مداخله شناختی- رفتاری گروهی مختصر برای هراس اجتماعی در دوران کودکی

Twenty-three preadolescent children (ages 8–11) meeting criteria for social phobia were randomly assigned to either a 3-week cognitive-behavioral group intervention or a wait-list control group. The intervention consisted of psychoeducation, cognitive strategies, and behavioral exposure. Outcome measures included diagnostic interview as well as parent and child report measures of anxiety and depression. Improvements were observed at posttest, with results stronger for parent report and interviewer ratings than for child self-report. At 3-week follow-up, children receiving the intervention demonstrated significant improvements on the majority of child, parent, and interviewer reports of social anxiety and related symptoms relative to wait-list participants. Preliminary support is provided for the utility of a brief intervention for preadolescent children with social phobia. Limitations and implications for future research are discussed.

Social phobia (social anxiety disorder), though once referred to as the “neglected anxiety disorder” (Liebowitz, Gorman, Fyer, & Klein, 1985), is now recognized as a prevalent and potentially debilitating disorder. Research on social phobia in adulthood has consistently shown that individuals with social phobia experience substantial impairment in daily functioning and diminished quality of life (Stein & Kean, 2000). Specifically, individuals with social phobia are less likely to marry, more likely to abuse substances, and are at increased risk for depression and suicide (Ballenger et al., 1998; Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992; Turner, Beidel, Borden, Stanley, & Jacob, 1991). Accordingly, effective programs have been developed for the treatment of social phobia in adults (e.g., Heimberg, 1991; Turner, Beidel, Cooley, Woody, & Messer, 1994). Meta-analyses suggest that maximum benefits are derived from cognitive-behavioral treatments, with exposure acting as a critical treatment element, possibly enhanced by cognitive restructuring (Feske & Chambless, 1995 and Taylor, 1996). However, only recently has attention been directed to the assessment and treatment of social phobia in children (Kashdan & Herbert, 2001). Prior to publication of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), social phobia was rarely diagnosed prior to adolescence. Although prevalence of social phobia in childhood and adolescence was previously reported at approximately one percent (Kashani & Orvaschel, 1990), it now appears that this is an underestimate of true prevalence rates (Kendall & Warman, 1996; Stein, Chavira, & Jang, 2001). Prevalence of social phobia in a younger population, using DSM-IV criteria, has not yet been clarified (Velting & Albano, 2001). A number of factors have contributed to the greater recognition of social phobia as a significant problem for children. Symptoms of social phobia were found to overlap with those of the former diagnostic category avoidant disorder, which affected younger children (Francis, Last, & Strauss, 1992; Last, Perrin, Hersen, & Kazdin, 1992). The similarities between these two diagnoses resulted in the removal of avoidant disorder from the DSM, and consequently, an increased emphasis on childhood presentations of social phobia in the DSM-IV. Research is also beginning to highlight similar relationships between social phobia and selective mutism, another disorder of earlier childhood (Black & Uhde, 1995). Moreover, although onset of social phobia is still believed to occur most often during the adolescent years (Beidel, 1998 and Wittchen & Fehm, 2001), children as young as 8 years of age have been identified as suffering from the disorder (Beidel & Turner, 1998), and childhood onset may be associated with greater severity (Ballenger et al., 1998, Davidson, 1993, Stein et al., 2001 and Velting & Albano, 2001). In fact, some authors have speculated that a bimodal distribution exists for the onset of social phobia, with one group developing signs of the disorder very early in childhood and another with onset in adolescence (Stein et al., 2001). Social phobia in childhood, as in adulthood, appears to be related to substantial impairment and distress. Specifically, children with social phobia may have few friends, limited involvement in outside activities, somatic symptoms, and difficulty attending school (Beidel, Turner, & Morris, 1999). Given the likelihood that social phobia is a more prevalent and debilitating disorder in childhood than previously believed, and the possibility that early onset may result in greater severity of symptoms later in life, it is important that effective treatments be developed for younger children. Studies examining treatments for childhood anxiety disorders have included some children who likely suffered