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          Modular CBT for Youth Social Anxiety Disorder: A Case Series Examining Initial
          Effectiveness
          Telman, L.G.E.; Van Steensel, F.J.A.; Verveen, A.J.C.; Bögels, S.M.; Maric, M.
          DOI
          10.1080/23794925.2020.1727791
          Publication date
          2020
          Document Version
          Final published version
          Published in
          Evidence-Based Practice in Child and Adolescent Mental Health
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          CC BY-NC-ND
          Link to publication
          Citation for published version (APA):
          Telman, L. G. E., Van Steensel, F. J. A., Verveen, A. J. C., Bögels, S. M., & Maric, M. (2020).
          Modular CBT for Youth Social Anxiety Disorder: A Case Series Examining Initial
          Effectiveness. Evidence-Based Practice in Child and Adolescent Mental Health, 5(1), 16-27.
          https://doi.org/10.1080/23794925.2020.1727791
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          Download date:26 Sep 2022
                EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH
                2020, VOL. 5, NO. 1, 16–27
                https://doi.org/10.1080/23794925.2020.1727791
                Modular CBT for Youth Social Anxiety Disorder: A Case Series Examining Initial
                Effectiveness
                                         a                                  a                          b                     a,b,c
                Liesbeth G. E. Telman , Francisca J. A. Van Steensel , Ariënne J. C. Verveen , Susan M. Bögels                  ,
                and Marija Maricb
                a                                                                                                         b
                 Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, The Netherlands; Department of
                Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands; cUvA Minds, Academic Outpatient Child and Adolescent
                Treatment Center, Amsterdam, The Netherlands
                   ABSTRACT                                                                                              KEYWORDS
                   Cognitive Behavioral Therapy (CBT) is the most efficacious treatment for childhood anxiety            CBT; social anxiety disorder;
                   disorders. At the same time, several studies showed that for children and adolescents with social     children and adolescents;
                   anxiety disorder (SAD), standard protocolized CBT seems to be less efficacious than for youth with    modular treatment;
                   other types of anxiety disorders, suggesting that children with SAD need a different approach. The    mindfulness
                   purpose of this study was to examine the effectiveness of a modularized cognitive behavioral
                   therapy (CBT) for children with SAD, including mindfulness. Ten children and adolescents (50%
                   girls, aged 8–17 years) referred for SAD were measured at pretreatment, posttreatment and
                   10 weeks follow-up. Results showed that 5 youths (50%) were free of their SAD posttreatment,
                   and 8 (80%) at follow-up. Clinically meaningful improvements from pretest to follow-up were
                   found in 90% and 60% of the cases, for the total anxiety symptom score and social anxiety
                   symptom score, respectively. Pre-post-follow-up group analyses revealed significant improve-
                   ments in SAD severity (combined parent and child report) and social anxiety symptoms across
                   child, mother, and father report. The remission rate of 80% and substantial social anxiety symptom
                   decline is promising, providing a starting point for improving treatments of youth with SAD.
                Social anxiety disorder (SAD) is one of the most                   Webb, 2004; Wittchen & Fehm, 2003). If
                common mental disorders and anxiety disorders                      untreated, SAD generally persists in adulthood,
                in children and adolescents, with prevalence rates                 relates to reduced quality of life, and does not
                reaching 10% in adolescence (Burstein et al., 2011;                remit until up to 40 years after onset (Comer &
                Kessler et al., 2012; Merikangas et al., 2010). The                Olfson, 2010). Thus, there is a clear need for
                DSM-5 (American Psychiatric Association [APA],                     effective treatment of SAD early in development.
                2013) characterizes SAD as a persistent, intense                      Cognitive Behavioral Therapy (CBT) is the most
                fear of social situations in which the individual                  efficacious treatment for anxiety disorders (ADs)
                maybenegatively evaluated by others. In children,                  in children and adolescents, with moderate to
                this fear must occur in peer settings and not just in              large effect sizes compared to other therapies
                interactions with adults (APA, 2013). SAD is                       (Reynolds, Wilson, Austin, & Hooper, 2012) and
                a typical childhood onset disorder, as first inci-                 approximately 50–70% of children being free of
                dence after the age of 21 is very low (Bögels                      their primary AD after treatment (e.g., Bodden
                et al., 2010; Burstein et al., 2011). Untreated SAD                et al., 2008; Hudson et al., 2015a; In-Albon &
                in children and adolescents leads to negative con-                 Schneider, 2007). CBT for childhood ADs gener-
                sequences such as impairments in interpersonal                     ally consists of a “skill-building” phase in which
                functioning, loneliness, school refusal and drop-                  children acquire skills that reduce anxiety (e.g.,
                out, lower educational level, subsequent anxiety,                  psycho-education, cognitive restructuring, coping
                depressive, and substance use disorders (e.g.,                     skills), and an “exposure” phase in which children
                Beidel, Turner, & Morris, 1999; Burstein et al.,                   are gradually exposed to their feared situation and
                2011; Kendall, Safford, Flannery-Schroeder, &                      practice new skills (Detweiler, Comer, Crum, &
                CONTACT Marija Maric     m.maric@uva.nl  Department of Developmental Psychology, University of Amsterdam, Nieuwe Achtergracht 129B,
                Amsterdam 1018 WT, The Netherlands
                ©2020 The Author(s). Published with license by Taylor & Francis Group, LLC.
