Discussion: Issues with Young Children

View the video Curing Kids with Extreme Social Phobias. In your post, compare and contrast social phobia in children versus adolescent development, considering each subset and the implications of diagnosis.
How would you propose an intervention strategy for a child with a phobia compared to an adolescent with a phobia? Provide substantial support that addresses this disorder from this module’s readings.

Library Article: Psychopathology of Adolescent Social Phobia
This article reviews the basis of psychopathology in social phobia. The article reviews the symptomatology, causes, and treatment of social phobia in children and adolescents.
Library Article: Building a World-Class Mental Health Care System for America
This article stresses the importance of building an accessible mental health system in the United States. The article also briefly compares and contrasts the differences in standards of care across countries.
Library Article: Investigating the Impact of Strength-Based Assessment on Youth With Emotional or Behavioral Disorders
This article examines the credibility and usability for assessments in youth in determining a mental illness.
Library Article: Behavioral Treatment of Childhood Social Phobia
The article explores the behavioral treatment modalities available to children and their families for addressing social phobias and how to control problematic symptoms impairing daily functioning.
Video: Curing Kids with Extreme Social Phobias (cc) (5:48) https://www.youtube.com/watch?v=T8Ja4tXFxc4
This video provides a firsthand perspective on social phobia in children and how debilitating a phobia can be without proper and effective treatment.

References

Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treatment of childhood social phobia.  Journal of Consulting and Clinical Psychology, 68(6), 1072–1080. https://doi- org.ezproxy.snhu.edu/10.1037/0022-006X.68.6.1072

Beidel, D., Turner, S., Young, B., Ammerman, R., Sallee, F., & Crosby, L. (2007). Psychopathology of  Adolescent Social Phobia. Journal of Psychopathology & Behavioral Assessment, 29(1), 46–53.  https://doi-org.ezproxy.snhu.edu/10.1007/s10862-006-9021-1

Cox, K. F. (2006). Investigating the Impact of Strength-Based Assessment on Youth with Emotional or  Behavioral Disorders. Journal of Child & Family Studies, 15(3), 278–292. https://doi- org.ezproxy.snhu.edu/10.1007/s10826-006-9021-5

Gore, T. (2000). Building a world-class mental health care system for America. Professional Psychology:  Research and Practice, 31(5), 467–468. https://doi-org.ezproxy.snhu.edu/10.1037/0735- 7028.31.5.467

J Psychopathol Behav Assess (2007) 29:47–54 DOI 10.1007/s10862-006-9021-1

ORIGINAL PAPER

Psychopathology of Adolescent Social Phobia Deborah C. Beidel · Samuel M. Turner · Brennan J. Young · Robert T. Ammerman · Floyd R. Sallee · Lori Crosby

Published online: 1 July 2006 C© Springer Science+Business Media, Inc. 2006

Abstract Sixty-three adolescents with social phobia and 43 with no psychiatric disorders were compared across a number of clinical variables. In addition to clinically impair- ing social fear, adolescents with social phobia had signifi- cantly higher levels of loneliness, dysphoria, general emo- tional over-responsiveness and more internalizing behaviors than normal controls and 57.1% of socially phobic adoles- cents had a second, concurrent diagnosis, 75% of which were other anxiety disorders. In addition, adolescents with social phobia were significantly less socially skilled. Though sim- ilar in some respects to childhood social phobia, adolescent social phobia has a unique clinical presentation. The impor- tance of developmental differences on the development of age-appropriate interventions is discussed.

