School-Based Intervention for Adolescents with Social ... - Springer Link

C 2005) Journal of Abnormal Child Psychology, Vol. 33, No. 6, December 2005, pp. 707–722 ( DOI: 10.1007/s10802-005-7649-z

School-Based Intervention for Adolescents with Social Anxiety Disorder: Results of a Controlled Study Carrie Masia-Warner,1,4 Rachel G. Klein,1 Heather C. Dent,2 Paige H. Fisher,1 Jose Alvir,1 Anne Marie Albano,1 and Mary Guardino3 Received June 18, 2003; revision received July 19, 2004; accepted August 15, 2004

Social anxiety disorder, whose onset peaks in adolescence, is associated with significant impairment. Despite the availability of effective treatments, few affected youth receive services. Transporting interventions into schools may circumvent barriers to treatment. The efficacy of a school-based intervention for social anxiety disorder was examined in a randomized wait-list control trial of 35 adolescents (26 females). Independent evaluators, blind to treatment condition, evaluated participants at preintervention, postintervention, and 9 months later. Adolescents in the intervention group demonstrated significantly greater reductions than controls in social anxiety and avoidance, as well as significantly improved overall functioning. In addition, 67% of treated subjects, compared to 6% of wait-list participants, no longer met criteria for social phobia following treatment. Findings support the possible efficacy of school-based intervention for facilitating access to treatment for socially anxious adolescents. KEY WORDS: social anxiety; adolescents; school intervention; behavior therapy.

Social anxiety disorder, whose onset peaks in adolescence, is associated with significant impairment (e.g., few friends, loneliness, depressed mood, disturbances in school performance, difficulty with interpersonal relationships) (Albano, 1995; Beidel, Turner, & Morris, 1999; Wittchen, Stein, & Kessler, 1999). Epidemiological research suggests that social phobia in youth is common (see Klein & Pine, 2002). Prevalence rates are particularly high for adolescents, ranging from 4 to 9% (Verhulst, van der Ende, Ferdinand, & Kasius, 1997; Wittchen et al., 1999). Studies of social phobia in clinical and epidemiological samples have found stability into adulthood, and suggest that social phobia may contribute to increased risk for suicide attempts, alcohol use, inability to work, depression, and severe social restrictions (Essau, Conradt, & Petermann, 1999; Liebowitz, Gorman, Fryer, & Klein,

1985; Pine, Cohen, Gurley, Brook, & Ma, 1998; Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992; Turner, Beidel, Dancu, & Keys, 1986; Wittchen et al., 1999). Recognition of the significance of social phobia in youth has led to the development of three clinic-based treatments designed specifically for children and adolescents. Spence (1995) developed Social Skills Training: Enhancing Social Competence in Children and Adolescents (SST), a program emphasizing social skills training and exposures, but also including problem-solving, cognitive restructuring, and relaxation techniques. The 12week program consists of weekly hour-long group sessions, followed by a 30-min practice of learned social skills in a simulated environment. In a trial evaluating SST, clinic children, ages 7–14, were assigned to either child-focused SST (n = 19), SST plus parent involvement (n = 17), or a waiting list (n = 14) (Spence, Donovan, & Brechman-Toussaint, 2000). At posttreatment, significantly more children who received SST alone, or SST with parent involvement, no longer met diagnostic criteria for social phobia compared to the wait-list control group (WLC), 58%, 87.5%, and 7%, respectively. In addition, compared to the WLC, both treatment groups

1 New

York University Child Study Center, NYU School of Medicine, New York. 2 Psychology Department, University of Denver, Denver, Colorado. 3 Freedom from Fear, Staten Island, New York. 4 Address all correspondence to Carrie Masia-Warner, NYU Child Study Center, 215 Lexington Avenue, 13th floor, New York 10016; e-mail: [email protected].

