Cognitive-Behavioral Therapy for Social Phobia in Adolescents: Stand Up, Speak Out Therapist Guide (

Cognitive-Behavioral Therapy for Social Phobia in Adolescents: Stand Up, Speak Out Therapist Guide (Programs That Work): Medicine.
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At post-treatment and at the 6-month follow-up, all participating adolescents and parents were invited back to the clinic for a diagnostic assessment. All self-assessment scales were administered online post-treatment and at follow-up. The intervention was 12 weeks of ICBT supplemented with group exposure, comprising nine internet-delivered modules completed individually from home and three group exposure sessions at the clinic table 2. The online treatment platform used in this study was developed for delivery of ICBT and has been tested in a number of previous studies for different psychiatric disorders in youth.

Therapists in the study were three clinical psychologists and two master students at their final year of training in clinical psychology. ICBT, internet-delivered cognitive—behavioural therapy. The internet modules included educative texts, animations, audio clips and exercises. Parents were also encouraged to bring up parent-specific topics with their therapist, for example, how to support the adolescent before or during exposures.

Parents could send messages to the therapist throughout the 12 weeks of treatment with the purpose to keep parents active as cotherapists. Adolescents and parents were instructed to log in and complete one module each week. The modules were assigned in a predetermined order, and therefore, all modules but the first were initially locked.

Once the participant completed a module, the therapist made the next one available. The therapists had asynchronous contact online with adolescents and parents every week, commenting on their progress on work sheets and through a built-in message function.


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Therapists were instructed to log in and provide feedback to their families three times per week. The group exposure sessions at weeks 4, 6 and 10 ensured that key components of the treatment were demonstrated in a correct way and that participants could practice, for example, exposure under observation of a therapist.

To ensure large enough group sizes, cohorts of six participants started the treatment at the same time. Linear mixed models were used to analyse changes from pretreatment to post-treatment and from post-treatment to 6-month follow-up. Mixed model analyses use all available data and account for correlations between measurements within the same subject. All mixed models in this study included a fixed effect for time pre, post and 6-month follow-up and a random effect for individual subjects. Potential missing bias was investigated using t-tests that compared the baseline characteristics of those who had complete data at post-treatment with those who had missing data.

Adolescents completed on average 5. The frequency of completed modules by the adolescents was distributed as follows: None completed fewer than two modules. None of the adolescents meeting inclusion criteria at baseline assessment declined participation, which indicates good acceptability of the offered treatment. Figure 2 illustrates that a majority of the adolescents were satisfied with the treatment, would recommend the treatment to a friend and found the programme easy to understand. The average time a clinician spent giving feedback and guidance to participants including time spent on the adolescent and parent was In total thus, each family got Means, SD and effect sizes for pre to post changes are presented in table 3.

Intention-to-treat analyses of the primary outcome measure CGI-S showed a significant decrease of SAD severity from pretreatment to post-treatment, t Means, SD, pre to post and post to 6-month follow-up comparisons and effect sizes of all outcome measures. Table 3 gives an overview of means, SD and effect sizes from post-treatment to the 6-month follow-up.


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    • The improvements seen at post-treatment were generally maintained and further augmented at the 6-month follow-up with small effect sizes, except for self-focus SPWSS that deteriorated slightly. Comparison of pretreatment and 6-month follow-up levels of social anxiety showed overall improvements with large effect sizes: All these participants fulfilled diagnostic criteria for SAD at post-treatment assessment and five out of six still fulfilled diagnostic criteria for SAD at follow-up. Those who reported increased stress and anxiety associated these symptoms with the first weeks of treatment and typically described a decrease as treatment continued.

    Two adolescents reported that the negative event increased negative thoughts in one case and increased panic anxiety in the other case still had some impact on their well-being at the end of treatment.