D. C. Beidel · S. M. Turner · B. J. Young Maryland Center for Anxiety Disorders, Department of Psychology, University of Maryland, College Park, MD, USA

R. T. Ammerman Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA

F. R. Sallee Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA

L. Crosby Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA

D. C. Beidel (�) Penn State College of Medicine, Department of Psychiatry, H073, 500 University Drive, Hershey, PA, 17033-0850, USA e-mail: [email protected]

Keywords Social phobia . Comorbidity . Functional impairment . Adolescent

Social phobia, characterized by “a marked and persistent fear of one or more social situations in which the person is exposed to unfamiliar people or to possible scrutiny by oth- ers” (American Psychiatric Association [APA], 1994), has been relatively well-studied in both adults (e.g., Liebowitz, Gorman, Fyer, & Klein, 1985; Turk, Heimberg, & Hope, 2001; Turner & Beidel, 1989) and children (e.g., Beidel, Turner, & Morris, 1999; Velting & Albano, 2001). Social phobia in adolescents, however, has received considerably less attention and most studies actually report data from mixed samples of children and adolescents (e.g., Francis, Last, & Strauss, 1992; Spence, Donovan, & Brechman- Toussaint, 1999; Strauss & Last, 1993) or adolescents and adults (e.g., Wittchen, Stein, & Kessler, 1999). Rarely has the psychopathology of this group been examined separately.

Prevalence rates for adolescent social phobia range from 5 to 16% of the general population (Essau, Conradt, & Peterman, 1999; Hayward, Killen, Kraemer, & Taylor, 1998; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Wittchen et al., 1999), and several studies have begun to describe its presentation. Adolescents with social phobia typically fear formal and informal social interactions, pub- lic observation and performance, and situations requiring assertive behavior (Hofmann et al., 1999; Wittchen et al., 1999). Among mixed samples of children and adolescents, depression, social isolation, and fear of failure and criticism are elevated (Francis et al., 1992; Strauss & Last, 1993). In addition, social phobic adolescents are at risk for aca- demic impairment (Wittchen et al., 1999) and substance abuse (Clark et al., 1995; DeWit, MacDonald, & Offord, 1999).

Springer

48 J Psychopathol Behav Assess (2007) 29:47–54

There are conflicting reports regarding the presence and type of comorbid disorders in youth with social phobia (Ollendick & King, 1998). Using DSM-III-R criteria, over- anxious disorder was the most common comorbid condition among mixed samples of children and adolescents with pri- mary social phobia (Francis et al., 1992; Last, Perrin, Hersen, & Kazdin, 1992; Strauss & Last, 1993). Among a small sam- ple of 17 German adolescents, the most common comorbid condition was somatoform disorder, followed equally by ma- jor depression, agoraphobia, and alcohol abuse (Essau et al., 1999). Consistent with the adult literature (e.g. Regier, Rae, Narrow, Kalber, & Schatzberg, 1998), several studies sug- gest that adolescents with social phobia are at increased risk for a major depressive disorder (Essau et al., 1999; Last et al., 1992). However, one large epidemiological sample of 2,242 high school students did not find higher rates of major depression among adolescents with social phobia (Hayward et al., 1998). Thus, the relationship between social phobia and depression, as well as the presence of other disorders, requires further elucidation.

Whereas socially phobic children have impaired social skills (Beidel et al., 1999; Spence et al., 1999), skill deficits in adolescents with social phobia have yet to be documented. Developmentally, as peers increasingly become the focus of an adolescent’s attention, social anxiety may play an impor- tant role in the ability to join peer groups or establish and maintain friendships. Excessive social anxiety may inter- fere with the normal process of peer socialization (Ballenger et al., 1998; Inderbitzen, Walters, & Bukowski, 1997) as well as play a mediational role in decreased social support and social functioning, especially among girls (Inderbitzen et al., 1997; La Greca & Lopez, 1998; Vernberg, Abwender, Ewell, & Beery, 1992). Despite their hypothesized presence, the is- sue of social skill deficits among diagnosed social phobic adolescents remains largely unknown.

In summary, studies examining social phobia in adoles- cents are scarce, and often data are based on very small sam- ples or those that combine pre-adolescents and adolescents, making it difficult to draw conclusions specific to adolescents (Kashdan & Herbert, 2001). Additionally, to date, no study has addressed the impact of social phobia on adolescent so- cial and emotional functioning. Understanding its clinical presentation is necessary for the development of more effec- tive intervention strategies. The current study had two goals. The study was designed to (a) elucidate the clinical presen- tation of DSM-IV social phobia in adolescents by examining patterns of fear and avoidance and the presence of comor- bid disorders and (b) determine the impact of social phobia on aspects of social and emotional functioning by compar- ison to adolescents without psychiatric disorders. Although previous investigations have examined these factors in pre- adolescent children and adults (Beidel et al., 1999; Turner &

Beidel, 1989), to date, no data exist solely for an adolescent population.