from social phobia (e.g., Barrett, Dadds, & Rapee, 1996; Flannery-Schroeder & Kendall, 2000, Kendall, 1994, Kendall & Southam-Gerow, 1996 and Kendall et al., 1997). It is somewhat difficult to generalize these study findings to children with social phobia, as these participants often did not carry a clear diagnosis of social phobia, and generally represented a small portion of the overall sample. However, the majority of these studies have demonstrated long-term benefits with cognitive-behavioral interventions delivered in either group or individual formats (Barrett, 1998 and Flannery-Schroeder & Kendall, 2000), and have suggested a potential added benefit by including a family management component (Barrett et al., 1996). This research on the treatment of childhood anxiety disorders provides important information that may be applied to treatments directly targeting social phobia in childhood. Specific treatments for children and adolescents with social phobia have only recently begun to be developed. These treatments have drawn from psychotherapy outcome research for other childhood anxiety disorders, as well as established adult treatment programs for social phobia, such as Cognitive-Behavioral Group Therapy (CBGT; Heimberg, 1991) and Social Effectiveness Therapy (SET; Turner et al., 1994). These recent research efforts will be briefly reviewed. CBGT has been evaluated with adolescents (CBGT-A). In an initial pilot study (Albano, DiBartolo, Holt, Heimberg, & Barlow, 1995) adolescents administered this treatment demonstrated improvements at posttest, with a majority of the participants no longer meeting criteria for social phobia at 1-year follow-up. Self-reported anxiety and depression decreased over the course of the treatment. This pilot study did not include a control group, but laid the groundwork for continued study of this promising treatment protocol. A recent replication of this study utilizing a no-treatment control group (Hayward et al., 2000) revealed an initial reduction in interference, social anxiety symptoms, and the percentage of adolescents meeting criteria for social phobia, for the treatment group relative to the control group. Unfortunately, gains were not maintained at 1-year follow-up, contrary to findings from the initial pilot study of CBGT-A. Spence, Donovan, and Brechman-Toussaint (2000) have also developed a cognitive-behavioral treatment program for children with social phobia, consisting of cognitive challenging, social skills training, and behavioral exposure (Spence et al., 2000). This intervention was found to result in decreased social and general anxiety and changes in diagnostic status. Gains appeared to be maintained at a 1-year follow-up. SET has also been applied to children (SET-C; Beidel, Turner, & Morris, 2000). SET-C includes elements of psychoeducation, social skills training, exposure, and social interactions with nonanxious peers (peer generalization). Positive benefits have been achieved through use of this treatment protocol with regard to diagnostic status, social anxiety, general anxiety, and social skill. Gains appeared to be maintained at 6-month follow-up. Most recently, treatment elements from the SET-C protocol were included in a school-based group behavioral treatment, Skills for Academic and Social Success (SASS; Masia, Klein, Storch, & Corda, 2001), which focuses primarily on education, realistic thinking, social skills training, exposure, and unstructured social situations to allow for practice of skills. Application of this intervention in a pilot study of six children resulted in reductions in ratings of social fears and avoidance, and half of the participants no longer met criteria for social phobia following the intervention (Masia et al., 2001). Clearly, early investigations are promising; however, this research is still in its infancy. Continued research efforts with these and other interventions will hopefully guide clinicians in effectively treating children who present with social phobia. The present study describes an effort to develop a brief group intervention targeting preadolescents with social phobia. This cognitive-behavioral intervention contains elements of more comprehensive treatment programs and was delivered over the course of 3 weeks in three intensive group sessions. Psychoeducation, cognitive exercises, and behavioral exposure were included, with unstructured snack or lunch times held mid-session for practice of skills. Primary aims of the study were the exploration of the feasibility of a brief intervention for childhood social phobia, with emphasis on whether change could be achieved within a short period of time. Outcome measures included parent and child reports of anxiety and depression, parent report of social competence, clinician ratings of symptom severity, and diagnostic interviews.