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Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

demonstrated significantly greater reductions in children’s self-reports of social and general anxiety and increases in parent reports of their children’s social skills. Both treatment groups maintained relative gains at 12-month follow-up. Outcomes for SST treatment with and without parent involvement did not differ significantly at any point. Social Effectiveness Therapy for Children (SET-C: Beidel, Turner, & Morris, 1998) is a 12-week treatment, designed for children ages 8–12, that consists of 24 sessions focused on behavioral exposure and social skills training. Two sessions, an individual exposure session and a social skills training group, are conducted weekly. Social skills groups are followed by peer generalization social activities with outgoing, unfamiliar peers. Beidel and colleagues (Beidel, Turner, & Morris, 2000) compared SET-C, to a control intervention, Testbusters, a program that includes study-skills and test-taking strategies but does not address social anxiety. Children in the SET-C program (n = 30), compared to those in the control group (n = 20), demonstrated significant decreases in symptoms and improved functioning. In addition, 67% of the SET-C treated group no longer met diagnostic criteria for social phobia compared to only 5% of the control group. Treatment gains were maintained at 6-month follow-up. These treatment differences are particularly impressive given the contrast with an attention rather than a wait-list control. A more cognitively oriented approach to treatment, Cognitive-Behavioral Group Therapy for Adolescents (CGBT-A: Albano, Marten, Holt, Heimberg, & Barlow, 1995), consists of 16, 90-min group sessions that include psychoeducation, cognitive restructuring, problemsolving, social skills, and behavioral exposure. A controlled study of socially phobic adolescent girls compared CBGT-A to a wait-list control group (Hayward et al., 2000). Significant reductions in clinician-rated interference scores were obtained in the CBGT-A group (n = 11) compared with the wait-list control (n = 22). At posttreatment, 45% of the treated group no longer met criteria for social phobia compared to 5% of the untreated group. The treated group reported significantly decreased social phobia symptoms on the Social Phobia and Anxiety Inventory, but their scores were still in the clinical range. At 1-year follow-up, groups no longer differed. Despite the availability of promising clinic-based programs, socially anxious adolescents are rarely referred (Kashdan & Herbert, 2001) and are unlikely to receive treatment (Essau et al., 1999; Wittchen et al., 1999). This problem is consistent with a larger literature documenting a considerable gap between youth who are in need of treatment and those who actually receive any mental healthcare (Burns et al., 1995; Leaf et al., 1996). Accord-

ing to the Surgeon General’s 1999 report on mental health, 6–9 million youngsters with emotional problems are not receiving the help they require (U.S. Department of Health and Human Services, 1999). There is growing recognition that community mental health centers and other standard sites for service delivery are insufficient for ameliorating this situation (Weist, 1999). Waiting lists are often long, no-show and drop-out rates are high, youngsters are often reluctant to receive services in these settings, and research has failed to support the effectiveness of community treatment (Weist, 1999; Weisz, Donenberg, Han, & Weiss, 1995). The failure to provide treatment to youth represents a major public health concern. Incorporating effective interventions into schools may help to circumvent this problem. In fact, the majority of the small percentage of children who do obtain services, receive them at school (Burns et al., 1995; Burns & Hoagwood, 2002; Farmer, Stangl, Burns, Costello, & Angold, 1999; Hoagwood & Erwin, 1997; Leaf et al., 1996; Staghezza-Jaramillo, Bird, Gould, & Canino, 1995). Consistent with this finding, the U.S. Surgeon General’s report designates schools as a key setting for identifying and addressing mental health concerns in youth (U.S. Department of Health and Human Services, 1999). This proposed solution for increasing healthcare access is based on several observations. First, schools provide unparalleled access to youth (Adelman & Taylor, 1999; Weist, 1997), and therefore, represent a single location through which the majority can be reached (Anglin, 2003). Second, school programs reduce barriers to treatment such as cost and transportation (Catron, Harris, & Weiss, 1998). In a study of children with depressive and disruptive disorders (Wu et al., 1999), children’s use of school-based services, compared to community mental health services, was less influenced by demographic and parental factors, indicating that the school setting may offer opportunities that would not be otherwise available. Third, schools provide increased opportunity for prevention and early identification and intervention, which may prevent the development of serious secondary dysfunction (Weist, 1999). In addition, children and families may avoid seeking help partly due to the stigma associated with mental health treatment. Offering services in a familiar setting like schools may make treatment more acceptable (Catron & Weiss, 1994; Weist, 1999) since many children already receive school-based services for nonmental health concerns. This is especially important for adolescents, who are reluctant to seek help and are an underserved population (Laitinen-Krispijn, van der Ende, Wierdsma, & Verhulst, 1999; Verhulst & van der Ende, 1997), perhaps

