Behavioral and Cognitive-Behavioral Treatments for ...

Journal of Experimental Psychopathology JEP Volume 2 (2011), Issue 4, 615–628 ISSN 2043-8087 / DOI:10.5127/jep.014011

Behavioral and Cognitive-Behavioral Treatments for Youth with Social Phobia Lindsay Scharfstein and Deborah C. Beidel University of Central Florida

Abstract Pediatric social phobia (SP) is characterized by a pervasive pattern of social timidity. SP is most often diagnosed in mid- to- late adolescence, affecting approximately 3-5% of youth. This article reviews behavioral (BT) and cognitive-behavioral treatments (CBT) for youth with SP and outlines several limitations in the current literature. Although these treatments are all presumed to be efficacious for youth with SP and are often the treatment of choice, examination of outcome often occurs in samples with mixed anxiety disorders (AD) (including generalized anxiety disorder and separation anxiety disorder). Outcome is often assessed without considering diagnostic status, obfuscating important treatment distinctions. Further, SP often accounts for only a small portion of the samples in controlled treatment trials that include different diagnostic categories. When outcomes are examined by diagnosis, recovery rates for SP often are lower in comparison with other ADs, suggesting that factors unique to SP youth are not being adequately addressed with some forms of CBT. In contrast, interventions that include social skills training result in outcome rates for SP that are equivalent to the overall rates for BT/CBT for mixed diagnostic groups. The critical role of assessment and treatment of skills deficits in youth with SP is highlighted. © Copyright 2011 Textrum Ltd. All rights reserved. Keywords: social phobia; social anxiety disorder; treatment; review; social skills Correspondence to: Lindsay Scharfstein, University of Central Florida, P.O. Box 161390, Orlando, FL 32816-1390. Email: [email protected] Received 28-Nov-2010; received in revised form 12-Feb-2011; accepted 01-Mar-2011

Journal of Experimental Psychopathology, Volume 2 (2011), Issue 4, 615–628

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Table of Contents Introduction Review Inclusion Criteria Search Procedure Results Critique of the Literature Children with Primary SP are Underrepresented in Controlled Treatment Trials SP Youth are Treated in Mixed AD Groups and Results are Reported Collectively Differential Outcome for Children with SP in Comparison with other AD Youth Treatments With and Without SST and Assessment of Social Skills Summary and Future Directions References

Introduction Pediatric social phobia (SP) is characterized by a pervasive pattern of social timidity. Children with SP experience a marked and persistent fear of one or more social or performance situations in which the individual is exposed to unfamiliar people or to possible scrutiny by others. Although adults with SP must have insight that their social fears are excessive, developmentally appropriate descriptors for children acknowledge that they may fail to recognize their fears as unreasonable. Feared situations usually encompass a broad range of social situations, including speaking, eating, writing, or reading in front of others, attending birthday parties or dances, participating in organized groups/clubs, using public restrooms, speaking to unfamiliar children or adults, talking on the telephone, and interactions in informal social situations (Beidel, Turner, & Morris, 1999). Unstructured peer interactions, such as playing games with friends or joining in activities during recess are the most frequent distressing events, occurring as often as every other day (Beidel et al., 1999). Exposure to feared situations almost invariably provokes anxiety and children with SP either avoid or tolerate these situations with great distress, resulting in significant impairment in their social, emotional, and academic functioning (American Psychiatric Association [APA], 2000). Children and adolescents were eligible for a diagnosis of SP in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, APA, 1980). Although several research groups were investigating childhood SP during that time (Beidel, 1991; Francis, Last, & Strauss, 1992) youth were rarely assigned this diagnosis during the 1980’s (~ 1 %; Anderson, Williams, McGee, & Silva, 1987; Kashani & Orvaschel, 1990), likely because of the substantial symptom overlap with overanxious disorder (OAD) and avoidant disorder of childhood (AVD). In light of changes in the DSM-IV (APA, 1994), including the deletion of AVD, removal of social fears from the diagnostic criteria of OAD, and incorporation of OAD into the diagnosis of GAD, classification of socially anxious youth became more precise and resulted in an increased prevalence of childhood SP. For example, in one clinic sample, 18% of children received a diagnosis of SP using the DSM-III-R criteria compared to 40% using the DSM-IV diagnosis of SP (Kendall, 1996). More precise classification has led to a greater understanding of its epidemiology and psychopathology. SP is considered the most common pediatric anxiety disorder (AD), with current prevalence between 35% of children and adolescents (Beidel & Turner, 2007). SP has an early onset, most commonly occurring in mid- to- late adolescence, although children as young as 8 have been reliably diagnosed with this disorder. Regarding developmental differences in clinical presentation, childhood SP is associated with higher comorbidity (e.g., with separation anxiety disorder; SAD) and poorer social skill,