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    To our knowledge, this is the first study evaluating the feasibility and efficacy of therapist-guided and parent-guided ICBT, supplemented with group exposure sessions, for adolescents with SAD. The results suggest that such a combined treatment format is both feasible and potentially efficacious and that the improvements are maintained at least 6 months beyond treatment termination. Feasibility was indicated by the high proportion of participants who reported satisfaction with the programme and who would recommend it to a peer, as well as by the high attendance rate at group sessions and good completion of online sessions.

    The results showed substantial reductions of social anxiety symptoms on all clinician-rated, adolescent-rated and parent-rated measures at post-treatment, as well as improvements in secondary outcomes such as overall anxiety and level of functioning. These symptom reductions were maintained or further improved at the 6-month follow-up. The adolescents completed on average nearly two-thirds of the nine online modules, which is more than in previous studies on ICBT for youth with SAD where participants completed less than half of the modules on average.

    Even if completion of previous modules was not a prerequisite for attendance at group sessions, participants tended to complete them before attending the sessions. Participants also had peer and therapist support in the group on aspects of the internet-delivered modules that they found difficult eg, designing an idiosyncratic exposure hierarchy , which might have led to more motivation to work with modules after group sessions. It has been proposed that socially anxious children and adolescents have a tendency to avoid practising skills on their own that they have learnt online, such as conducting in vivo exposure.

    A majority of the participants completed a large number of online treatment modules and group sessions, which gave them time to conduct a significant amount of exposure introduced in online module 3 and social skills training introduced in group session 1 at week four. However, we did not track the number of completed exposure and social skills training exercises in other ways than by proxy, through measuring module completion and group attendance.

    Discrepancies between our and previous results may also be attributable to differences in study samples, study design or other methodological aspects.


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      • Around a fifth of the participants reported a negative event during the course of the treatment. Some of the events were expected, such as increased social anxiety when exposure was initiated. Reports of increased stress were also associated with the first weeks of the treatment and can be interpreted as an initial difficulty combining treatment with other demands such as schoolwork. Two participants reported having experienced some negative events that affected their well-being beyond the treatment termination, but these participants still benefited from treatment.

      Overall, the treatment seems feasible and possibly efficacious for adolescents with SAD and their parents, but to be considered for implementation in regular care, an intervention must also be feasible from an organisational point of view. A possible drawback with the addition of group exposure to ICBT is that it limits the flexibility of the intervention. For instance, several patients must be recruited and able to commence treatment at the same time. SAD is a challenging disorder to treat and interventions aspiring to be effective may need to include direct and frequent therapist guidance.

      However, development of new treatments should consider treatment efficacy and accessibility, flexibility and cost-effectiveness. A possible alternative to group-based exposure sessions is to add other forms of direct communication between patients and ICBT therapists, for example, video conferencing or equivalent, something that future studies should investigate further. Although this feasibility trial has several strengths, some important limitations need to be considered when interpreting the results.

      Causal inferences of observed changes are not possible due to lack of a control condition. Thus, improvement could be an effect of non-specific factors such as the therapist attention or of the passage of time. However, SAD has been shown to commonly follow a chronic course when left untreated, 2 and it is not likely that spontaneous remission would explain a significant part of the improvements in the study. Additionally, results were maintained and slightly improved at follow-up, indicating that treatment gains were stable over time, even after the attention from a therapist had ceased.

      A small proportion of the participants did seek additional care between post-treatment and 6-month follow-up, which could have affected the results. However, these participants continued to report high levels of social anxiety at follow-up, implying that additional care had limited impact on the long-term outcome. Although social anxiety is generally more common among women, the current sample had an over-representation of girls.

      The effect of gender on the results in this trial is unclear and may be further analysed in future trials with larger samples. Another limitation concerns assessment at post-treatment and follow-up. Although attempts to reduce bias were made by having these assessments conducted by clinicians not involved in the treatment, assessors were not blind to the fact that the participant had received treatment.

      The intervention was highly acceptable to the families and significantly reduced social anxiety symptoms up to 6-month follow-up. Participants were generally satisfied with the treatment, and the completion rates of internet modules and attendance at group sessions were high, indicating that the treatment is feasible and acceptable to the SAD youth population. Furthermore, per-patient therapist time was limited, even considering the time spent on group sessions; thus, ICBT supplemented with group-based exposure sessions might be cost-effective when compared with traditional face-to-face CBT.

