Social anxiety in pre-adolescent children: What do we know about maintenance?

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.

Testing theoretical processes that maintain paediatric social anxiety: A comparison between children and adolescents with social anxiety disorder, other mental disorders, and non-clinical controls

BACKGROUND

Paediatric social anxiety disorder (SoAD) responds poorly to treatment. Improved understanding of potential psychological maintaining processes may indicate fruitful directions to improve treatment outcomes. The current study compared self-reported psychological processes and state anxiety in response to two social tasks experienced by children and adolescents with SoAD against comparison samples.

METHODS

641 children and adolescents aged 6-17 years (Mage = 9.45 yr; 47.6% girls) engaged in a brief, impromptu speech and a social discussion with a confederate. Participants included 307 with SoAD, 285 with other mental disorders, and 49 non-clinical controls. Participants who completed each task self-reported their anticipated probability and cost of negative evaluation, self-focused attention, personal evaluation of social performance, and engagement in post-event rumination (assessed 1 h later). Independent raters also scored their social performance. Relationships between the variables were tested through path analysis.

RESULTS

Participants with SoAD were more likely to avoid and reported significantly greater state anxiety than both comparison groups. They also reported higher levels of each of the putative maintaining processes than either comparison group. In contrast, independent observers did not discriminate between groups on their overt social performance. Path analyses demonstrated good fit of a priori models to the data for both social tasks.

CONCLUSIONS

Paediatric SoAD is associated with strong expectation of the probability and cost of negative evaluation, excess self-focused attention, and more negative evaluation of one's own social performance. In turn, these putative processes are strong predictors of state anxiety and post-event processing in response to both a speech and social interaction.

Reduced early neural processing of faces in children and adolescents with social anxiety disorder

Social anxiety disorder (SAD) is one of the most common mental disorders during childhood and adolescence. Yet, little is known about its maintenance in youth. Cognitive models of SAD indicate that attentional biases play a key role in the dysfunctional processing of social information, such as emotional faces. However, previous research investigating neural correlates of childhood SAD has produced inconsistent findings. The current study aims to investigate neural face processing in children and adolescents with SAD, while taking into consideration methodological limitations of previous studies. We measured event-related potentials (P100, N170, EPN, LPP) in response to happy, neutral, and angry adult faces, and non-social household objects, in a sample of youth (aged 10-15 years) with SAD (n = 57), clinical controls with specific phobias (SP; n = 41), and healthy controls (HC; n = 61). Participants completed an emotion/object identification task while continuous EEG was recorded. Analyses revealed lower N170 amplitudes in the SAD group compared to HCs, irrespective of emotion. In addition, younger children (aged 10-12 years) with SAD showed lower EPN amplitudes and higher early LPP amplitudes (only trend level) in response to neutral and happy faces compared to younger HCs. These effects were specific to faces and were not evident in the neural processing of non-social household objects. Overall, the findings indicate that different neural response patterns are already present in youth with SAD. Group differences, particularly in younger children, suggest age-related differences in neural face processing in childhood SAD and underpin the necessity of developmental approaches.

Daily-life reactivity and emotion regulation in children with social anxiety disorder

Prominent models of adult social anxiety disorder emphasize the role of hyperreactivity and emotion regulation (ER) difficulties. However, it is unclear whether these factors are relevant in childhood, a critical period for the development of this disorder. We used ecological momentary assessment with mobile phones to assess daily-life emotional reactivity and use and effectiveness of ER strategies in children aged 10-13 years. We compared three groups: Social anxiety disorder (n = 29), clinical controls with mixed anxiety disorders (n = 27) and healthy controls (n = 31). We also investigated long-term effects of ER on trait social anxiety 12 months later. Hierarchical linear modelling revealed higher emotional reactivity and more use of suppression in children with social anxiety disorder compared to clinical and healthy controls. Contrary to our expectations, children with social anxiety disorder reported more use of avoidance and reappraisal compared to clinical, but not healthy, controls. The groups did not differ in subjective effectiveness of ER strategies. Use of suppression, avoidance, and rumination each predicted an increase in social anxiety 12 months later. Taken together, our results extend previous findings from lab and questionnaire studies and illustrate the role of maladaptive ER for child social anxiety disorder.

Social anxiety, self-esteem and quality of life among hypertensive patients during COVID-19 local epidemic in China: A mediation analysis

OBJECTIVES

To explore the mediating role of self-esteem in social anxiety and QoL during the COVID-19 local epidemic in China.