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whereas adolescents with this disorder exhibit higher levels of fear and behavioral avoidance (Rao et al., 2007), and an increased risk for alcohol or substance use (Clark, 1993). Children and adolescents with SP experience severe emotional and physical reactions to anxiety provoking situations including trembling, blushing, sweating, increased heart rate, behavioral avoidance, and in some cases, oppositional behavior, school refusal, or selective mutism. Children may also complain of headaches or stomachaches and their anxiety may manifest in crying or clinging to adults in response to feared stimuli. Further, pediatric SP is associated with high levels of general arousal, loneliness, and dysphoria (Beidel et al., 1999; La Greca & Lopez, 1998; Last, Perrin, Hersen, & Kazdin, 1992), and may be a risk factor for depressive disorders (Stein et al., 2001). Although formerly perceived as shyness or a temporary phase that children will outgrow, pediatric SP results in considerable functional impairments and significant symptom sequelae. With regard to social and interpersonal functioning, SP youth are characterized by impaired social skills and peer-related deficits. Compared to typically developing (TD) youth, children with SP are less socially competent, have fewer friends, and have difficulty making new friends (Beidel et al., 1999; Scharfstein, Alfano, Beidel, & Wong, 2011; Spence, Donovan, & Brechman-Toussaint, 1999), and at school, they receive few positive responses and more negative and “ignore” responses from peers (Spence et al., 1999). During social interactions, children with SP exhibit less overall social skill, an ineffective ability to manage the conversational topic, and deficient speech production compared to TD youth and children with Asperger’s Disorder (Scharfstein, Beidel, Sims, & Rendon Finnell, 2011). Using digital analysis of verbal communication, children with SP speak more softly and have less variation in their voice volume than TD children, and have higher vocal pitch and more vocal pitch variability (jitteriness) than children with Asperger’s Disorder. This overall vocal pattern is associated with heightened anxiety. Further, according to peer ratings, children with SP are liked less than children with GAD, SAD, and children without anxiety (Verduin & Kendall, 2008). Thus, children with SP suffer from deficits in interpersonal functioning in comparison with TD children, and children with various AD and other psychological disorders, and without remediation efforts, social impairments appear to remain stable over time (e.g., Hymel, Rubin, Rowden, & LeMare, 1990). Understanding the nature of their specific social deficits and overall symptom picture has informed researchers and clinicians regarding targeted treatments for SP youth. Efficacious interventions exist for the treatment of children and adolescents with anxiety disorders. However, specific efficacy for SP youth is often unclear as the majority of reviews and meta-analyses within the childhood anxiety literature report treatment outcome for AD youth as a unitary group (e.g., Cartwright-Hatton, Roberts, Chitsabesan, Fothergill & Harrington, 2004; Ollendick & King, 1994; Ollendick & King, 1998, Silverman, Pina, Viswesvaran, 2008), or as a specific sub-group of anxious youth, wherein SP is conceptualized as sharing the same underlying anxiety construct as SAD and GAD (Velting, Setzer, & Albano, 2004), rather than by individual diagnosis. Rarely have reviews focused solely on treatment outcome of BT/CBT for SP youth (e.g., Mancini, Van Ameringen, Bennett, Patterson, & Watson, 2005). Reporting outcomes for children with SP as part of a unitary AD group, or as belonging to a specific AD group, may misrepresent the efficacy of these treatments for SP youth. In considering clinical implications for examining outcome by AD diagnosis, one-third of children who are treated with behavioral (BT) and cognitive-behavioral therapy (CBT) continue to meet diagnostic criteria for an AD (Cartwright-Hatton et al., 2004), indicating non-response in a considerable proportion of these youth. Notably, when posttreatment status is examined by specific AD, youth with SP appear to fare worse than their non-socially anxious counterparts (Crawley, Beidas, Benjamin, Martin, & Kendall, 2008; Hudson Rapee, Lyneham, Wuthrich, & Schniering, 2010). One hypothesis for the differential outcome in SP youth is that the core features of the disorder are not being adequately addressed in treatment (e.g.,