School-Based Intervention for Social Anxiety because of age-related worries about stigma or being labeled abnormal (HoganBruen, Clauss-Ehlers, Nelson, & Faenza, 2003). Moreover, partnering with schools creates opportunities to educate and support school personnel and parents in identifying mental health issues and making appropriate referrals for treatment. This is particularly relevant for social anxiety for several reasons: (1) students with social anxiety are often overlooked, most likely due to their quiet, compliant manner, (2) it is common for adults to underestimate the adversity associated with problems experienced by socially anxious youth, and (3) few teachers and parents believe that social anxiety requires treatment even when they recognize extreme shyness or nervousness (Masia, Klein, Storch, & Corda, 2001; Pandey et al., 2003), and they expect that youngsters will “grow out” of their anxiety (HoganBruen et al., 2003). In addition, parents frequently consult teachers about their children’s problems (Cohen, Kasen, Brook, & Struening, 1991), and teachers’ opinions of the need for treatment have a major impact on referral decisions (Angold et al., 1998; Costello & Janiszewski, 1990; Hoberman, 1992; Tarico, Low, Trupin, & Forsyth-Stephens, 1989; Wu et al., 1999; Zahner & Daskalakis, 1997). Therefore, it is likely that educating teachers and parents about the symptoms of social anxiety disorder and its associated impairment will enhance recognition of this disorder in youth. Finally, treatment implemented within schools allows for real-world interventions. It provides opportunities for practicing skills in realistic contexts and with diverse individuals (e.g., teachers, staff, and peers), thereby increasing the likelihood of generalization to the natural environment (Evans, 1999; Evans, Langberg, & Williams, 2003). School-based intervention is likely to be beneficial for treating social anxiety disorder since: (1) school is the setting where socially anxious adolescents incur the greatest disadvantage (Hofmann et al., 1999) and (2) it allows for real-life exposures to the most commonly avoided situations (e.g., answering questions in class, speaking with office personnel, and initiating conversations with unfamiliar peers). Lastly, peers and teachers with whom socially anxious students routinely associate can also be enlisted to support students’ progress. This type of approach reduces the division between the treatment setting and natural environment, and may enhance the effectiveness of school interventions compared to clinic-based treatments (Evans et al., 2003). Based on the many potential advantages to providing services in schools, there has been a proliferation of school-based programs (Adelman & Taylor, 1998). Despite this expansion of mental health services, the majority of these initiatives have not been subjected to system-

709 atic evaluation and their effectiveness is largely unknown (Adelman & Taylor, 1998; Hoagwood & Erwin, 1997; Leff, Power, Manz, Costigan, & Nabors, 2001; Power, Manz, & Leff, 2003; Rones & Hoagwood, 2000). A recent review of research on school-based mental health services found that only 47 of 337 published program evaluations used adequate designs for testing effectiveness. Some positive effects were found for programs addressing depression, conduct and emotional problems, and substance use (see Rones and Hoagwood, 2000 for a review). Overall, however, few studies target specific psychiatric disorders, utilize methodological controls, or implement wellarticulated interventions and standard outcome measures (Hoagwood & Erwin, 1997). In addition, no scientifically rigorous studies of school-based prevention or intervention programs for anxiety were found. Since anxiety disorders are among the most common mental disorders in children and adolescents (Costello & Angold, 1995; Klein & Pine, 2002), and are associated with school absence and refusal, controlled studies of school-based treatment for anxiety disorders are especially important (Rones & Hoagwood, 2000). Considering the growing evidence supporting child mental health treatments tested in university research settings (Weisz et al., 1995; Weisz, Weiss, & Donenberg, 1992), as well as concern over access to services and poor outcomes experienced by youth with mental disorders, the Surgeon General has called for increased development and proliferation of evidence-based interventions into community settings (Hoagwood, Burns, Kiser, Ringeisen, & Schoenwald, 2001; U.S. Public Health Service, 2000). We cannot assume, however, that treatments validated in research settings will demonstrate the same efficacy in other environments. Rather, it is important to consider the context in which the service will be delivered (Adelman & Taylor, 1998; Hoagwood et al., 2001). An important direction for school-based mental health, therefore, is to determine the transportability and efficacy of evidencebased programs in school settings (Graczyk, Domitrovich, & Zins, 2003), including how to adapt these treatments to facilitate their use in school settings without impacting their efficacy (Hoagwood et al., 2001; Schoenwald & Hoagwood, 2001). To determine if providing treatment for social anxiety disorder in schools was feasible and potentially efficacious, Masia and colleagues (Masia et al., 2001) conducted an initial feasibility study of school-based behavioral intervention for adolescents with social anxiety disorder. The intervention, Skills for Academic and Social Success (SASS; Masia et al., 1999), was developed with the goal of adapting clinic-based procedures to be practical for delivery in high schools. Based on the