DESIGN

A cross-sectional survey.

METHODS

This study conveniently selected 344 hypertensive patients from a Grade-A tertiary hospital in Wuhu, Anhui Province, as the study population. Participants completed the demographic questionnaire, the social phobia inventory, the self-esteem scale and the 36-item short-form health survey.

RESULTS

Social anxiety, self-esteem and QoL were significantly correlated with each other. Social anxiety showed no direct effect on QoL (β = 0.011, p > 0.05). Social anxiety showed an indirect effect on QoL (β = -0.248, p < 0.001). Self-esteem fully mediated the association between social anxiety and QoL in hypertensive patients.

PATIENT OR PUBLIC CONTRIBUTION

Hypertensive patients in this study were participants during the data collection process. Nursing staff from the cardiology department at the hospital of a hospital in Wuhu City, Anhui Province assisted in the recruitment phase of the data collection process.

Increasing the Efficacy of Treatment for Socially Anxious Youth Through Theoretically Derived Improvements: A Pilot Study

Cognitive behavioural therapy is the first line of treatment for social anxiety disorder; however, children with social anxiety disorder do not respond as well to generic cognitive behavioural therapy programs, compared to children with other anxiety disorders. The aim of the study was to provide a preliminary examination of the efficacy and applicability of a new disorder specific intervention for children with social anxiety disorder. Five children aged 7-13 years, with a primary or secondary DSM-5 diagnosis of social anxiety disorder were provided with an adapted version of the Cool Kids anxiety program. Three out of the five children were in remission from social anxiety disorder at the end of the intervention and at 3-month follow-up. Statistically significant improvements were also noted in overall anxiety symptoms and functioning. Preliminary evidence was found for the efficacy of a social anxiety version of the Cool Kids program.

Association between negative parent-related family interactions and child social anxiety: A cross-cultural systematic review and meta-analysis

This meta-analysis systematically evaluates the strength and direction of the association between negative parent-related family interactions and child social anxiety, and identifies several influencing moderators. Two investigators independently searched international (PsycINFO, PubMed, and Web of Science) and Chinese (CNKI, WanFang, and VIP) databases from their inception dates until March 5, 2023, for suitable articles. Of the 5771 identified records, 85 studies were selected based on inclusion of at least one of the following three dimensions of negative family interactions: insecure attachment (n = 27), parent-related family conflicts (n = 19), or negative parenting styles (n = 46). Meta-analyses showed that all three dimensions were significantly associated with child social anxiety (insecure attachment: r = 0.271, p < 0.0001; parent-related family conflicts: r = 0.226, p < 0.0001; negative parenting styles: r = 0.186, p < 0.0001). For all three dimensions, this association was stronger in children from East Asian culture than in those from European or American culture. In addition, age group, information source, and publication year also significantly moderated this association. Our findings will help guide further research and provide recommendations for the development of effective interventions for reducing social anxiety.

Anxiety disorders in children and adolescents: A summary and overview of the literature

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Social skills deficits and self-appraisal biases in children with social anxiety disorder

Social Anxiety Disorder is highly prevalent among children and leads to poor long-term outcomes if left untreated. Theoretical models of anxiety differ in whether children with Social Anxiety Disorder experience objective social skills deficits, negative self-interpretation biases, or some combination of the two. This pilot study evaluated evidence in support of the "deficit" and "bias" models. Approval was obtained from the ethics committee of a large private university in Cambridge, MA, USA, and data collection was completed in 2015. We recruited 68 parent-child dyads for a study in which anxious children (with Social Anxiety Disorder) and non-anxious children underwent a child-adapted version of the Trier Social Stress Test. Children were aged 8-14, 67.6% male, and self-identified as 54.4% White, 7.4% Black, 4.4% Latinx, 13.2% Asian, 14.7% multiethnic, and 5.9% "other" or no response. Performance ratings were obtained from children, their parents, and external observers. We found evidence of both specific social skills deficits and self-appraisal biases in anxious children. Anxious children struggled with signs of physical discomfort but not with actual speech content. Although children were generally able to accurately evaluate their social performance, older anxious children were most self-critical. Parents were similarly accurate in appraisals of their children's social performance. Anxious children responded favorably to positive feedback with improved self-evaluations of performance and decreased anxiety. Findings suggest that a comprehensive "integrated" theoretical model of Social Anxiety Disorder should include both skills deficits and self-appraisal biases.