                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-
                nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built
                upon in any way.
                                                                    EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH       17
               Albano, 2014). Nevertheless, a substantial number               adult and youth anxiety (disorders), it has been
               of studies from multiple sites (e.g., Crawley,                  suggested that these clients could benefit from
               Beidas,    Benjamin, Martin, & Kendall, 2008;                   mindfulness interventions, especially when inte-
               Ginsburg et al., 2011; Hudson et al., 2015a,                    grated    with   existing    CBT protocols (Maric,
               2015b; Wergeland et al., 2016) have shown that                  Willard, Wrzesien, & Bögels, 2019;vanBockstaele
               delivery of this general form of CBT is less suc-               &Bögels,2014). Mindfulness as a method implies
               cessful for SAD than for other types of ADs in                  welcoming daily hassles and stressors with atten-
               both children and adults, even at long-term fol-                tion, acceptance and calmness. By increasing aware-
               low-up (Kodal et al., 2018).                                    ness for the present moment and encouraging the
                  Onestrategy to enhance therapy outcomes that is              individual to divert its attention to internal experi-
               recently gaining in popularity (Ng & Weisz, 2016)is             ences and environmental stimuli, mindfulness may
               to deliver therapy in a more individualized way. In             be a method to target (distorted) cognitive pro-
               general, this meanstailoringtheselection andimple-              cesses (van Bockstaele & Bögels, 2014). This may
               mentation of therapy techniques to the personal                 sound paradoxical as CBT models for SAD (e.g.,
               needs of the clients (Crawley et al., 2008; Hudson              Clark & Wells, 1995) view the tendency to focus on
               et al., 2015b; Kendall, Settipani, & Cummings, 2012).           internal experiences as one of the key mechanisms
               With regard to CBT manuals, these are individua-                that keeps the problem going. However, in essence
               lized by dividing it into separate self-contained mod-          and practice, the two approaches (CBT and mind-
               ules such as cognitive therapy and problem-solving              fulness) are more complementary than contrasting.
               skills, that can be matchedtotheindividualstrengths             Mindfulness teaches the clients to attend to all their
               andneeds, and used multiple times or not at all (Ng             experiences – cognitions and emotions – con-
               &Weisz,2016).Suchmodulartherapiesforchildren                    sciously and non-judgmentally, providing clarity,
               with anxiety disorders, depression, trauma, and/or              in this way either helping the client to let go of
               conduct problems have so far shown to offer incre-              the disturbing thoughts or identifying thoughts that
               mental benefit over usual care and protocolized                 can be further actively challenged in cognitive ther-
               CBT,andasteeperdecreaseinchild’sanxietysymp-                    apy. Earlier on, Bögels and Mansell (2004) proposed
               tomsthanthestandardtreatment(Chorpita,Taylor,                   six different change mechanisms of attentional pro-
               Francis, Moffitt, & Austin, 2004; Chorpita et al.,              cesses training in SAD: reducing hypervigilance by
               2013; Weisz et al., 2012). For children with SAD,               focusing on broader aspects of self and environ-
               modular therapy could, for example, provide thera-              ment; reducing attentional avoidance; reducing self-
               pists withmoretimetoinvestinsymptomsthathave                    focused attention; increasing mindfulness to coun-
               previously been identified as needing more attention            ter mindless ruminating; increasing attention con-
               duringtreatmentinchildrenwithSADsuchaschal-                     trol; and increasing self-esteem through enhanced
               lengingcommoncognitivebiasesandinbuildingthe                    concentration (also called “flow”). In line with this
               therapeutic alliance (Crawleyet al., 2008). Moreover,           reasoning, treatment of SAD in adults with mind-
               modular therapy could also support trends in usual              fulness was found to be more effective than waitlist
               clinical practice, in whichtherapists–possibly dueto            in decreasing social anxiety symptoms (Bögels,
               time constraints – tend to use parts of treatment               2006). In addition, the mindfulness groups demon-
               manuals instead of the whole manual (Chu et al.,                strated similar improvements when compared to
               2015). Concluding from this literature, modular                 (group) CBT (Goldin et al., 2016;Kocovski,
               therapy appears to have the potential to improve                Fleming, Hawley, Huta, & Antony, 2013). At this
               treatment outcomes for children dealing with psy-               moment, empirical evidence regarding the efficacy
               chopathology, and may be a promising strategy for               of mindfulness in children and adolescents with
               improving effectiveness in particular for children               ADis lacking (Maric et al., 2019).