Method

Participants

The sample consisted of 63 adolescents meeting DSM-IV diagnostic criteria for social phobia. Participants responded to media advertising for free treatment for “shy” adolescents and were recruited from two metropolitan areas in the East- ern and Midwestern United States. One hundred and fifty individuals responded to the media advertisements. Of that number, fifty chose not to participate once the treatment study was explained and an additional 37 of those screened by telephone were determined not to have social phobia as a primary diagnosis (i.e., these adolescents had comorbid di- agnoses of conduct disorder, oppositional disorder, attention deficit-hyperactivity disorder or significant depression and the primary diagnosis was unclear). The adolescents in this study ranged in age from 13 to 16 years (M = 14.30 years; SD = 1.07 years), and there were 30 boys (47.6%) and 33 girls (52.4%). Forty-three were Caucasian (68.3%), 16 were African American (25.4%), one was Asian American (1.6%), and one was Hispanic (1.6%). Ninety-one percent came from families classified in the middle three socioeco- nomic categories, as identified by the Hollingshead Index of Social Position (Hollingshead, 1957).

The normal control sample consisted of 43 adolescents, recruited from media advertisements for “friendly” peers to participate in a study with shy children. An examina- tion of the scores of this group on the inventories included in this investigation indicated that these children were best considered “typical” adolescents and did not represent a “super normal” group (i.e., their scores fell within 1 stan- dard deviation of the mean for normative samples, not in the extreme tail of the distribution). Normal control peers ranged in age from 13 to 16 years (M = 14.49 years; SD = 1.14 years), and there were 18 boys (41.9%) and 25 girls (58.1%). Twenty-one adolescents were African American (48.8%), 17 were Caucasian (39.5%), and one was Hispanic (2.3%). Only one demographic variable was found to differ significantly between the social phobic and control groups; there were significantly more African Amer- ican adolescents among the control group than the so- cial phobic group (X2 (1, N = 59) = 9.161, p < .005). None of the control group met criteria for any Axis I or II disorders based on an initial telephone screen and the follow- up diagnostic interview described below.

The study was approved by the Institutional Review Boards at the University of Maryland-College Park and

Springer

J Psychopathol Behav Assess (2007) 29:47–54 49

Cincinnati Children’s Hospital Medical Center. All parents signed consent forms and adolescents signed assent forms.

Assessment

The assessment described below constituted the pretreat- ment assessment battery developed for the treatment pro- tocol. Adolescents were informed that this assessment was part of the intake process. Normal control participants were told that they were participating in a protocol designed to ex- amine the differences between adolescents with or without social fears.

Semistructured interview

Both social phobic and normal control adolescents and their parents were assessed for the presence of DSM-IV Axis I disorders by a Ph.D.-level clinician, using the Child/Parent version of the Anxiety Disorders Interview Schedule (ADIS- C/P; Silverman & Albano, 1996). The ADIS-C/P is a semistructured interview that includes an 8-point clinician rating (CSR) that quantifies the severity of assigned diag- noses. The clinician interviewed the parent first, then the ado- lescent. Using the information obtained from both sources, the clinician arrived at a final, composite diagnosis. In addi- tion, overall social functioning was rated using the Chil- dren’s Global Assessment Scale (K-GAS; Shaffer et al., 1983). In order to calculate inter-rater reliability, twenty- five percent of the diagnostic interviews of both groups were randomly selected and videotaped by a second rater unaware of the initial diagnosis. Using the kappa coefficient, inter- rater agreement for the diagnosis of social phobia was κ = .79. There were three cases of disagreement, and in those instances, the final diagnosis was determined by the first author based on a review of all assessment data. Other diag- noses were assigned too infrequently for kappa coefficients to be calculated. Inter-rater reliability (Pearson’s correlation coefficient) was r = .84 for the CSR and r = .80 for the K-GAS.