Prevention and Treatment of Social Anxiety Disorder in Adolescents: Protocol for a Randomized Controlled Trial of the Online Guided Self-Help Intervention SOPHIE

BACKGROUND

Social anxiety symptoms are highly prevalent among adolescents and are associated with poor quality of life and low psychosocial functioning. If untreated, social anxiety often persists into adulthood and increases the risk for comorbid disorders. Therefore, early interventions for social anxiety to prevent negative long-term consequences are critical. However, adolescents rarely seek help and often avoid face-to-face psychotherapeutic interventions due to the perceived lack of autonomy and anonymity. Thus, online interventions represent a promising opportunity to reach adolescents who have social anxiety but do not seek help yet.

OBJECTIVE

This study aims to evaluate the efficacy, moderators, and mediators of an online intervention developed to reduce social anxiety in adolescents.

METHODS

A total of 222 adolescents aged 11-17 years with subclinical social anxiety (N=166) or with a diagnosis of social anxiety disorder (N=56) are randomly assigned to the online intervention or a care-as-usual control group. The 8-week guided online intervention is based on the Cognitive Model of Social Phobia and evidence-based online interventions for social anxiety adapted to the specific needs of adolescents. The care-as-usual group will be given access to the online intervention after the follow-up assessment. Participants are assessed at baseline, at 4 and 8 weeks post intervention, and at 3-month follow-up assessment on the primary outcome, that is, social anxiety, on secondary outcomes (eg, level of functioning, fear and avoidance, general anxiety, depression, quality of life, self-esteem, and negative effects of the intervention), on potential moderators (eg, therapy motivation, therapy expectancy, and satisfaction with the intervention), and potential mediators (eg, therapeutic alliance and adherence to the intervention). Data will be analyzed based on an intention-to-treat approach and both groups (intervention and care-as-usual) will be compared at each assessment time point. Furthermore, potential mechanisms of change and generalization of intervention effects on daily life are assessed using an ecological momentary assessment procedure that includes items on maintaining mechanisms of social anxiety, social context, and affect. Participants are prompted 3 times a day during the first 8 weeks of the study and again for 2 weeks following the follow-up assessment.

RESULTS

Recruitment is ongoing; initial results are expected in 2024.

CONCLUSIONS

Results are discussed considering the potential of online interventions as a low-threshold prevention and treatment option for adolescents with social anxiety and in light of current advances in dynamic modeling of change processes and mechanisms in early intervention and psychotherapy in adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04782102; https://clinicaltrials.gov/ct2/show/NCT04782102.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44346.

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.

In the moment social experiences and perceptions of children with social anxiety disorder: A qualitative study

OBJECTIVES

Childhood social anxiety disorder (SAD) is a common and disabling condition. General forms of cognitive behavioural treatments have demonstrated poorer efficacy for childhood SAD when compared to other childhood anxiety disorders and further understanding of the psychological factors that contribute to the maintenance of childhood SAD is warranted. Examining the social experiences of children with SAD may help to identify relevant psychological factors and increase our understanding of what keeps childhood SAD going.

METHODS

The current study used reflexive thematic analysis to analyse the transcripts of interviews with 12 children aged 8-12 years with SAD who had been interviewed about their 'in the moment' social experiences during a social stress induction task. The interview topic guide included factors hypothesized to maintain SAD in adult cognitive models of the disorder.

RESULTS

The interviews revealed both variety and commonalities in the experiences and interpretations of social events in children with SAD, captured in three related main themes: (i) Discomfort being the centre of attention, (ii) (Lack of) awareness of cognitions and (iii) Managing social fears. Findings indicated likely developmental influences on which maintenance mechanisms apply at which point in time.

CONCLUSIONS

There is variation in the psychological mechanisms that children with SAD endorse and developmental factors are likely to influence when specific mechanisms are relevant. We now need further studies that take a developmentally informed approach to understand the nature of the association between the factors identified in this study and social anxiety in childhood to inform the development of more effective interventions for childhood SAD.

Clinical, demographic and theory-derived maintaining factors as moderators of treatment outcome in internet-delivered cognitive behavioural therapy for children and adolescents with social anxiety disorder

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10-17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials.

