Internet-delivered therapist-assisted cognitive therapy for adolescent social anxiety disorder (OSCA): a randomised controlled trial addressing preliminary efficacy and mechanisms of action

Examining two of the ingredients of Cognitive therapy for adolescent social anxiety disorder: Back-translation from a treatment trial

BACKGROUND

Cognitive Therapy for Social Anxiety Disorder (CT-SAD) based on the Clark & Wells model is a complex intervention comprised of a series of therapeutic elements. Two of the key ingredients are the self-focused attention and safety behaviour experiment and video feedback. The present study examined the effects of these two therapeutic procedures in adolescents with SAD, as well as common themes of the young people's social fears and negative self-images.

METHOD

35 participants with a diagnosis of SAD completed internet-delivered CT-SAD as part of a randomised controlled trial. We conducted a series of paired samples t-tests to evaluate the effects of the self-focused attention and safety behaviour experiment and video feedback. We applied Latent Dirichlet Allocation to identify latent topics based on participants' description of their social fears and negative self-images that were elicited during the course of these therapy procedures.

RESULTS

Participants reported lower anxiety and more positive self-appraisals when focusing externally and dropping safety behaviours, compared to when focusing internally and using safety behaviours (ps < 0.0025). After they watched the videos compared to before, they reported more positive appraisals of their appearance and performance (ps < 0.0025). The differences in these outcomes were significantly larger when they focused internally and used safety behaviours, compared to focusing externally and dropping safety behaviours (ps < 0.0025). Topic modelling identified six social fear topics and five negative self-image topics.

CONCLUSIONS

Self-focused attention, safety behaviours, and negative self-imagery are modifiable with the 'self-focused attention and safety behaviour experiment' and 'video feedback' as part of internet delivered CT-SAD.

Experiences of interoception and anxiety in autistic adolescents: A reflexive thematic analysis

Most autistic adolescents experience anxiety. Interoception, defined as one's ability to detect and interpret bodily signals, might contribute to this. The aim of this exploratory, qualitative study was to gain a better understanding of interoceptive experiences in autistic adolescents and how this relates to anxiety. Semi-structured 1:1 interviews were conducted with 13 UK-based, autistic adolescents, aged 14-17 years, who reported experiencing significant, day-to-day anxiety. Interviews were analysed using a reflexive thematic analysis approach. Interoception appeared relevant to experiences of anxiety in most participants, although this influence was exerted through various routes. While hypoawareness of interoceptive signals led to a reduced ability to detect and regulate anxiety, hyperawareness became overwhelming and anxiety-inducing. Overly negative evaluations of interoceptive signals, including catastrophising about the signals indicating danger, also triggered anxiety. Relationships between interoception and anxiety appeared bidirectional, with anxiety also affecting interoceptive awareness and evaluation. Interoceptive experiences were variable both across and within participants, with factors such as arousal and cognitive overload affecting experiences. Future research should focus on assessing the feasibility of interventions based on the mechanisms identified here.Lay abstractAnxiety is common in autistic adolescents. The detection and interpretation of signals coming from inside the body (e.g. heartbeat and hunger) is assumed to be related to both anxiety and autism. We interviewed 13 autistic 14- to 17-year-olds who reported experiencing significant anxiety, to explore the role that bodily signals played in their experiences of anxiety. Across most participants, there did appear to be a relationship, although the exact way it was related varied. When participants were very aware of bodily signals, they could become overwhelming, but if they were not aware at all, then it was difficult for them to notice themselves getting anxious until it was too late. If participants interpreted these signals negatively, for example, assuming the signals meant something was wrong with their body, they were also more likely to feel anxious. Whether participants were aware or negatively evaluated these signals was very variable and appeared to be context-dependent.

Understanding Mechanisms that Maintain Social Anxiety Disorder in Autistic Individuals Through the Clark and Wells (1995) Model and Beyond: A Systematic Review

Given the high co-occurrence of social anxiety in autism, no reviews to date have explored how cognitive and behavioural mechanisms identified to maintain social anxiety in non-autistic individuals may operate in autistic individuals. This systematic review evaluated: (1) empirical evidence underlying the Clark and Wells (1995) Cognitive Model of Social Anxiety in autistic individuals; (2) how vulnerability factors identified from autism literature (beyond core autistic traits) may be associated with social anxiety beyond the cognitive model. Published peer-reviewed English articles until 27th November 2023 were retrieved from PubMed, EMBASE, Ovid MEDLINE and PsycINFO. Quality appraisal and risk of bias were assessed using The Standard Quality Assessment Criteria for Evaluating Primary Research papers from a Variety of Fields tool. 47 articles met full inclusion criteria and included autistic individuals (with clinical diagnosis), a measure of social anxiety, and a mechanism outlined by either (or both) research questions. The majority of the 3340 participants across studies were male without intellectual disability, White/Caucasian, with 7 studies reporting an average age above 30 years old. Most studies used only self-report measures that may have inflated associations observed between social anxiety and mechanisms. All studies employed cross-sectional design, and no causality inferences could be drawn. Methodological issues around potential construct overlaps between social anxiety and autistic traits are highlighted. Overall, there is evidence in support of the as reported by Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model, as greater fear of negative evaluation from others, use of safety behaviours and somatic symptoms, and peer victimisation were associated with greater social anxiety. The review contributes evidence in support of autism specific contextual, predisposing/antecedent and maintenance factors of social anxiety beyond the original Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model. Given the potential for considerable heterogeneity for each highlighted process at an individual level across autistic individuals, clinicians can broaden formulation conversations with autistic clients to understand how autism related factors may influence the development and maintenance of social anxiety symptoms when applying and adapting the Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model.