Self-report inventories

Adolescents completed four self-report inventories. The Children’s Depression Inventory (CDI; Kovacs, 1992) is a 27-item assessment of depressive symptomatology. Partic- ipants also completed the 24-item Loneliness Scale (LS; Asher & Wheeler, 1985), which assesses for feelings of so- cial isolation, and the Eysenck Personality Questionnaire- Junior (EPQJ; Eysenck & Eysenck, 1975), an assessment of introversion and neuroticism. Finally, adolescents’ social anxiety across a broad range of situations was assessed using the Social Phobia Anxiety Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1995).

Parent-report inventory

One parent (primarily the mother) completed the Child Be- havior Checklist (CBCL; Achenbach, 1991). The Internaliz- ing and Externalizing subscales were used in this study.

Behavioral assessment

Adolescents’ social skill and anxiety were assessed through participation in two behavioral tasks: role play and read aloud. In each of five role play scenes, participants responded to statements or questions posed by same-aged peers trained to give friendly but neutral (i.e., non-leading) responses. The scene content included starting a conversation with an un- familiar peer, offering to help another peer, giving a com- pliment, receiving a compliment, and responding assertively to a peer’s inappropriate behavior. During the read aloud task, the adolescent read aloud “The Ransom of Red Chief” to an audience comprised of an adult and same-aged peer. Participants’ responses were videotaped and coded for so- cial anxiety and skill on a 4-point Likert scale by raters who were blind to diagnostic status and purpose of the study. Anxiety ratings ranged from 1 = “not at all anxious” to 4 = “severely anxious.” Social skill ratings ranged from 1 = “not effective at all” to 4 = “effective.” Twenty-five percent of all assessments were rated independently by a sec- ond rater, also blind to diagnostic status. Interrater reliability (Pearson’s r) for anxiety during the role play scenarios was r = .87 and during the read aloud task was r = .81. Inter- rater reliability for social skill during the role play scenarios was r = .89 and r = .90 for reading aloud.

Results

Descriptive pathology of adolescents with social phobia

Ratings of fear and avoidance in social situations

With respect to the study’s first aim, ratings of fear and avoid- ance across social and performance situations were exam- ined. Table 1 depicts the percentage of the adolescent sample who indicated at least moderate fear (a rating of 4 or higher on a scale of 1–8) for each ADIS-C/P situation. Interestingly, 6 of the 8 most-feared situations involved unstructured so- cial interactions describing general conversation skills (e.g., “starting or joining a conversation,” or “inviting a friend to get together”). The least frequently feared situation, still endorsed by over half of the sample was “dating” (54.0%).

When encountering feared situations, adolescents, like children and adults, endorse the use of avoidance strategies to decrease or eliminate their distress. Table 1 also depicts

Springer

50 J Psychopathol Behav Assess (2007) 29:47–54

Table 1 Fear and avoidance of social situations by adolescents with social phobia

Endorsing situation % Endorsing at least moderate distress

% Avoidance

Oral reports or reading aloud 90.5 65.1 Attending dances, parties, or

activity nights 90.5 65.1

Asking the teacher a question or asking for help

87.3 69.8

Starting or joining in on a conversation

87.3 73.0

Musical or athletic performances

87.3 52.4

Speaking to adults 85.7 68.3 Speaking to new or unfamiliar

people 85.7 63.5

Inviting a friend to get together 81.0 57.1 Refusing an unreasonable

request 77.8 51.0

Taking tests 76.2 22.2 Writing on the chalkboard 76.2 49.2 Gym class 76.2 28.6 Walking in the hallway or

standing at a locker 76.2 41.3

Asking someone else to change his/her behavior

76.2 54.0

Answering questions in class 74.6 58.7 Working or playing with a

group 74.6 41.3

Using school or public bathrooms

74.6 22.2

Meetings, such as boy or girl scouts

74.6 42.9

Answering or talking on the telephone

74.6 34.9

Having a picture taken 71.4 20.6 Eating in front of others 68.3 25.4 Dating 54.0 31.7

the percentage of socially phobic adolescents who reported at least some avoidance of social situations. The nine most- feared situations were avoided by over 50% of the adoles- cents. The least-avoided situation (“having a picture taken”) was avoided by 20% of the social phobic adolescents.