Development and Preliminary Validation of the Child & Adolescent Social Cognitions Questionnaire

Negative cognitions play a central role in adolescent social anxiety, and yet there is a lack of empirically validated measures assessing these in detail. This study describes the adaptation of the Child & Adolescent Social Cognitions Questionnaire (CASCQ) from the adult version of the scale and its preliminary validation in a general adolescent school sample (N = 671). Exploratory and confirmatory factor analysis on split halves of the data indicated two factors, labelled 'negative self-concept' and 'anxious appearance', provided the best fit. Totals and subscales possessed good internal consistency and convergent validity. Findings suggest that the CASCQ is a reliable and valid measure of social anxiety-related cognitions in youth and may be useful for research and clinical purposes. Further examination of the scale with pre-adolescents and clinical samples is warranted.

Effects of Cognitive Reappraisal on Subjective and Neural Reactivity to Angry Faces in Children with Social Anxiety Disorder, Clinical Controls with Mixed Anxiety Disorders and Healthy Children

Cognitive models of social anxiety suggest that social anxiety disorder (SAD) is characterized by both enhanced emotional reactivity and deficits in emotion regulation. Emotional reactivity to socially threatening children's faces and their modulation through reappraisal were measured via subjective ratings and electrocortical responses in children (age 10-13) with SAD (n = 28), clinical controls with mixed anxiety disorders (n = 28), and healthy controls (n = 29). Children with SAD showed higher subjective reactivity to the images of angry children's faces while all children reported reduced reactivity in their subjective ratings following reappraisal. Reduced electrocortical reactivity after reappraisal was only evident in older children and boys and was unrelated to anxiety. The present study indicates that cognitive reappraisal may be beneficial in reducing subjective reactivity in children with anxiety disorders, while neural effects of reappraisal may emerge at older ages.

Rumination in Children with Social Anxiety Disorder: Effects of Cognitive Distraction and Relation to Social Stress Processing

According to cognitive models of social anxiety disorder (SAD), both anticipatory processing and post-event processing are core mechanisms in disorder maintenance leading to dysfunctional coping with social situations through negative self-evaluation and increased anxiety. To date, little is known about these processes during late childhood, a critical period for disorder development. Further, it remains unclear if dysfunctional rumination in children can be altered through psychotherapeutic interventions such as cognitive distraction. In the current study, children aged 9 to 13 years with SAD and age- and gender-matched healthy controls (HCs, each: n = 30) participated in an experimental laboratory social stress task while anticipatory processing, post-event processing, subjective anxiety, self-evaluations, and autonomic arousal (skin conductance level) were assessed. Further, the impact of a brief cognitive distraction intervention on post-event processing was assessed. Children with SAD reported more negative anticipatory and post-event processing compared to HC children. Further, negative anticipatory processing was associated with higher subjective anxiety and reduced subjective performance ratings during the social stress task. In the aftermath of the stressor, distraction led to reduced subjective anxiety in the group with SAD and lower autonomic arousal in all children but did not alter post-event processing. The current study suggests that both anticipatory and post-event processing already play a key role in the maintenance of SAD in childhood. While distraction may be beneficial in reducing prolonged subjective anxiety and autonomic arousal after social situations, more research on interventions targeting ruminative processes is needed.

Research Review: The relationship between social anxiety and social cognition in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Childhood Social Anxiety Disorder (SAD) is common and impairing. The recommended treatment is a disorder specific form of cognitive behavioural therapy (CBT) that includes social skills training and, whilst they appear to be more effective than more general treatments, it is not clear whether social skills training is the critical component involved in improved outcomes, particularly given that evidence for the relationship between social anxiety and social skills deficits in children is inconsistent. This may be partly due to an overlap in their observable features, and because the nature of the association may vary in different contexts (e.g. according to child age). An alternative approach is to examine the association between social anxiety and the social cognitive capacities that underpin social skills. This paper aims to examine the association between social anxiety and social cognition in children and adolescents, and examine conceptual and methodological moderators of this relationship.

METHODS

Papers published between 1980 and 2019 were screened systematically. Fifty studies were identified from which an effect size could be calculated for the relationship between social anxiety and social cognition, including 15,411 children and adolescents.

RESULTS

An overall significant, but moderate effect (r = -.15) was identified, where increased social anxiety was associated with lower social cognitive ability. Moderation analyses revealed specific associations within studies examining social anxiety among participants with and without ASD who were older than 7 years old, and studies assessing the relationship between social anxiety and specific aspects of Theory of Mind (ToM). No significant association was identified between social anxiety and emotion recognition.

