and this is especially true with social phobia. Systematic within session and in-vivo homework exposure situations are constructed to address each child's individual fears. Also, specific skills deficits such as conversational and basic social skills, problem solving, and assertiveness skills are taught and reinforced through the exposure process. Finally, relapse prevention methods are utilized to assist the child with maintaining and consolidating their treatment gains. Overall, cognitive behavioral programs allow the child or adolescent to access new and adaptive behaviors for managing their anxiety and daily challenges.
Description of the disorder in youth
Social Phobia (SP) has only recently begun to be empirically investigated in youth (Albano, 1995; Albano et al., 1996; Francis, Last, & Strauss, 1992; Last, Perrin, Hersen, & Kazdin, 1992; Strauss & Last, 1993). As such, SP is one of the more common principal diagnoses in children who present for treatment at specialized clinics (Albano et al., 1996; Chapman, Mannuza, & Fyer, 1995; Last et al., 1992; Vasey, 1995). Further, it is believed that social phobia may be underreported and undertreated in children since, like many of the internalizing disorders, the symptoms may not be easily recognized as evidence of a psychological disorder (Albano, DiBartolo, et al., 1995). This disorder has an onset in early adolescence (11.3 years), rarely remits, and is represented equally in males and females (Davidson et al., 1993; Last et al., 1992; Vasey, 1995). The finding that social phobia is more common in adolescence corresponds to the developmental age related social fears in nonclinical child populations. It is in adolescence that anxieties about school and social activities increase (King, 1995; Strauss & Last, 1993).
Social phobia causes impairment in the individual's social, academic, and occupational functioning (Rapee, 1995). For instance, children and adolescents with this disorder may avoid taking classes or joining extra-curricular activities that require public speaking or interacting with strangers; they also avoid social gatherings which prevents them from making friends. In children and adolescents, the social avoidance also prevents the person from dating, making friends, participating in sports, speaking up in class, and joining social or academic groups. Consequently adolescents with social phobia meet age-specific developmental challenges such as employment and dating later than peers (Albano et al., 1996). Moreover, individuals with social phobia are generally submissive in relationships and are viewed by their peers as being likely targets of ridicule, isolation, and aggression (Davidson et al., 1993; Walters, Cohn, & Inderbitzen, 1996).
During feared situations youth with social phobia are excessively concerned about being rejected or negatively evaluated and their thoughts are characterized by negative self-depreciation and physiological symptoms (Albano, DiBartolo, et al., 1995; Albano, Marten, et al., 1995). Often anticipatory anxiety occurs well before the feared social event creating negative cognitions and expectations, which can in turn negatively affect the individual's performance in the social situation. The negative performance (either perceived or real) thus reinforces the individual's fear of negative evaluation and enhances anxiety, creating a vicious cycle (Albano & Barlow, 1996; American Psychiatric Association, 1994).
There are other negative associated features of social phobia. Youth with SP tend to have poor social networks, underachieve in school and work, and have poor social skills (Albano, et al., 1996; Rapee, 1995). In adutls, social phobia is also associated with increased suicide attempts, poor medical health, lack of social support, poor occupational performance, and antisocial behavior in general (Davidson et al., 1993; Rapee, 1995). Research with children and adolescents has found high rates of comorbidity among social phobia and other DSM-III-R anxiety disorders (Brady & Kendall, 1992; Last et al., 1992; Last, Strauss, & Francis 1987; Perrin & Last, 1995). Albano, Chorpita, DiBartolo, and Barlow (1996) investigated comorbidity using DSM III-R criteria, in 174 children and adolescents (aged 7 to 17) referred to an anxiety disorders clinic. Diagnostic categories with fewer than 10 subjects were omitted resulting in a sample of 138 subjects. The results of this study indicated extensive comorbidity: 31% of the subjects met criteria for two diagnoses; 20% met criteria for three diagnoses; 15% met criteria for four or more diagnoses, while 34% only met criteria for one diagnosis. Of the sample of 138 subjects, 30% received a principal diagnosis of social phobia. Of the children diagnosed with social phobia, 29% received no additional diagnosis, 26% received one additional diagnosis, 26% received two additional diagnoses, and 19% received three or more diagnoses. The most frequent comorbid diagnoses with the social phobic sample were overanxious disorder (43%), simple phobia (26%), and mood disorder (19%).
In addition, research indicates that children with social phobia are at a high risk for developing major depression (Last et. al, 1992) and substance abuse disorders (Kessler et al., 1994). As such, social phobia tends to have a chronic course and individuals rarely recover (Davidson et al., 1993). Thus, when left untreated the potential consequences of social phobia are broad, impacting the emotional, occupational, and social functioning of the individual over the long term. Consequently, social phobia in children and adolescents is an area in need of much research.
Cognitive behavioral treatment of social phobia in youth incorporates education, skill building, cognitive-restructuring, and both within- and between-session exposure to anxiety-provoking social situations. A brief description of the individual treatment components for CBGT-A are presented below.
Education: Accurate information about the nature of anxiety and its three components (cognitive, physiological, behavioral) is presented to increase awareness and understanding about the initiation and maintenance of anxiety. Self-monitoring, in the form of a daily diary and additional specific homework assignments, are assigned to facilitate the identification of social anxiety cues, specific thoughts, and avoidance behavior.