      Further controlled trials are needed. The authors would like to thank Ulrika Thulin for invaluable help with writing the treatment modules, and Cornelia Hanqvist and Jon Juselius for assisting with providing the treatment. MN was the project manager in collaboration with JH.

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      All statistical analyses were conducted by JH and MN. MN drafted the manuscript in collaboration with JH. All authors have read and approved the final manuscript. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making. Provenance and peer review: Not commissioned; externally peer reviewed. No additional data are available.

      National Center for Biotechnology Information , U. Published online Dec Received Jun 21; Accepted Oct 4. No commercial use is permitted unless otherwise expressly granted. This article has been cited by other articles in PMC.

      Child & Adolescent Special Interest Group

      Design A proof-of-concept, open clinical trial with 6-month follow-up. Intervention 12 weeks of intervention, consisting of nine remote therapist-guided internet-delivered CBT sessions and three group exposure sessions at the clinic for the adolescents and five internet-delivered sessions for the parents.

      Results Adolescents were generally satisfied with the treatment, and the completion rate of internet modules, as well as attendance at group sessions, was high. Conclusion Therapist-guided and parent-guided internet-delivered CBT, supplemented with a limited number of group exposure sessions, is a feasible and promising intervention for adolescents with SAD. Strengths and limitations of this study. This is the first study to investigate the feasibility and efficacy of a combined internet cognitive—behavioural therapy and group exposure treatment for youth with social anxiety disorder.

      Introduction Social anxiety disorder SAD is characterised by an intense fear of being scrutinised and negatively evaluated in social or performance situations. Participants Participants were 30 adolescents, 13—17 years old, with a principal diagnosis of SAD, and their parents. Open in a separate window. Procedure Figure 1 gives an overview of inclusion procedures and assessment points. Intervention The intervention was 12 weeks of ICBT supplemented with group exposure, comprising nine internet-delivered modules completed individually from home and three group exposure sessions at the clinic table 2.

      Learn about emotions, fear and social anxiety. How to do functional analyses of my own behaviour. Learn to reduce self-focus and safety behaviours. Learn about exposure and how to be a cotherapist during exposure.

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      Learn about exposure to social situations. Set treatment goals and build an individual exposure hierarchy. Learn about common parental challenges. How to reward my adolescent. Learn about social skills. Modelling and practice of social skills. Modelling and mapping of safety behaviours and how to reduce them. Set an individual exposure hierarchy.

      Learn about negative thoughts and how to handle them. Evaluation of parent modules and treatment. Extended practice of focus shift. Learn how to say no and other self-assertive behaviours. Social mishaps in public environment. What did I learn? What do I want to practice further? Make an evaluation of the treatment.

      Cognitive-Behavioral Therapy for Social Phobia in Adolescents

      Clinician support The average time a clinician spent giving feedback and guidance to participants including time spent on the adolescent and parent was Changes in clinical outcomes from pretreatment to post-treatment Means, SD and effect sizes for pre to post changes are presented in table 3. Table 3 Means, SD, pre to post and post to 6-month follow-up comparisons and effect sizes of all outcome measures.

      Changes in clinical outcomes from post-treatment to 6-month follow-up Table 3 gives an overview of means, SD and effect sizes from post-treatment to the 6-month follow-up. Discussion To our knowledge, this is the first study evaluating the feasibility and efficacy of therapist-guided and parent-guided ICBT, supplemented with group exposure sessions, for adolescents with SAD. Limitations Although this feasibility trial has several strengths, some important limitations need to be considered when interpreting the results. Supplementary Material Reviewer comments: Click here to view. Acknowledgments The authors would like to thank Ulrika Thulin for invaluable help with writing the treatment modules, and Cornelia Hanqvist and Jon Juselius for assisting with providing the treatment.

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