Psychological interventions for social anxiety disorder in children and adolescents: A systematic review and network meta-analysis

BACKGROUND

Social anxiety disorder (SAD) is a high-prevalence mental disorder among children and adolescents. The aim of this study is to compare and rank the effectiveness of several psychotherapies for SAD among children and adolescents.

METHODS

Only randomized controlled trials (RCTs) were utilized by searching PubMed, Embase, Cochrane Library, and Web of Science. We used network meta-analysis in the Bayesian framework to analyze the data. This study is registered with PROSPERO, number CRD42023476829.

RESULTS

In total, 30 RCTs with 1547 individuals were included, and nine psychotherapies with three control conditions were compared and ranked in this study. The findings revealed that internet-delivered cognitive behavioural therapy (surface under the cumulative ranking curve [SUCRA: 71.2 %]), group cognitive behavioural therapy (SUCRA: 68.4 %), and individual cognitive behavioural therapy (SUCRA: 66.0 %) significantly reduced social anxiety symptoms; internet-delivered cognitive behavioural therapy also significantly decreased depression symptoms in these patients (SUCRA: 92.2 %). In addition, group cognitive behavioural therapy can enhance functioning in these patients (SUCRA: 89.6 %).

CONCLUSION

These results suggest that internet-delivered cognitive behavioural therapy is the optimal type of psychotherapy for reducing social anxiety and depression symptoms in children and adolescents with SAD, internet-delivered parent-child interaction therapy and cognitive bias modification of interpretation have relatively poor treatment effects on social anxiety symptoms in children than other psychological interventions, and group cognitive behavioural therapy has better benefits in enhancing the functioning among children and adolescents with SAD. Further studies are needed to ascertain these results due to the limited number of included studies.

Internet-based cognitive behavioral intervention for adolescents with anxiety disorders: a study protocol for a parallel three armed randomized controlled trial

BACKGROUND

Anxiety disorders are among the most prevalent mental health concerns affecting children and adolescents. Despite their high prevalence, statistics indicate that fewer than 25% of individuals in this demographic seek professional assistance for their condition. Consequently, there is a pressing need to develop innovative interventions aimed at improving treatment accessibility.

OBJECTIVES

This study aims to assess the effectiveness of Internet-delivered Cognitive Behavioral Therapy (iCBT) for adolescents with anxiety, with a specific emphasis on involving parents in the treatment process.

METHODS

The study is structured as a parallel three-armed randomized controlled trial, comparing Internet-delivered Cognitive Behavioral Therapy (iCBT) with planned feedback, iCBT with on-demand feedback, and a waitlist control group, each group including 56 participants. Participants in the two iCBT conditions will undergo a 14-week treatment regimen, while those in the waitlist control group will wait for 14 weeks before starting iCBT with planned feedback. Additionally, participants in the iCBT groups will be randomly assigned to receive a booster session or not. The study design is factorial including two factors: type of therapist feedback (factor 1) and booster or no booster (factor 2). The study population comprises adolescents aged between 12 and 17 years, residing in Denmark, diagnosed with an anxiety disorder according to DSM-5 criteria. The primary outcome measures are the Youth Online Diagnostic Assessment and the Spence Children's Anxiety Scale. Assessments will occur at baseline, post-treatment, and at 3-, 6-, and 12-month follow-ups post-treatment.

DISCUSSION

The findings of this study are anticipated to contribute to improving the accessibility of evidence-based treatments for adolescents with anxiety.

TRIAL REGISTRATION

The study is registered at clinicalTrials.gov, under protocol ID 22/59602. The Initial release was the 16.10.2023, first posted due to technical problems 16.04.2024. https://clinicaltrials.gov/study/NCT06368557?locStr=Odense,%20Denmark&country=Denmark&city=Odense&page=2&rank=13 .

Adolescents' experience of receiving internet-delivered cognitive therapy for social anxiety disorder

Background

Social anxiety disorder (SAD) is a debilitating condition that usually begins in adolescence. We recently demonstrated preliminary efficacy of an internet-delivered therapist-assisted version of Cognitive Therapy for Social Anxiety Disorder (SAD) for adolescents called Online Social anxiety Cognitive therapy for Adolescents (OSCA). Here we report on the helpfulness, support, and overall acceptability of OSCA from the perspective of trial participants.