CONCLUSIONS

Significant associations between social anxiety and social cognitive abilities appear to be accounted for by elevated social anxiety among children with ASD, and those with difficulties in specific aspects of ToM but not broader social skills, such as emotion recognition. This reinforces the importance of accurately identifying and treating social anxiety within ASD populations. In addition, treatments for social anxiety among neurotypical populations may benefit from targeting particular aspects of ToM rather than emotion recognition and other broad social skills.

The role of emotion regulation in socially anxious children and adolescents: a systematic review

While numerous studies suggest that emotion dysregulation is important in maintaining social anxiety among adults, the role of emotion regulation in children and adolescents with social anxiety is not yet well understood. In this systematic review, we use the process model of emotion regulation as a framework for understanding emotion regulation in children and adolescents with social anxiety. We performed a systematic literature search in the electronic data bases Medline and PsycINFO. Additional studies were identified by hand search. We identified 683 studies, screened their titles and abstracts, viewed 142 studies, and included 55 of these. Study results indicate that children and adolescents with social anxiety disorder or high social anxiety show emotion dysregulation across all five domains of emotion regulation, such as enhanced social avoidance, more safety behaviors, repetitive negative thinking, biased attention and interpretation of social information, and reduced emotional expression. While enhanced social avoidance seems to be specific to childhood social anxiety, other maladaptive emotion regulation strategies, such as repetitive negative thinking, seem to occur transdiagnostically across different childhood anxiety disorders. Implications for current theory, interventions and future research are discussed.

Effects of Group-Based CBT on Post-Event Processing in Children with Social Anxiety Disorder Following an Experimental Social Stressor

Theoretical models and previous research suggest that post-event processing (PEP) after social situations maintains social anxiety disorder (SAD). To date, little is known about PEP in childhood, a critical period for disorder development, or about possible positive effects of cognitive behavioral therapy (CBT) on PEP in children. Children with SAD (n = 71; aged 9-13 years) and healthy controls (n = 55) participated in a social stress task (Trier Social Stress Test for Children, TSST-C), which was repeated in children with SAD after either 12 sessions of CBT or a waiting period. PEP was assessed daily with regard to both valence and frequency, as well as in more detail regarding specific negative and positive ruminative thoughts 1 week after each TSST-C. Daily PEP after the TSST-C was more frequent and more negative in children with SAD compared to healthy controls, in particular during the first 2 days after the TSST-C. After CBT treatment, children with SAD reported more positive PEP but not less negative PEP compared to children in the waitlist control group. The current study suggests that negative PEP in children with SAD is most pronounced in the first days following social stress. Group-based CBT seems to be effective in building up positive cognitions after social stress in children, but developing specific interventions targeting negative PEP immediately after a social stressor may be necessary to further increase treatment efficacy.

Age Moderates Link Between Training Effects and Treatment Response to Attention Bias Modification Treatment for Social Anxiety Disorder

Attention bias modification treatment (ABMT) aims to reduce anxiety symptoms via practice on computerized attention training tasks. Despite evidence of efficacy, clinical effects appear heterogeneous. More research on ABMT mechanisms and moderators of treatment response is needed. Age is one potentially important moderator, as developmental differences in training effects may impact response. We examined developmental links between ABMT training effects and response in social anxiety disorder (SAD). We pooled data from two randomized controlled trials in treatment-seeking youths and adults with SAD (N = 99) that used identical ABMT methods. We first characterized learning effects associated with the eight-session ABMT training protocol. We then tested whether learning magnitude predicted the clinical (change in SAD symptoms) and cognitive (change in attention bias) responses to treatment. Finally, we tested whether age moderated the association between ABMT learning and treatment response. Results indicate that ABMT was associated with an incremental learning curve during the protocol, and that learning improved with age. Age further moderated the association between learning gains during the ABMT protocol and subsequent reduction in self-reported SAD symptoms, such that this association was stronger with age. These effects were not evident in bias scores or clinician ratings. Finally, pre-treatment SAD symptoms and bias scores predicted ABMT learning gains. This study highlights the links among age, learning processes, and clinical response to ABMT. These insights may inform attempts to increase the clinical efficacy of ABMT for anxiety.