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social skills deficits). Social skills deficits are common among children with a formal diagnosis of SP; however, social skills training (SST) is not typically included in most BT/CBT for anxious youth. Thus, children with SP may respond less favorably to treatment that does not include SST and a careful review of the overall treatment outcome for children with SP is warranted. The aims of this review are as follows: a) report on current treatments for SP youth, b) identify significant limitations in the extant literature, c) review the specific nature of treatment response for childhood SP, and d) identify possible factors contributing to a differential treatment response in youth with SP compared to other AD children.

Review Inclusion Criteria To be included in the review, studies had to meet the following criteria: a) consist of a population where at least some of the children or adolescents (age 18 or younger) were diagnosed with primary social phobia (SP) or avoidant disorder of childhood (AVD), b) use an experimental research design (randomization to an intervention group and a comparison or control group, c) evaluate a psychosocial intervention, and d) include the diagnostic breakdown of children in the sample by primary AD (i.e., the number of children diagnosed with primary SP is reported in comparison with children diagnosed with other AD as primary).

Search Procedure A computerized multi-database search was conducted in 2010, selecting the PsycInfo and MEDLINE databases from the EBSCO search engine. The terms social phobia, social anxiety disorder, social anxiety, childhood anxiety, and treatment were entered into the descriptor fields. The reference section of the articles was then reviewed for any studies not identified in the search procedure.

Results A total of 27 peer-reviewed journal articles on psychosocial interventions meeting selection criteria were identified and included in this review (See Table 1). The articles used diverse research designs and approaches to treatment. In some instances, treatment was compared to a waitlist control (WL), an active control condition, or an active treatment. Of the existing psychosocial interventions for the treatment of childhood SP, BT and CBT are often the treatment of choice by practitioners and have considerable efficacy. In general, treatment length is brief (usually 12-16 sessions) and the goal of reducing anxious arousal is targeted using some form of exposure to feared situations (e.g., imaginal exposure, in vivo exposure). Treatment programs may also include other behavioral techniques (e.g., SST, relaxation training) or cognitive approaches (e.g., cognitive restructuring, coping exercises). Programs vary in whether these components are included and the degree to which cognitive versus behavioral techniques are emphasized. Three treatment programs have been designed specifically for an SP youth population, Group Cognitive Behavior Treatment for Adolescents (CBGT-A; Albano, 1995), Social Effectiveness Therapy for Children (SET-C; Beidel, Turner, & Morris, 2004), and a CBT program (Spence, Donovan, & BrechmanToussaint, 2000). CBGT-A, the first treatment program designed for adolescents with SP, has two components: a) psychoeducation and skill building, and b) exposure. Each component is 8 weeks in length. During the psychoeducation and skill building phase, children participate in SST, social problemsolving skills, assertiveness, and cognitive restructuring. During the exposure phase, in vivo and simulated within-session exposure to feared situations is conducted according to each child’s individual


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fear hierarchy. Group members serve as interpersonal partners during exposure exercises. The final treatment session involves exposure, discussion of termination, and plans for follow up. Table 1: Proportion of Children with Social Phobia (SP) or Avoidant Disorder (AVD) in Randomized Controlled Psychosocial Treatment Trials Trial Baer and Garland (2005) Barrett (1998)

12 (100) 4 (6.7)

Barrett et al. (1996)

19 (24.1)

Beidel et al. (2000)

67 (100)

Cobham et al. (1998)

3 (4.5)

Crawley et al., (2008)

48 (28.9)

Flannery-Schroeder and Kendall (2000)

5 (11.1)

Gallagher et al, (2004)

23 (100)

Ginsburg and Drake (2002) Hayward et al., (2000)

a

n (%)

____

a

35 (100)

Kendall (1994)

9 (19.1)

Kendall et al. (1997)

17 (14.4)

Kendall et al. (2008)

63 (39.1)

Liber et al. (2008)

22 (17.3)

Lyneham and Rapee (2006)

21 (21)