Methods

Participants were 17 young people aged 15-18 years who had participated in a trial of OSCA. Post-treatment, participants completed an online treatment acceptability questionnaire and took part in a semi-structured interview to gain an understanding of their experience of OSCA.

Results

Overall, there was a very high rate of treatment satisfaction. Core aspects of the treatment were viewed as most helpful, including behavioural experiments even though participants found them challenging. Participants found the online nature of the treatment helpful, allowing for easier communication with the therapist, regular encouragement from the therapist, and the ability to go back to their treatment and view their progress. Challenges were, for some, the quantity of content and practical issues around scheduling the short weekly calls with their therapist.

Conclusions

This study suggests that young people felt helped and supported by OSCA.

Cognitive and behavioural processes in adolescents with social anxiety disorder

BACKGROUND

A better understanding of the processes that maintain social anxiety disorder (SAD) in adolescents could improve treatment outcomes. This study aimed to establish whether cognitive and behavioural processes known to be important in the maintenance of adult SAD are observed in adolescent populations and whether they are specific to SAD.

METHODS

We recruited three groups of adolescents (12-18y): (1) 90 adolescents with a SAD diagnosis, (2) 58 adolescents with an anxiety disorder that was not SAD, and (3) 45 community-based adolescents. Participants completed measures of negative social cognitions, social attitudes, safety behaviours, self-focused attention, and social anxiety, anxiety, and depression symptoms.

RESULTS

The clinical SAD sample endorsed higher levels of negative social cognitions, attitudes, and safety behaviours compared to both control groups. Self-focused attention was higher in the clinical SAD sample compared to the anxiety clinical control group but not compared to the community control group.

CONCLUSIONS

This study provided evidence of SAD-specific mechanisms including negative social cognitions, attitudes and safety behaviours in adolescents. The study did not provide evidence of disorder-specific mechanisms of self-focused attention but this may have been due to methodological limitations. These findings indicate avenues for further research and point to the potential value of Cognitive Therapy for the treatment of adolescent SAD.

Editorial: Treating Social Anxiety Disorder in Children and Young People: Challenges and Opportunities

In this issue of the Journal, Rapee et al.1 report a rigorous randomized controlled trial (RCT) comparing transdiagnostic treatment and specialized social anxiety treatment for children and young people with social anxiety disorder (SAD). The study is a welcome addition to the literature that highlights the need to renew our efforts to improve understanding and treatment of SAD in childhood.

Social Anxiety and Suicidality in Youth: A Systematic Review and Meta-analysis

Suicide is a leading cause of death among young people every year. Identifying risk factors provides opportunities to intervene, and social anxiety may represent one such factor. This systematic review and meta-analysis aimed to review the evidence of associations between social anxiety and suicidality in youth (10-25 years). Embase, PsycInfo, and Medline were searched to identify relevant articles. Meta-analysis was conducted to examine the mean effect sizes of concurrent and prospective associations between social anxiety and three indices of suicidality in adolescents aged 10-25 years. Meta-analyses of 16 studies showed that social anxiety was associated cross-sectionally with suicide attempt (r = 0.10, 95% CI: 0.04, 0.15), suicidal ideation (r = 0.22, 95% CI: 0.02, 0.41), and suicide risk (r = 0.24, 95% CI: 0.05, 0.41), and prospectively at trend level with suicidal ideation (r = 0.62, 95% CI: -0.03, 0.90). An examination of the prospective associations with suicide attempt and risk was not possible due to a lack of studies. Several studies suggested that results could not be solely attributed to depressive symptoms. A high level of heterogeneity was observed in each meta-analysis. Moderation analysis was possible for gender and publication year only; neither was significant. Findings provide further evidence of a link between social anxiety and suicidal thoughts and behaviors in youth but are limited by the small number of studies of mixed quality. This review supports future research into social anxiety symptoms as potential risk factors and treatment targets for suicidal youth.

Remotely delivered cognitive therapy for social anxiety disorder in adolescence: Preliminary efficacy evidence based on changes throughout treatment

Cognitive therapy has been established as the frontline treatment for adults with social anxiety disorder (SAD); its efficacy with socially anxious adolescents is incipient but promising. This work investigated change in social anxiety symptoms reported by adolescents and their therapist as they go through remotely delivered 10-session cognitive therapy (i.e., CT@TeenSAD). Participants were 21 adolescents (81% females; M _age = 16.10) diagnosed with SAD. They reported on change on their social anxiety symptoms at the beginning of each session; their therapist reported on how their symptoms had improved at the end of each session. Results, though preliminary, show that sessions had a significant impact on self- and therapist reported change, with consistent and continuous improvement across intervention sessions. Gender did not impact on that change, but therapist did: though the same pattern of change emerged for both therapists, it was more evident for the therapist with the greatest previous clinical experience. Overall, current findings align with the cognitive therapy framework of progressive gains throughout therapy. They also add evidence on the applicability and usefulness of an online cognitive approach to adolescents diagnosed with SAD.