Treating adolescents with social anxiety disorder in school: an attention control trial
The following paper reviews the journal article “Treating adolescents with social anxiety disorder in school: an attention control trial” by Carrie Masia Warner et al, published in the Journal of Child Psychology and Psychiatry in 2007. The paper is divided into two main parts. The first part summarizes the research being conducted while the second part focuses on my views and reactions after critically reading this article.
Social anxiety in adolescents is an underdiagnosed and understudied disorder, with a prevalence ranging from 4 to 9% and long-lasting detrimental consequences. Several clinic-based treatments for this disorder have been devised including Social Skills Training (SST), Cognitive-Behavioral Group Therapy for Adolescents CBGT-A, and Social Effectiveness Therapy for Children (SET-C) (qt. in Warner). However, there has been a paucity of school-based interventions for the treatment of this disorder. This study was a randomized control trial, controlling for attention as a confounding factor, comparing the efficacy of cognitive-behavioral treatment i.e. Skills for Academic and Social Success (SASS), and attention control treatment i.e. Educational-Supportive Group Function (ESGF). The study population comprised of 9th to 11th graders, from two New York City high schools, with similar baseline demographic features. These individuals were first screened for anxiety disorder using three validated scales including the Multidimensional Anxiety Scale for Children (MASC), the Social Phobia and Anxiety Inventory for Children (SPAI-C), and Social Anxiety Scale for Adolescents (SAS-A). Those identified as high-risk individuals were subsequently diagnosed with social anxiety using the Anxiety Disorders Interview Schedule for DSM-IV: Parent and Child Versions (ADIS-PC). Participants were randomly assorted into active and control groups. The selected 36 students then received 12-week treatment sessions of either SASS or ESGF. SASS included sessions on psychoeducation, realistic thinking, social exposure, social skills, relapse prevention, and attending social events. On the other hand, ESGF was more nonspecific and included sessions addressing general relaxation techniques. The outcome of treatment was assessed, at the end of treatment and then at 6 months follow-up, using the Social phobia diagnosis and severity (ADIS-PC) and Clinical Global Impression Scale–Improvement (CGI-I). Outcome variables were then analyzed using completer analyses, intent-to-treat analyses, and sensitivity analyses. Chi-Squared test was used for the analysis of categorical variables while analysis of covariance (ANCOVA) or multivariate analysis of covariance (MANCOVA) was used for continuous variables. The results showed that cognitive-behavioral treatment (SASS) was more effective than attention control treatment (ESGF). Patients undergoing SASS had lower post-treatment severity of anxiety disorder as compared to ESGF. The response rate was also higher for SASS (82.4%) as compared to ESGF (6.7%). At the end of treatment 59% of the SASS group no longer qualified for a diagnosis of social phobia versus 0% of the ESGF group. SASS also had the added advantage of the treatment effect being continued for 6 months after treatment cessation (qt. in Warner).
The issue of social anxiety in adolescents in a school setting has been identified but not addressed adequately. Therefore, in my opinion, this unexplored arena needs attention and further research. I, therefore, chose this paper which addresses this very important issue of adolescent social anxiety and has laid the foundation for further research in this area. This study is unique for being the first one of its kind since no similar attention control trials have been performed prior to this. All the assessment and outcome measure scales used in this study have been previously validated and have a high sensitivity and specificity. Moreover, the researchers also made sure that all confounding factors were controlled for, the treatment was double-blinded and there was no selection bias. This, in my opinion, contributes to the strength of this study making its findings more reliable.
This study is also an important milestone from a public health perspective since it advocates school-based treatment for anxiety disorder and similar illnesses rather than a clinic-based approach which has a stigma attached to it. I also found certain limitations in this study. The sample size was too small and the sample consisted mostly of females. This limits the generalizability of the results. Also, only two high schools from a particular area were chosen. Future studies can improve this by recruiting a larger number of patients who are from different schools having varying socioeconomic and cultural backgrounds, as these factors also contribute towards both the etiology and management of social anxiety and related disorders.
References
Warner, Carrie Masia. “Treating adolescents with social anxiety disorder in school: an attention control trial.” Journal of Child Psychology and Psychiatry (2007): 676–686.