                                                                               S
               with SADs.                                                         In the present study, we incorporated these
                  Another recent line of thinking regarding the                recent suggestions in the treatment of youth with
               treatment of psychopathology has focused on the                 anxiety disorders. We implemented a modular
               implementation of innovative therapy techniques,                CBT adapted from the Dutch CBT manual
               such as mindfulness approaches. With regard to                  Discussing+Doing        = Daring (Bögels,           2008)
             18     L. G. E. TELMAN ET AL.
             including modules such as cognitive therapy and       e.g., not daring to play with other kids to not going
             exposure; and additional elements of mindfulness      to school) and rated their anxiety as severely
             therapy. Accordingly, we aimed to explore: (i) the    impairing (using Clinical Severity Rating of
             effectiveness  of  modularized CBT (including         ADIS-C/P; Silverman & Albano, 1996) for their
             mindfulness) in these 10 youths; and (ii) which       daily functioning. The average CSR for both
             modules and treatment components were used in         study completers (n = 10) as well as the partici-
             each participant. The expectation is that explora-    pants who were excluded (n = 5, as 1 ADIS-C/P on
             tion of these questions in children and adolescents   pre-treatment was missing) was 6.8.
             with SAD on a single-case level will provide us          The children and adolescents were aged
             with initial information about the utility of         8–17 years (mean age = 11.70, SD = 2.69), 50%
             a modular CBT approach for treating SAD in            girls. The majority of the sample had a Dutch
             youth.                                                ethnicity (n = 8); two participants indicated
                                                                   Asian or South-American ethnicity. Both parents
                                                                   were included in the study, the majority were
             Method                                                married (90%), and their educational levels were
             Participants and procedure                            on average (distribution of, respectively, low-
                                                                   middle-high educational level for mothers: 11%-
             This study is part of a larger currently ongoing      44%-44%; for fathers: 30%-30%-40%). Participants
             study examining working mechanisms of modular-        were treated by eight different therapists; partici-
             ized CBT for childhood ADs in a sample of at least    pants 2 and 8, and 6 and 7 had the same therapist.
             100childrenintheagerange7–18 years, with              All therapists were female, had a master’s degree in
             various primary anxiety disorders. The inclusion      psychology, their ages ranged from 23 to 59 years
             criteria for the current study were a) primary diag-  (M=35.63, SD = 11.64), and experience as a men-
             nosis of SAD based on DSM-5 criteria (APA, 2013);     tal  health-care professional ranged from 1 to
             b) no comorbid pervasive developmental disorder;      40 years (M = 12.38, SD = 13.35).
             c) having completed at least a pretest and posttest
             measure; and d) IQ > 80. After the final assessment   Measures
             point, families received a gift card of 20 euros.
             Participants gave active informed consent, and ethi-  Anxiety diagnosis
             cal  approval   was obtained from the Ethical         SAD and comorbid disorders were assessed with
             Committee of the University of Amsterdam.             the Dutch version of the Structured Clinical
                Initially, 16 participants were selected based on  Interview for DSM-5 Disorders for Children
             their SAD. Six participants were not included in      (Wante, Braet, Bögels, & Roelofs, in press).
             the current study because of the incomplete assess-   Parent and child reports were combined based
             ments at pre- and post-treatment and/or follow-up     on standard procedures used in the SCID-junior.
             (either child or parent report, and/or audiotapes or  The SCID-junior was used instead of the com-
             therapist information was missing). In comparison     monly     used    Anxiety    Disorders   Interview
             to the 10 study completers, the six participants      Schedule – Child/Parent Versions (ADIS-C/P;
             who were excluded had on average the same diag-       Silverman & Albano, 1996) because the SCID-
             nosis severity at pretest, were one year older, and   junior is based on DSM-5 instead of DSM-IV
             received fewer treatment sessions. With regard to     criteria. In order to compare the severity of diag-
             treatment outcomes (child and parent data were        noses to previous studies, we additionally deter-
             collapsed due to some missing data), it was found     mined an impairment score between 0 and 8,
             that four out of six were free from their social      comparable to the Clinical Severity Rating (CSR)
             anxiety disorder at follow-up and three out of six    of the ADIS-C/P. Research investigating the psy-
             scored below the SCARED cutoff for social anxiety     chometric    properties  of  the   SCID-junior   is
             at follow-up. None of the 10 included cases were      ongoing (C. Braet, personal communication,
             suicidal or housebound; however, all participants     July 12, 2017). In our larger, currently ongoing
             did avoid one or more situations (ranging from,       study (Van Steensel, Telman, Maric, & Bögels, in