Social anxiety disorder in children: investigating the relative contribution of automatic thoughts, repetitive negative thinking and metacognitions

BACKGROUND

Social anxiety disorder (SAD) is common in youths. However, our understanding of SAD in children is inferior to that of SAD in adolescents or adults, and it is unclear if known adult SAD maintenance mechanisms may also operate in children with SAD.

AIM

The paper sets out to investigate the specificity of positive automatic thoughts, social threat negative automatic thoughts, repetitive negative thinking, positive and negative metacognitions in predicting SAD symptoms and diagnoses in clinically anxious children.

METHOD

We enrolled 122 clinically anxious children aged 7-13 years; of these, 33 had an SAD diagnosis.

RESULTS

SAD symptoms correlated positively with social threat negative automatic thoughts, repetitive negative thinking, and negative metacognitions, and negatively with positive automatic thoughts. Linear regression indicated that, of these variables, only social threat negative automatic thoughts predicted social anxiety symptoms. Logistic regression indicated that social threat negative automatic thoughts, a higher number of diagnoses and negative metacognitive beliefs specifically predicted the presence of SAD diagnosis.

CONCLUSIONS

Our findings suggest that content-specific social threat negative automatic thoughts was the only variable that specifically distinguished both higher levels of social anxiety symptoms and diagnoses.

Practitioner Review: Anxiety disorders in children and young people - assessment and treatment

Despite significant advancements in our knowledge of anxiety disorders in children and adolescents, they continue to be underrecognised and undertreated. It is critical that these disorders are taken seriously in children and young people as they are highly prevalent, have a negative impact on educational, social and health functioning, create a risk of ongoing anxiety and other mental health disorders across the life span and are associated with substantial economic burden. Yet very few children with anxiety disorders access evidence-based treatments, and there is an urgent need for widespread implementation of effective interventions. This review aimed to provide an overview of recent research developments that will be relevant to clinicians and policymakers, particularly focusing on the development and maintenance of child anxiety disorders and considerations for assessment and treatment. Given the critical need to increase access to effective support, we hope this review will contribute to driving forward a step change in treatment delivery for children and young people with anxiety disorders and their families.

Experience Versus Report: Where Are Changes Seen After Exposure-Based Cognitive-Behavioral Therapy? A Randomized Controlled Group Treatment of Childhood Social Anxiety Disorder

A considerable number of children and adolescents with social anxiety disorder (SAD) do not benefit from treatment as much as expected. However, treatment success should not be measured with social anxiety reports alone; the cognitive, behavioral, and physiological components of social stress should also be assessed. The authors examined an exposure-based SAD-specific group cognitive behavioral therapy (CBT) in a randomized controlled trial (N = 67, age 9-13 years, blind randomized allocation to treatment [CBT; n = 31] and waitlist control [WLC; n = 36] groups). Success was operationalized as a clinically significant reduction of symptoms measured with SAD-specific questionnaires, structured interviews, and changes in response to the Trier Social Stress Test (TSST). In the CBT group, there was a trend toward a significant increase in positive cognitions in the TSST after treatment (d = 0.37), whereas these positive cognitions decreased in the WLC group (d = 0.40). No significant results involving group appeared for negative cognitions, behavior and physiology. Children in the CBT group, but not parents, further reported less social anxiety in one questionnaire from pre- to post-treatment (d = 0.89). A structured interview confirmed a decrease in severity of SAD in the CBT group. While the gold standard of a blind interview showed efficacy of treatment, not all trait and state measures demonstrated similar success patterns.Trial registration Eligibility criteria and some of the dependent variables (cognitions, physiology) for treatment success were registered with the German Research Foundation (TU 78/5-2, HE 3342/4-2) prior to recruitment. Clinical assessment of diagnosis and behavioral data were not a priori planned as outcome measures for this trial and therefore analyzed in a post-hoc approach.

Mental Imagery in Social Anxiety in Children and Young People: A Systematic Review

Current cognitive models of social anxiety disorder (SAD) in adults indicate that negative self-images play a pivotal role in maintaining the disorder. However, little is known about the role of negative imagery in the maintenance of social anxiety for children and young people. We systematically reviewed studies that have investigated the association between imagery and social anxiety in children and young people. Four databases were searched for ‘social anxiety’ and related terms (including ‘social phobia’ and ‘performance anxiety’) combined with ‘imagery’, ‘representation*’, and ‘observer perspective’. The nine studies that met the inclusion criteria provided some evidence that children and young people with higher social anxiety report more negative, observer’s perspective images, and some evidence to support the cognitive models of SAD’s conceptualisation of imagery. Only two studies included samples with pre-adolescent children. The literature is limited by a number of methodological issues, including inconsistencies in, and a lack of good psychometric measures for, imagery in children and young people. More conclusive evidence is needed to develop significant and robust conclusions.