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documentation of social skills deficits in socially anxious youth (Beidel et al., 1999; Spence, Donovan, & Brechman-Toussaint, 1999) and the demonstrated efficacy of the SET-C protocol (Beidel et al., 2000), the SASS program was primarily derived from SET-C, with modifications for an adolescent population (e.g., developmentally appropriate social skills, addition of training in realistic thinking) and the school environment (e.g., briefer sessions and incorporation of teachers). The 14-session pilot SASS program consisted of one psychoeducational session, one session of realistic thinking, five sessions of social skills training, five sessions of exposure, and one session of relapse prevention as well as two unstructured social activities (e.g., pizza parties). Teachers were also asked to conduct practice exercises with group members (e.g., calling on them in class, etc.). Six high school students participated in this small open trial of the SASS intervention. Overall, all participants showed marked or moderate improvements. Most important, the program was well-received by students, parents, and teachers, and appeared ecologically valid (Masia et al., 2001). The pilot study supported the feasibility of this approach. Following the pilot study, additional components were added to the SASS intervention to more fully take advantage of the school context and enhance generalization of clinical gains. First, the social activities seemed to be particularly powerful, and thus, two additional events were added. To increase social interactions for the socially anxious students and create more realistic situations, the social events were “typical teenage outings” in the community and outgoing school peers were invited to attend. Second, a more formal teacher component was developed to facilitate teacher involvement in identifying students’ specific difficulties and assisting in classroom exposures. Lastly, due to experiences with parental obstacles to treatment progress, two parent sessions focusing on psychoeducation and management of child anxiety were developed to encourage parental contributions to clinical gains. The modified program is described in more detail below. The current investigation represents an initial examination of the efficacy of the revised SASS program.

METHOD Recruitment Step One of Recruitment: School Screening Participants were drawn from a population of 1,521 adolescents in grades 9 through 11 from two parochial high schools in New York City. A screening using three

social anxiety self-rating instruments and teacher nominations was conducted to identify students likely to have social anxiety disorder. Of the 1,521 eligible students, 1,358 (89.3%), completed the Social Phobia and Anxiety Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1995), the Social Anxiety Scale for Adolescents (SAS-A; LaGreca, 1998), and the social subscale of the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997) during a school guidance period. In addition, the first author conducted teacher workshops on the symptoms and impairment associated with social anxiety, and she asked teachers to nominate up to five students in their classrooms who appeared quiet, shy, and nervous. Students who scored in the top 15% on self-rating instruments or were nominated by teachers were selected for further screening (475/1521, 31.2%). Step Two of Recruitment: Telephone Screening The parents of the 475 “positive” screens were telephoned for a brief interview. Parents who indicated social anxiety associated with impairment in functioning (171/475, 36%) were invited to participate in a diagnostic evaluation with their child in home. Eighty adolescents and their parents (80/171, 47%) agreed to participate. Final Recruitment Step: Diagnostic Interview The interview session began by explaining the interview procedures, describing the research study, and obtaining informed consent from both the parent and the adolescent. Parents and adolescents were then interviewed separately, by the same evaluator, using the Anxiety Disorders Interview Schedule for DSM-IV: Parent and Child Versions (ADIS-PC; Silverman & Albano, 1996). Students were considered appropriate for the study if they received a DSM-IV diagnosis of social anxiety disorder with significant impairment as defined by an ADIS-PC Clinician Severity Rating of four or higher (at least moderate severity) on the 8-point severity scale. Students were excluded from the study if they: 1) were currently receiving psychological or pharmacological treatment for social phobia; 2) warranted a diagnosis of substance use disorder, oppositional defiant disorder, conduct disorder, or major depression that was of greater severity than social phobia; 3) were experiencing psychotic symptoms or current suicidal or homicidal thoughts; or 4) had a current major life event requiring immediate attention (e.g., a parent dying). Among those interviewed (n = 80), 42 adolescents (52.5%) met study criteria. Of the 38 (47.5%) who did not:

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Table I. Participant Characteristics SASS intervention (n = 18) Gender (n, % female) Ethnicity (n, %) Caucasian African American Asian American Latin American Other Mean age (SD) Grade (n, %) 9 10 11 Generalized type (n, %) Comorbidity (n, %) GAD Dysthymia Agoraphobia Eating disorder NOS

Wait-list control (n = 17)

Total (n = 35)

14 (77.8)

12 (70.6)

26 (74.3)

16 (88.9) 2 (11.1) 0 0 0 15 (.59)

13 (76.5) 1 (5.9) 1 (5.9) 1 (5.9) 1 (5.9) 14.5 (.94)

29 (82.9) 3 (8.6) 1 (2.9) 1 (2.9) 1 (2.9) 14.8 (.81)

4 (22.2) 13 (72.2) 1 (5.6) 17 (94.4) 9 (50) 6 (33.3) 3 (16.7) 1 (5.6) 1 (5.6)

9 (52.9) 7 (41.2) 1 (5.9) 16 (94.1) 8 (47.1) 8 (47.1) 2 (11.8) 0 0

13 (37.1) 20 (57.1) 2 (5.7) 33 (94.3) 17 (48.6) 14 (40.0) 5 (14.3) 1 (2.9) 1 (2.9)

32 (40%) did not receive a diagnosis of social phobia, four (5%) were excluded due to current major depression, one (1.3%) was currently receiving treatment, and one (1.3%) needed immediate other assistance due to his mother’s pending death. Agreement on social phobia diagnoses was determined on a random sample of 28 audiotaped interviews that were independently rated by a second clinician. Agreement occurred in 26 of the 28 (98%) cases. In the first case of disagreement, the interviewer had assigned a diagnosis of generalized anxiety disorder. For the other, the interviewer rated the subject’s social anxiety at a subclinical level. Both cases were reviewed with the interviewers and expert clinicians, and given a diagnosis of social phobia. Enrolled Participants Of the 42 adolescents admitted to the study, five (12%) were diagnosed with a “specific” subtype of social phobia, as their main concerns surrounded performance situations and public speaking in class. The other 37 adolescents received a diagnosis of social anxiety disorder, generalized subtype, as their anxiety interfered with a wide range of social and performance situations. Only four of these students (9.5%) had ever sought treatment for anxiety. Students were randomly assigned to either the SASS intervention (n = 21) or wait-list control condition (n = 21). Randomization occurred within schools (i.e., there was an intervention group and a control group in each school) to control for possible differences in school en-

vironments. Seven participants (three assigned to SASS and four to wait-list) terminated their participation early in the study. One drop-out from the intervention group attended only the first session, the second noncompleter attended two sessions, and the third attended four. There were no significant differences in demographic information or initial diagnostic severity between completers and noncompleters. However, adolescents with fears restricted to public speaking were more likely to terminate participation than those meeting criteria for the generalized subtype (60% versus 10.8%, Fisher’s Exact Test = .03) Demographic data for adolescents who completed the study are depicted in Table I. Mean age was 14.8 years (range = 13–17 years). The majority were female (74.3%, n = 26). Ethnicity was as follows: 82.9% Caucasian, 8.6% African American, 2.9% Asian American, 2.9% Latin American, and 2.9% other. About half of the sample had other disorders, the most common being generalized anxiety disorder (40%) and dysthymia (14.3%). School-Based Intervention: Skills for Social and Academic Success The process of moving efficacious treatments into other settings is complex and requires adaptations (Schoenwald & Hoagwood, 2001). In transporting a clinic-based protocol to a school setting, several considerations guided the SASS intervention design: 1) sessions could last no longer than a typical class period, approximately 42 min, 2) sessions could not interrupt academic