Manassis et al. (2002)

5 (6.4)

Masia-Warner et al. (2005)

42 (100)

Masia-Warner et al. (2007)

36 (100)

Muris et al. (2002)

3 (15)

Nauta et al. (2003)

31 (34.8)

Rapee et al. (2006)

64 (24)

Shortt et al. (2001)

10 (14.1)

Silverman, et al. (1999b)

15 (26.8)

Silverman et al. (1999a)

10 (9.6)

Southam-Gerow et al. (2010)

13 (27.1)

Spence et al. (2000)

50 (100)

Spence et al. (2006)

30 (41.7)

Not reported by diagnosis

SET-C is a 12-week, behavioral treatment program, consisting of three treatment components that are completed simultaneously: a) in vivo exposure sessions, b) SST, and c) peer generalization sessions. In vivo exposure sessions are conducted on an individual basis, targeting each child’s specific social fears. Exposure tasks may include performing in front of others or asking questions of adults. SST sessions are structured using instruction, modeling, behavioral rehearsal, feedback, and social reinforcement. Skills include recognition of social cues, initiating and maintaining conversations, listening and remembering skills, joining groups, maintaining friendships, giving and receiving compliments, and assertiveness skills. Homework is assigned weekly. Peer generalization sessions are designed to facilitate the generalization of social skills to the community. Immediately following SST, participants practice skills just learned with non-anxious, same- age peers in natural settings (e.g. bowling, miniature golf, laser tag). Therapists are present during facilitation activities, however, they only mediate interactions when necessary (e.g. if a child is isolating from other group members). Skills for Social and Academic Success (SASS; Fisher,


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Masia-Warner, & Klein, 2004), a school-based intervention derived primarily from SET-C, and other school-based versions of the SET-C program have been developed and evaluated in randomized, controlled trials (Baer & Garland, 2005; Masia-Warner, et al., 2005; Masia-Warner, Fisher, Shrout, Rathor, & Klein, 2007). Spence and colleagues (2000) evaluated CBT in a child-only or child plus parent involvement format. Both variations are 12 weeks in length and are conducted in groups. SST is the primary focus of the intervention, but treatment also includes relaxation, social problem-solving, positive self-instruction, cognitive challenging, and gradual exposure. SST is structured using modeling, role plays, prompts, and reinforcement. Skills covered during SST include molecular social skills (e.g., eye contact, posture, facial expression, tone, voice volume), general skills (e.g., listening, showing interest), friendship skills, and prosocial behaviors (e.g., sharing, offering help, joining in, inviting others, giving compliments). Children also participate in social practice games aimed to facilitate skill generalization. In the child plus parent involvement version of the treatment, parents are taught to model socially proactive behavior, encourage their child to participate in social activities, and reinforce their child for practicing social skills. Using the Chambless et al. (1996) and Chambless and Hollon (1998) criteria, SET-C and group CBT (including CBGT-A) have been classified as probably efficacious interventions for children with SP (Silverman, Pina, & Viswesvaran, 2008). SET-C demonstrated efficacy in comparison to a psychological placebo (i.e., Testbusters; Beidel, Turner and Morris 2000). In a controlled trial, children treated with SET-C demonstrated a significantly greater decrease in social anxiety, increase in social skill, and an increase in overall social functioning than children treated with Testbusters (designed to treat test anxiety; see above for treatment components of SET-C). With respect to clinical symptom reduction, at post treatment, 67% of children in the SET-C group no longer met diagnostic criteria for social phobia, compared with only 5% in the active control condition. Treatment gains for children in the SET-C condition were maintained at both short-term (6-month) and long-term (5 year) follow-up (Beidel, Turner, & Young, 2006). SET-C also demonstrated efficacy in comparison to fluoxetine and a pill placebo (Beidel, Turner, Sallee, Ammerman, Crosby, & Pathak, 2007). SET-C and fluoxetine were more effective than placebo in terms of reducing social anxiety, but only SET-C improved overall social skill and social competence (Beidel et al., 2007), as well as appropriateness of topic management, motor movement, facial orientation, and posture (Scharfstein, Beidel, Rendon Finnell, & Distler, 2011). Empirical support for group CBT as a probably efficacious intervention for SP youth has been demonstrated in controlled trials comparing group CBT to a WL control condition (Gallagher, Rabian, & McCloskey, 2003; Hayward et al., 2000; Spence et al., 2000). Gallagher et al. (2003) randomized children with SP to a brief, 3-session intervention or WL. The active treatment was conducted in group format (9 hours over a 3-week period) and consisted of psychoeducation, recognizing behavioral, cognitive, and physiological aspects of anxiety, using cognitive strategies (e.g., modifying negative selftalk), and exposure. At posttreatment, although significantly more children in the treatment group (37%) were free of SP than the WL group (0%), the response rate for the treatment group was low. Using a longer treatment and an adolescent female population (Hayward et al., 2000), youth with SP were randomized to either CBGT-A or no treatment (see above for treatment components of CBGT-A). At posttreatment, there was a significant reduction in the number of adolescents in CBGT-A (45%) meeting criteria for SP, compared to the WL condition (4%). At follow-up one year later, these posttreatment differences disappeared. Finally, Spence et al. (2000) randomized children with SP to group CBT with parent involvement, group CBT without parent involvement, or WL. Results indicated that at posttreatment, significantly more children in CBT with parent involvement (87.5%) and CBT without parent involvement (58%) no longer met criteria for SP compared to the WL group. Although there were no statistically significant differences between the treatment conditions, more children were free of SP at