Cognitive Restructuring. In CBGT-A, adolescents are taught to identify cognitive distortions ("errors in thinking") which perpetuate the vicious cycle of anxiety. A process of evaluating these negative thoughts through the use of dispute handles and rationale responding is then presented. Thus, adolescents are taught to devise rational thoughts for anxiety provoking situations based upon a realistic appraisal of the social situation. Therapists rely on modeling, role playing, and systematic exposure exercises to train the youth in acquiring this skill.
Social Skills. Social skills training is incorporated into CBGT-A as a fixed component. It is hypothesized that some social phobic youth present with deficient social skills due to lack of practice and/or insufficient opportunity to acquire and practice the skill stemming from behavioral avoidance (Albano, 1995; Beidel & Turner, 1998). Following a careful assessment of the individual's skill level, social skills training may be applied for interpersonal interactions, maintenance of relationships, and assertiveness through modeling, and role playing (see below).
Problem Solving. CBGT-A also provides a component geared towards teaching a "coping template" to identify general problem situations and develop realistic ways to manage such situations. It is again hypothesized that phobic youth may have limited experience in dealing with difficult situations through the use of proactive plans. Problems such as being teased, time pressures, conflict with siblings or parents, and such can be addressed through this component of treatment.
CBGT-A incorporate systematic exposure procedures to facilitate treatment progress. Indeed, exposure may be the hallmark of behavioral treatments for phobic disorders. In CBGT-A, exposures directly target the cognitive component and behavioral avoidance of anxiety, while demonstrating to the children that the sensations of anxiety will dissipate through habituation. Maintenance and generalization are promoted through the assignment of between-session homework exposures or programmed practice.
At present, parents are actively involved in selected treatment sessions in the CBGT-A protocol, although we are evaluating the relative impact of their involvement in our continuing research. Parental involvement is minimal and focused on providing education about the disorder and encouraging the parents to coach their adolescents in applying their skills between sessions and after termination.
Overall Program Structure
CBGT-A involves 16 sessions, each 90 minutes in length, administered by two trained co-therapists. Groups are usually coed and have four to six adolescents in attendance. Sessions are tapered in frequency, such that sessions 1 through 4 occur over the first two weeks; sessions 5 through 11 occur weekly; and sessions 12 through 16 are held every other week. Phase I involves eight sessions of skills training and psychoeducation, whereas Phase II is comprised of eight exposure sessions. Participants are provided with structured experience during these within-session exposures to practice their skills and confront difficult social situations. Homework assignments are utilized as a mechanism to foster generalization and maintenance of treatment gains.
Major mechanisms of change
Exposure is the key to successful treatment of social phobia. Empirical studies of adults with social phobia point to the overall significance and effectiveness of exposure-based methods for prompting and maintaining clinical change. Support for this statement may be found in summary chapters of relevant reviews and meta-analytic studies in Heimberg, Leibowitz, Hope, and Schneier (1995), and Beidel and Turner (1998). Exposure alone has been found superior to cognitive behavioral packages or control conditions (Feske & Chambless, 1995) in adults. To date, no systematic study of the relative contribution of treatment components found in CBGT-A have been conducted. However, the extant literature attests to the effectiveness of behavioral treatment strategies involving imaginal, assisted, simulated, and in-vivo exposure for the range of phobic disorders in youth (see Barrios & O'Dell, 1989, for a review).
Research support for efficacy
The CBGT-A program for treatment of social phobia in adolescents was originally developed based upon empirical support for the cognitive behavioral treatment of shyness in youth and social phobia in adults. Cognitive behavioral group treatment for social phobia in adolescents (CBGT-A) has at its empirical roots the successful treatment of adult social phobia (Heimberg, Salzman, Holt, & Blendell, 1993). The multicomponent Cognitive Behavioral Group Treatment (CBGT) protocol developed by Heimberg and colleagues, consists of cognitive restructuring, exposure to simulated phobic events, and systematic homework assignments involving the application of techniques taught in group. This treatment program has been demonstrated to result in significant improvement on various cognitive, behavioral, and self-report measures in adults (see Hope & Heimberg, 1993, for a review) Gains are typically maintained throughout long-term follow-up (Heimberg, Dodge, Hope, Kennedy, & Zollo, 1990; Heimberg et al., 1993) and the program has demonstrated long term superiority over pharmacological interventions (Heimberg, 1998). Taking into consideration the developmental differences between adolescents and adults, Albano and colleagues adopted the CBGT program for application with youth. Specifically, a significant literature attests to the effectiveness of behavioral social skills training for shy adolescents (Christoff, Scott, Kelley, Baer, & Kelly, 1985; Franco, Christoff, Crimmins, & Kelley, 1983). As such, social phobic adolescents are hypothesized to be deficient in specific skills necessary for negotiating social situations and more general problematic situations (Albano, 1995). Thus, social skills and problem solving skills training were incorporated into CBGT-A.
Albano et al. (1995) report on a pilot investigation of the CBGT-A protocol with five adolescents. At three months post-treatment, social phobia had remitted to subclinical levels for four of the five adolescents. One-year follow-up indicated that four adolescents were completely remitted of the social phobia, with the fifth adolescent reporting only subclinical symptoms. Behavioral test data indicated that despite continued physiological arousal (heart rate), the adolescents reported lower subjective ratings of anxiety during two behavioral tasks. As such, the adolescents report of negative cognitions during these tasks decreased significantly across the follow-up period, while neutral (task oriented or non-negative) thoughts increased. Currently, the CBGT-A program is undergoing empirical study in several controlled clinical trials.