[Cognition in children with social anxiety disorder experiencing stress]

Cognition in children with social anxiety disorder experiencing stress Abstract. Empirical data on cognitions of children with social anxiety disorder (SAD) are inconclusive. Objective: The present study examines the significance of cognition in children with SAD. Method: Thirty children suffering from SAD and 30 control children free of diagnosis (HC) aged between 9 and 15 years took part in an experiment. Their cognition was assessed before, during, and after a stress-inducing social situation. The assessment method was a self-report measurement. Coping perception was also assessed. Results: Children with SAD did not report a higher level of negative or coping cognition than those in the HC group. An interaction was apparent on the positive cognition scale: Older children (11-12 or 13-15 years) with SAD reported less positive cognition than those in the HC group, and younger children with SAD (9-10 years) reported more than those in the HC group. No group differences were found for perceived coping. Conclusions: The findings are important to the cognitive model and for the psychological treatment of SAD in children.

Visual attention to emotional faces in adolescents with social anxiety disorder receiving cognitive behavioral therapy

Social anxiety disorder (SAD) is a psychiatric condition that often onsets in childhood. Cognitive models underline the role of attention in the maintenance of SAD, but studies on youth populations are few, particularly those using eye tracking to measure attention. Cognitive behavioral therapy (CBT) for SAD includes interventions targeting attention, like exposure to eye contact, but the link between CBT and attention bias is largely unexplored. This study investigated attention bias in youth with SAD and the association with outcome from CBT. Latency to attend to pictures of faces with different emotions (vigilance) and latency to disengage from social stimuli (avoidance) was examined in N = 25 adolescents (aged 13–17) with SAD in relation to treatment outcome. Vigilance was operationalized as the time it took to relocate the gaze from a central position to a peripherally appearing social stimulus. The latency to disengage from a centrally located social stimulus, when a non-social stimulus appeared in the periphery, was used as a proxy for avoidance. Attention characteristics in the SAD group were compared to non-anxious (NA) controls (N = 22). Visual attention was measured using eye tracking. Participants in both the SAD and NA groups were vigilant towards angry faces, compared to neutral and happy faces. Similarly, both groups disengaged attention faster from angry faces. Adolescents with SAD who disengaged faster from social stimuli had less social anxiety after CBT. The results indicate that anxious youth display a vigilant-avoidant attention pattern to threat. However, partly inconsistent with previous research, the same pattern was observed in the NA group.

Examining the Relation Between Adolescent Social Anxiety and Positive Affect Regulation: Self-Report vs. Observation

Social anxiety symptomatology is associated with disruptions in positive affect, though no study has examined deficits in responses to positive affect related to adolescent social anxiety symptoms. The present study tested whether adolescents' self-reported and observed social anxiety symptoms were uniquely associated with specific responses to positive affect. Moreover, we examined whether adolescent gender moderated these relations. Ninety adolescents (ages 11 to 18, M_age = 14.26, SD = 2.03; girls = 62%; white = 79%) completed self-report measures, participated in a social stressor task, and engaged in two positively-valenced interaction tasks with their female caregivers. Adolescent self-reported social anxiety symptoms were not uniquely associated with responses to positive affect. However, observed social anxiety symptoms were uniquely related to greater self-reported inhibiting positive affect responses and fewer observed positive affect maximizing behaviors. These findings highlight the need to examine self-reported and observed social anxiety symptoms in understanding associated disruptions in positive affect regulation.

Cultural evidence for interpretation bias as a feature of social anxiety in Chinese adolescents

Background and Objectives: Interpretation bias (IB), defined as the tendency to interpret ambiguous social situations in a threatening manner, has increasingly been studied in children and adolescents. Compared to Western samples, the relation between IB and social anxiety in Chinese youth has received little attention. The present study was to mainly examine the relationship between IB and social anxiety among Chinese adolescents. Design: Cross-sectional design was utilized. Methods: IB, measured by the Adolescents' Interpretation Bias Questionnaire (AIBQ), and social anxiety were surveyed among a group of high socially anxious Chinese adolescents (n = 25) and a control group (n = 29). Participants were asked to rate the likelihood of interpretations coming to mind in social/non-social situations and to choose the most believable interpretation. Results: The high social anxiety group had more negative interpretations and beliefs in social situations, and the interpretation bias was particular to social anxiety versus depression. Additionally, the cognitive content-specificity hypothesis was supported; the high anxious group showed interpretation bias in social situations, but didn't have more negative interpretations of non-social situations, after controlling for depression. Conclusions: The present study yielded comparable findings as found in Western samples regarding the relation between IB and social anxiety.

