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

Abstract

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.

Keywords: Group cognitive behavioral therapy; Social phobia; State measures; Treatment success.

Fig. 1

Flowchart of study participants for diagnostic data. SAD social anxiety disorder, HC healthy controls, n₁ research center 1, n₂ research center 2, FU follow-up. Analyzed data refer to questionnaires. Final sample sizes for all other analyses may vary due to single missing data points. Further detail is provided in the Method section. Results from the follow-up analyses are reported in the online supplements. Note: a healthy control group was recruited to address issues not covered in this manuscript (see Trial design) and is listed here for the sake of completeness

Fig. 2

Overall procedure including the Trier Social Stress Test for Children (TSST-C) before (TSST-C 1) and after (TSST-C 2) treatment or waiting. Analyzed measures are indicated by omission of brackets. CBT group receiving, WLC waitlist control, SISST-PS Social Interaction Self-Statement Test-Public Speaking, PQ-C Performance Questionnaire, Anxiety children’s self-rating of anxiety

Fig. 3

Positive and negative cognitions before (TSST-C 1) and after (TSST-C 2) treatment or waiting. SISST-PS Social Interaction Self-Statement Test-Public Speaking, CBT cognitive behavioral therapy group, WLC waitlist control group

Fig. 4

Social Phobia and Anxiety Inventory for Children (SPAI-C) course from admission to pretreatment/waiting (pre) to posttreatment/waiting (post) in the cognitive behavior therapy (CBT) treatment group and the waitlist control (WLC) group, including clinical cut-off at 18

Fig. 5

Severity scores pretreatment/waiting and posttreatment/waiting in the treatment group (CBT) and the waitlist control (WLC) group, including clinical cut-off at 4