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courses, 3) the school environment was to be used as a setting for exposures in order to encourage generalization, 4) teachers would be asked to identify students’ specific difficulties and assist in classroom exposures, 5) parents would learn techniques to decrease their children’s avoidance and enhance skills generalization, and 6) the program was to utilize outgoing school peers to facilitate social interactions. The SASS intervention is designed for implementation in school settings. It consists of 12 weekly group school sessions (approximately 40 min each), two brief individual meetings (15 min), and two group booster sessions. Additionally, four weekend social events (90 min) that include prosocial peers, called “peer assistants” (described below) provide real-world exposures and opportunities for skills generalization. Parents attend two group meetings (45 min) at school during which they receive psychoeducation regarding social anxiety and learn techniques to address their child’s anxiety. Teachers participate in two psychoeducational meetings (30 min) and conduct classroom exposures supervised by group leaders. The program is designed to be flexible to accommodate school calendars (e.g., vacations and exams), and typically spans about 3 months. All groups were co-led by a behaviorally trained clinical psychologist and a clinical psychology graduate student. Attendance at the program was high (90.3%). Attendance at parental sessions was lower, with a 69.4% participation rate.

Social Events

School Group Sessions

Parent Meetings

The 12 school meetings consist of one psychoeducational session, one session on realistic thinking, four social skills training sessions (i.e., initiating conversations, maintaining conversations and establishing friendships, listening and remembering, and assertiveness), five sessions of exposure, and one session on relapse prevention. Exposures are regularly integrated into the school environment and include the assistance of school personnel or peer assistants (e.g., ordering and returning food in the lunchroom, going to the office to ask the school secretary questions, starting a conversation with the principal).

Many parents have a limited understanding of the symptoms and impairment associated with social anxiety. They may misinterpret their child’s socially anxious behavior (e.g., “my child is unfriendly”) and are often frustrated by their child’s avoidance behaviors (e.g., refusing to answer the telephone). The two parent meetings focus on psychoeducation about social anxiety and ways to manage children’s anxiety and facilitate improvement.

Individual Meetings Each group member meets individually with group leaders at least twice during the program. These sessions are designed to identify individual treatment goals and problem-solve any treatment obstacles. Given the limited amount of time available during group sessions, individual meetings provide an opportunity to adapt the program to each student’s needs.

The four social events provide essential opportunities for group members to practice program skills with “realworld” school peers in natural community “hang-outs.” Activities may include bowling, laser tag, going to the mall, playing billiards, miniature golf, or a picnic. These events are attended by group members and peer assistants recruited from participating high schools. Peer Assistants Teachers and administrators are asked to nominate students who are friendly and kind to be peer assistants. A consent form is mailed to parents of nominated students to explain the role of peer assistants and to obtain signed permission to participate. The potential peer assistants are interviewed by a member of the research team and discussed with school personnel (e.g., counselors, principal) prior to final selection. Group leaders meet twice with peer assistants prior to the intervention to discuss their responsibilities. In addition to attending the social events, they assist with exposures and skill practice during the week when necessary (e.g., introducing a group member to a new peer in class). As peer assistants attend the same schools as program participants, their involvement facilitates peer support within the school environment.

Teacher Meetings Teacher education and collaboration are important benefits of conducting the intervention in a school setting. Teachers are often eager for information on how to assist shy students. Group leaders meet with teachers for two 30-min meetings. Teachers are educated about social anxiety, the goals of the SASS program, and ways to manage anxiety in the classroom. Teachers identify areas of social difficulty for participants, potential classroom exposures are discussed, and teachers provide feedback about students’ progress. Group leaders work with

School-Based Intervention for Social Anxiety teachers to develop appropriate, gradual exposures. For instance, if a group member fears bringing attention to himself, a teacher may have the student enter the classroom late, wait for the student to arrive before starting the lesson, and possibly reprimand him in front of classmates. Booster Sessions Two monthly group booster sessions are conducted with group members after the completion of the program. Their purpose is to monitor progress since termination, evaluate and discuss any obstacles to continued improvement, and highlight additional ways to practice skills and establish relationships. MEASURES Participants were evaluated at preintervention and postintervention. Since the wait-list controls were provided with treatment following postassessment evaluations, only SASS group subjects participated in 9-month follow-up assessments. Assessments included independent evaluator ratings, self-report inventories, and parent ratings. Trained independent evaluators, blind to treatment condition, conducted all clinical assessments in participants’ homes.