Are children with social anxiety disorder more likely than children with other anxiety disorders to anticipate poor social performance and reflect negatively on their performance?

BACKGROUND

The cognitive theory of social anxiety disorder (SAD) suggests that adults with SAD have a tendency to anticipate poor social performance and reflect negatively on their performance following a social event. While a number of studies with socially anxious adults have supported the role of poor performance anticipation and post-event rumination in SAD, to date, only a few studies have addressed whether this also applies to children with SAD.

METHODS

Children (7-12 years) diagnosed with SAD (n = 40), other anxious children (n = 40) and non-anxious children (n = 34) were exposed to a social stressor speech task and their pre- and post-performance appraisals assessed, taking into account objective performance ratings.

RESULTS

Although observers rated some aspects of performance as significantly worse among children with SAD than children with other anxiety disorders, children with SAD were not more likely than their anxious or non-anxious peers to show a general bias in pre- or post-performance appraisals. Furthermore, children with SAD were just as likely as their anxious and non-anxious peers to recognize good performance but were more critical of themselves when their performance was poor.

LIMITATIONS

The speech task did not involve a same-age peer. Participants were relatively affluent group of predominantly non-minority status. Specificity for SAD in relation to other anxiety disorders remains unclear.

CONCLUSIONS

Focusing on counteracting pre- and post-event social performance appraisals may potentially be inappropriate for childhood SAD. Children with SAD might benefit from interventions that focus on helping them to become less critical of themselves after social interactions have not gone well.

Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995)

Social anxiety disorder is a condition characterised by a marked and persistent fear of being humiliated or scrutinised by others. Age-of-onset data point to adolescence as a developmentally sensitive period for the emergence of the condition, at a time when the peer group becomes increasingly important. Social anxiety in adolescence is associated with considerable impairment that persists through to adulthood. There are clear potential benefits to delivering effective interventions during adolescence. However, there is limited evidence on the specific efficacy of available therapies. This is in contrast to adults, for whom we have interventions with very specific treatment effects. One such treatment is individual cognitive therapy. Cognitive therapy is based on the cognitive model of social anxiety proposed by Clark and Wells (in: Heimberg, Leibowitz, Hope, Scheiber (eds) Social phobia: diagnosis, assessment and treatment, The Guilford Press, New York, 1995). The present review examines the potential application of this adult cognitive model to the understanding of adolescent social anxiety and considers additional adolescent-specific factors that need to be accommodated. It is suggested that a developmentally sensitive adoption of the cognitive model of social anxiety disorder (Clark and Wells 1995) for adolescents may lead to better treatment outcomes.

Children with social anxiety disorder show blunted pupillary reactivity and altered eye contact processing in response to emotional faces: Insights from pupillometry and eye movements

Cognitive models and adult research associate social anxiety disorder (SAD) with hypervigilant-avoidant processing of social information, such as eye contact. However, processing biases in childhood SAD remain mostly unexplored. We examined 10- to 13-year-old children's eye contact processing and pupil dilation in response to happy, neutral, and angry faces in three groups: SAD (n = 31), mixed anxiety disorders (MAD; n = 30), and healthy controls (HC; n = 32). Compared to HC, SAD children showed faster first fixations on the eye region of neutral faces and shorter first fixation durations on the eye region of all faces. No differences between the two clinical groups emerged in eye movement results. SAD girls showed reduced pupil dilation in response to happy and angry faces compared to MAD and to happy faces compared to HC. SAD boys showed reduced pupil dilation in response to neutral faces compared to HC. Dimensionally, reduced pupil dilation was linked to social anxiety severity while eye movements were correlated with mixed anxiety and depressive severity. Results suggest that hypervigilant-avoidant eye contact processing and a blunted pupillary reactivity characterize children with SAD. Both transdiagnostic and disorder-specific processing biases are relevant for the understanding of childhood SAD.