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posttreatment following treatment involving parents. Significant reductions on clinician rated severity were reported for both treatment conditions. Although not specifically classified as probably efficacious for youth with SP, several other efficacious treatments are commonly used to treat anxious youth including children with SP (e.g., Coping Cat, FRIENDS). Coping Cat (Kendall, 1990) emphasizes the cognitive skills of recognizing and clarifying distorted cognitions and attributions, devising coping plans, and evaluating performance. The behavioral components include in vivo exposures, relaxation training, and contingent reinforcement procedures. In studies of children with various AD (including SP or AVD) Coping Cat has been demonstrated to be superior to a WL condition (Kendall, 1994; Kendall et al.,1997) and a family-based education, support, and attention control condition (i.e., FESA; Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008). Several variations of Coping Cat have been developed and evaluated in randomized, controlled trials, including Coping Koala (an Australian adaptation), FRIENDS (developed from Coping Koala), Being Brave (a modification for younger children), and Coping Bear (an adaptation for group therapy; e.g., Barrett, 1998; Flannery-Schroeder & Kendall, 2000; Shortt, Barrett, & Fox, 2001).

Critique of the Literature Despite demonstrated efficacy of BT and CBT, the current knowledge base regarding the efficacy of these interventions for SP is limited in several ways. Each limitation is discussed below.

Children with Primary SP are Underrepresented in Controlled Treatment Trials The first limitation is that knowledge of treatment efficacy for SP youth is partially derived from investigations in which clinically anxious youth are treated collectively. That is, children meeting criteria for various AD diagnoses are included in the study samples (e.g., SP, SAD, GAD, panic disorder, specific phobia, and less frequently obsessive compulsive disorder, and agoraphobia. Of the 27 studies reviewed, the majority (74%) of trials examined treatment outcome in this collective manner. Although much knowledge can be gained from including various primary AD within a single sample, primary SP often accounts for approximately 15% of the overall treatment samples (Table 1 depicts the proportion of SP youth in each treatment trial reviewed). Thus, the small numbers limit drawing strong conclusions about specific efficacy for this disorder. In contrast, 26% of the studies in this review evaluated treatment in exclusive sample of children with a primary diagnosis of SP, representing a clear advantage when attempting to determine the efficacy of these interventions specifically for this diagnosis. Interestingly, when this subset of studies was further reviewed, each research group reported examining a treatment that was designed specifically for children with SP. For example, the SET-C program or school-based adaptations of SET-C (e.g., SASS) were examined in several of the studies (Baer & Garland, 2005; Beidel et al., 2000; Masia-Warner et al., 2005; Masia-Warner et al., 2007). In another study (Hayward et al., 2000), youth were treated with CBGT-A (Albano, 1995). Notably, almost all (6 of 7) of these targeted treatments included SST (Baer & Garland, 2005; Beidel et al., 2000; Hayward et al., 2000; Masia-Warner et al., 2005; Masia-Warner et al., 2007; Spence et al., 2000), suggesting that when programs are designed specifically for this population, SST is considered an essential feature.