713 for each situation, but is given latitude to question responses and adjust ratings accordingly. The LSAS-CA provides a total score and six subscale scores: social anxiety, social avoidance, performance anxiety, performance avoidance, total anxiety, and total avoidance. The LSASCA has demonstrated satisfactory psychometric properties (Masia-Warner et al., 2003). Social Phobic Disorders Severity and Change Form (SPDSCF; Liebowitz et al., 1992) is a 7-point rating of severity and change specific to social phobia symptoms. It has been used to measure treatment response in welldesigned treatment trials of adult social phobia (Heimburg et al., 1998; Liebowitz et al., 1992). Severity ranges from 1 (normal) to 7 (among the most severely ill patients). In addition, change scores denote improvement in social anxiety symptoms ranging from 1 (markedly improved) to 7 (markedly worse). Ratings of 1 or 2 (markedly or moderately improved) define treatment responders. Ratings were based on child and parent responses during the clinical interview. Children’s Global Assessment Scale (CGAS; Shaffer et al., 1983) a clinician rating of functioning considering psychological, social, and school behavior, is scored from 0 to 100, with higher ratings indicating better functioning. Psychometric data support the use of the CGAS to assess overall impairment (Bird, Canino, Rubio-Stipec, & Ribera, 1987; Shaffer et al., 1983).

Independent Evaluator Ratings

Self-Report Inventories

Anxiety Disorders Interview Schedule for DSMIV: Parent and Child Versions (ADIS-PC; Silverman & Albano, 1996) provides coverage for anxiety and mood disorders, and screens for the presence of externalizing behavior disorders, psychosis, and eating disorders. Interviews are conducted with parents and children separately, and independent data are recorded. Based on information from both interviews, the independent evaluator assigns composite diagnoses and corresponding severity ratings. A diagnosis is assigned if a severity rating of 4 or greater on a 0–8 rating of distress/impairment is given. The ADIS has demonstrated sensitivity to treatment effects (Kendall et al., 1997). Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA; Masia-Warner, Klein, & Liebowitz, 2003) assesses a range of situations that children and adolescents with social phobia may fear and/or avoid. Its 24 items are divided into social interaction (12 items) and performance (12 items) situations. The independent evaluator asks the adolescent to provide separate ratings for anxiety and avoidance on a 0–3 Likert-type scale

Social Phobia and Anxiety Inventory for Children (SPAI-C; Beidel et al., 1995) consists of 26 items that assess specific somatic symptoms, cognitions, and behavior across potentially fear-producing situations. Questions are answered on a 3-point Likert-type scale ranging from (0) Never to (2) Most of the time or Always. The SPAI-C has been reported to have adequate psychometric properties (see Beidel et al., 1995; Beidel, Turner, & Fink, 1996; Beidel, Turner, Hamlin, & Morris, 2000). Social Anxiety Scale for Adolescents (SAS-A; LaGreca, 1998) contains 18 items focusing on social anxiety and four filler items reflecting activity or social preferences. Items are rated on a 5-point Likert scale from (1) not at all true to (5) all the time. The following three factors have been generated: Fear of Negative Evaluation (FNE), Social Avoidance and Distress-New (SAD-New), and Social Avoidance and Distress-General (SAD-General). The SAS-A has been found to be psychometrically sound (LaGreca & Lopez, 1998) and to discriminate adolescents with and without social phobia (Ginsburg, LaGreca, & Silverman, 1998).

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Children’s Depression Inventory (CDI; Kovacs & Beck, 1977) is a 27-item self-report measure that assesses the severity and presence of affective, behavioral, and cognitive symptoms of depression during the previous 2-week period. The CDI demonstrates good test–retest reliability and construct validity (Craighead, Smucker, Craighead, & Ilardi, 1998; Kovacs, 1992), and has been found to differentiate between depressed and nondepressed children (Carlson & Cantwell, 1979). Loneliness Scale (LS; Asher & Wheeler, 1985) consists of 16 items that assess feelings of loneliness (e.g., “I have nobody to talk to at school) rated on a 5-point scale. Factor analysis generated one primary factor with high internal consistency (Asher & Wheeler, 1985). Parent Report Social Anxiety Scale for Adolescents: Parent Version (SAS-AP; LaGreca, 1998) asks parents to report on their adolescent’s social anxiety on a 5-point Likert scale from (1) not at all true to (5) all the time. The SAS-AP items and factor structure are identical to the SAS-A.