SP Youth are Treated in Mixed AD Groups and Results are Reported Collectively When treatment trials include diverse samples of AD diagnoses, treatment outcome for these interventions most often is reported across all AD youth (i.e., collectively), rather than by specific diagnosis. Thus, important treatment distinctions can be blurred. Only 7 studies reported analyzing


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treatment outcome by diagnostic status. When outcome was examined across all AD groups, nonsignificant differences among the diagnostic groups were reported (Barrett, Dadds, & Rapee, 1996; Cobham, Dadds, & Spence, 1998; Shortt et al., 2001), with one exception. There were significant differences among children with AVD, SAD, and OAD on maternal report of state anxiety and maternal and teacher report of internalizing symptoms (see next section; Kendall et al. 1997). When diagnostic subgroups are examined, findings indicated nonsignificant treatment differences when children with OAD are compared to children without OAD (i.e., AVD, SAD; Kendall, 1994) and children with simple phobia compared to all other diagnostic groups combined (i.e., SP, agoraphobia; Silverman et al., 1999a). While these results clarify the nature of the treatment response for certain AD groups, they do not address outcome for SP. In the only study to specifically examine outcome for SP (Crawley et al., 2008), there were significant differences in treatment outcome for SP youth in comparison with other AD children (i.e., SAD, GAD; see next section). A number of factors may contribute to the practice of reporting treatment outcome collectively. The number of children with each primary AD may be too small to analyze outcome separately, suggesting the need to include adequate samples of each diagnostic group in treatment trials. Alternatively, samples with high rates of comorbidity with other AD, may assume equivalent outcomes among AD groups. Yet, without analyzing outcome by primary AD, conclusions regarding the equivalence of outcome among highly comorbid diagnoses are uncertain. There may also be an assumption that different diagnostic groups will not respond differentially to treatment, when disorders are conceptualized as sharing an underlying anxiety construct. However, even if they share an underlying emotion, there may be distinct diagnostic features that might require additional or different interventions. Thus, examining the efficacy of each intervention specifically for SP youth is necessary.

Differential Outcome for Children with SP in Comparison with other AD Youth As outlined above, the specific nature of the treatment response in children with SP is often uncertain as controlled treatment trials infrequently report treatment outcome by specific disorder. When treatment outcome variables are examined by specific diagnosis, children with SP often do worse, suggesting that a closer examination of therapy process or outcome is warranted. With respect to process, one investigation (Flannery-Schroeder & Kendall, 2000) reported significantly more children with primary SP dropped out of treatment relative to children with either primary SAD or GAD, although the exact number of dropouts was not reported. Furthermore, the reasons were unclear, but may be related to a less severe clinical presentation or perhaps a lack of “fit” between the treatment needs and the intervention provided. In terms of diagnostic recovery, youth with SP fare worse than their non-socially anxious counterparts. In a study comparing differential outcome of children with SP, SAD, and GAD (Crawley et al., 2008), children were classified as either primary SP or primary non-SP (i.e., SAD or GAD). At posttreatment, significantly fewer children with SP no longer met criteria for their primary diagnosis than the other groups (Crawley et al., 2008). Only 13 children with SP (40.1%) no longer met diagnostic criteria compared to 18 children with SAD (69.2%) and 37 children with GAD (71.2%; personal correspondence, Crawley [October 13, 2010]). Thus, children with SP responded less favorably to the treatment than those without primary SP. Although not statistically significant, lower rates of diagnostic recovery were also reported in another study where outcome of children with primary SP was compared to outcome for children with other AD (Shortt et al., 2001). The proportion of children who no longer met criteria for their primary diagnosis was lower for children in the SP group (56%) than for children in the SAD (73%) or GAD (71%) groups.