not account for treatment group as a random variable in the planned random regression models. Preassessment comparisons of the treatment and control groups were conducted using chi-square and t-tests for independent samples. Dichotomous outcomes, such as the SPDSCF-Change (number of patients rated as moderately or markedly improved) and ADIS diagnosis (number of participants diagnosis-free following the intervention), were examined using chi-square or Fisher’s Exact Test. The Mantel–Haenszel χ 2 test was used to compare postintervention comorbidity rates, controlling for baseline comorbidity. Effect sizes were calculated by dividing the difference in change between groups by the standard deviation of the change score. The criteria proposed by Cohen (1988) were used, in which 0.2 means a low effect size, 0.5 average, and 0.8 high. Finally, since only SASS intervention group subjects participated in follow-up assessments, paired sample t-tests were used to examine maintenance of treatment gains from postintervention to the 9-month follow-up.

RESULTS

DATA ANALYSIS

Pretreatment Comparisons

Seven individuals did not complete the study, and all refused a final evaluation upon termination. Three sets of analyses were performed: 1) completer analyses that included the 35 adolescents who completed the study; 2) random regression models that included all available data on the 42 randomized adolescents; and 3) intent-totreat analyses that carried forward the baseline measures for noncompleters. All analyses used a random regression approach (Gibbons et al., 1993), which allows the use of missing data. The major parameter of interest is the Group × Time interaction that estimates differential treatment effects. The three separate sets of analyses were compared to assess the robustness of the findings. Since analyses revealed identical results, only completer analyses are presented. The others are available from the first author. As the intervention was provided in six separate groups, random regression models tested whether treatment group accounted significantly for variance in outcome measures (i.e., cluster effects). If intracluster correlations were present, analyses would have to adjust for them by including the intervention group as a random variable. This requirement is similar to the need to account for intraindividual correlation when multiple observations within individuals are analyzed (Gibbons et al., 1993). Because these analyses yielded negative results, we did

There was no significant difference on any demographic variable between treatment (n = 18) and control (n = 17) groups. In addition, groups did not differ in rate of comorbidity. No significant group differences were found on any clinical measures. (See Tables I and II for demographics and preassessment values.) Independent Evaluator Ratings Table II presents descriptive information for outcome measures at pre- and postintervention. ADIS-PC Severity At posttreatment, severity ratings were significantly lower in the intervention than the control group, as indicated by a significant Group × Time interaction effect, F (1, 33) = 50.6, p < .0001. SPDSCF A significant Group × Time effect was obtained. As shown in Table II, the treated subjects had a substantial decrease in severity, in contrast to a slight increase in the wait-list group, F (1, 33) = 34.9, p < .0001.

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Table II. Mean (Standard Deviation) and Effect Size for Outcome Measures Pre Measure Clinician ratings ADIS-PC Severity SPDSCF LSAS-CA Total Social anxiety Perform anxiety Total anxiety Social avoid Perform avoid Total avoidance CGAS Self-ratings SPAI-C SAS-A FNE SAD-New SAD-General CDI LS Parent ratings SAS-A Parent FNE SAD-New SAD-General

Range

SASS (n = 18)

Post

Control (n = 17)

SASS (n = 18)

Control (n = 17)

p value

Effect size

0–8 1–7 0–144 0–36 0–36 0–72 0–36 0–36 0–72 0–100

5.4 (1.1) 4.3 (.84) 55.4 (25.0) 15.9 (7.6) 13.7 (6.2) 29.6 (12.6) 14.7 (8.3) 11.2 (6.5) 25.8 (12.9) 52.7 (8.9)

5.4 (1.3) 4.4 (1.0) 52.0 (25.0) 16.7 (9.3) 11.6 (4.8) 29.1 (13.0) 14.4 (8.8) 9.2 (5.3) 22.9 (13.0) 55.2 (10.8)

3.1 (1.1) 2.9 (.94) 33.9 (12.7) 11.4 (4.2) 8.0 (3.3) 19.4 (6.9) 8.8 (3.5) 5.6 (3.2) 14.6 (6.2) 73.1 (10.1)

5.8 (1.6) 4.9 (1.1) 46.4 (23.5) 16.1 (8.4) 9.5 (5.8) 25.6 (12.8) 13.9 (8.2) 6.9 (5.0) 20.8 (11.7) 51.5 (14.2)