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Differential treatment outcome has been evaluated for children treated with the Cool Kids program. Cool Kids is a CBT program with an optional social skills training module that includes basic social skills (e.g., body language, eye contact, voice, posture), but not more advanced social skills (e.g., conversation topics; personal correspondence, Hudson [November 14, 2010]). Recently, outcome data on over 300 clinically anxious children who completed the Cool Kids program were re-analyzed to investigate treatment response for children with SP compared to children with another primary AD (i.e., SAD, GAD, specific phobia, OCD, PD, posttraumatic stress disorder, anxiety disorder not otherwise specified; Hudson et al., 2010). At posttreatment, significantly fewer children with primary SP (25%) were free of their initial diagnosis than children without primary SP (51%; Hudson et al., 2010). Similarly, at follow-up, although diagnostic recovery rates improved for both groups, significantly fewer SP children (51%) no longer met criteria for their primary diagnosis compared to children with other AD as primary (65.3%). Notably, these findings were evident even after controlling for mood disorders, indicating that other issues account for poorer treatment response in children with SP.

Treatments With and Without SST and Assessment of Social Skills Given that one-third of children who are treated with CBT continue to meet diagnostic criteria for an AD (Cartwright-Hatton et al., 2004), together with findings that social skills mediate treatment outcome for children with SP (Alfano, Pina, Villalta, Beidel, Ammerman, & Crosby, 2009) and SP youth often have poorer treatment response relative to children with other AD, one hypothesis is that treatment is not adequately addressing the core features of the disorder. Thus, a final limitation of the literature is a lack of attention to the assessment and treatment of social skill deficits. In controlled outcome trials, the presence or absence of initial diagnosis, anxiety, and overall improvement are consistently evaluated. However, assessment of social skill as an outcome measure is variable. Thus, the specific impact of these interventions on social skill is unclear. Only 6 studies reviewed (2 with SST, 4 without SST) included a measure of social functioning as an outcome variable. Regarding treatments without SST, at posttreatment, there were no significant improvements in parent ratings on the Parent's Rating Scale of Child's Competence (PRSC), Social Activities Scale-Parent (SAS-P), or Friendship Measure-Parent (FMP; Flannery-Schroeder & Kendall, 2000). In two studies that evaluated social performance using the social competence scale of the Child Behavior Checklist-Social Competence (Achenbach, 1991), only one study reported improvement on this measure (Kendall, 1994). Using direct observation during a speech task, there was improvement on a total behavior score, but not on any of the individual behaviors observed (gratuitous verbalizations, gratuitous body movements, trembling voice, avoiding task, absence of eye contact, fingers in mouth, body rigidity; Kendall, 1994). In another study using the same observer codes, children improved on ratings of trembling voice and fingers in mouth (Kendall et al., 1997). However, the relevance of improvement on these behaviors to an overall impression of social skill is unclear. When social skills are assessed in studies evaluating treatment with SST, greater improvement in social skill is noted. In one study (Beidel et al., 2000), children treated with the SET-C program were rated by observers as significantly more socially skilled during social interactions with a peer than the control group (Beidel et al., 2007). No significant differences between the groups were found on observer ratings of social skill during a reading task. In another study (Spence et al., 2000), children in the active treatment conditions (with and without parent involvement) were rated by parents as significantly improved on social skills. There were no significant improvements on observer ratings of assertiveness during role play interactions or on observer ratings of the number of peer interactions at school, which the authors suggested may not have been sensitive enough to detect changes. Thus, although we are limited in our understanding of the specific impact of different treatments (with or without SST) on the


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social abilities in children with SP until appropriate randomized trials exist, there is sufficient evidence to support the use of SST to improve social skill and to hypothesize that it may need to be an integral component of treatments for youth with social phobia.

Summary and Future Directions SP is the most common disorder in childhood and results in considerable functional impairments. BT/CBT is the treatment of choice by practitioners and can be implemented in various formats (e.g., individual versus group, child focused-versus family-focused). Probably efficacious interventions for childhood SP include SET-C and group CBT. Given the robust literature indicating support for BT/CBT, we must now turn our attention to addressing the unique limitations in the treatment literature for children with SP. First, SP youth are underrepresented in treatment trials, and thus treatment samples focusing exclusively on SP children and mixed AD samples including adequate numbers of SP children are needed. Second, a shift from the practice of reporting outcomes for all AD youth collectively to analyzing treatment outcome by pretreatment diagnostic status, will clarify the specific nature of the treatment response for SP youth. Lastly, research suggests a poorer treatment outcome in children with SP in comparison with other AD youth, particularly when SST is not included in the intervention. Thus, the precise impact of interventions with and without SST on measures of social skill and other important outcome measures represents a critical area for future exploration that will optimize treatment outcome for SP youth.

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