Social phobic adolescents also reported substantial im- pairment due to their social fears and avoidance. Forty-eight (76.2%) reported having fewer friends than most other teens, and 20 (31.7%) were not involved in any extra-curricular ac- tivities. Seven adolescents (11.1%) refused to attend school on a regular basis, a number surprisingly high for this age group.

Social phobia subtypes and comorbid diagnoses

Based on this broad pattern of fear and avoidance, it is not surprising that only five adolescents (8% of the social pho-

Table 2 Comorbid diagnoses in social phobic adolescents

Secondary diagnosis %

None 42.9 Generalized anxiety disorder 31.7 Specific phobia 6.3 Attention-deficit/hyperactivity disorder 4.8 Major depression 4.8 Adjustment disorder with depressed mood 1.6 Dysthymic disorder 1.6 Obsessive-compulsive disorder 1.6 Oppositional-defiant disorder 1.6 Separation anxiety disorder 1.6 Selective mutism 1.6

bic sample) met criteria for the nongeneralized subtype. In other words, 92% of the social phobic sample met criteria for the generalized subtype. Thirty-six (57.1%) had a sec- ondary Axis I diagnosis (see Table 2). Among those with a comorbid disorder, 27 (75.0%) had a second anxiety disor- der, the majority of whom (74.1%) had generalized anxiety disorder. Four children were diagnosed with specific pho- bia (11.1%) and one each had obsessive-compulsive disor- der (2.8%), separation anxiety disorder (2.8%), and selec- tive mutism (2.8%). Mood disorders were diagnosed in 11% of this sample. Because the normal control sample was re- cruited specifically for that purpose, none of the children in that group met criteria for any Axis I disorder.

Social and emotional functioning of adolescents with social phobia

Self-report measures

The second aim of the study was to compare the social and emotional functioning of adolescents with social phobia to those with no disorder. Inter-item consistency (Cronbach’s alpha) was calculated for each of the self-report measures used in the investigation. Coefficients were as follows: SPAI- C á = .97; CDI á = .87; LS á = .86; EPQ-J Neuroticism á = .89; EPQ-J Extraversion á = .84.

To control for the experiment-wise-error rate, data were initially analyzed using Hotelling’s t2. The results indicated a significant between group effect (t(df = 15,54) = 30.36, p < .001). Therefore, follow-up between-group compar- isons were conducted using independent samples t-tests (see Table 3). Adolescents with social phobia reported sig- nificantly higher levels of social anxiety on the SPAI-C (p < .001) and higher levels of social isolation on the Lone- liness Scale (p < .001). For adolescents with social phobia, scores on both of these measures were in the clinical range when compared to published norms. Adolescents with social phobia also reported significantly more symptoms of depres- sion based upon the CDI (p < .001) and their mean score

Springer

J Psychopathol Behav Assess (2007) 29:47–54 51

Table 3 Scores of adolescents with social phobia or no disorder on measures of psychopathology

Measure Social phobia (n = 63)

Normal controls (n = 43)

Partial η2

Mean SD Mean SD

CDI 11.92 7.70 4.15 4.07∗∗ .258 EPQ-J: extraversion 11.60 5.10 19.88 2.68∗∗ .478 EPQ-J: neuroticism 10.05 5.21 5.43 3.39∗∗ .200 Loneliness scale 41.40 12.14 23.78 5.63∗∗ .426 SPAI-C 26.18 11.70 6.81 5.66∗∗ .497 Role play anxietya 2.59 1.14 1.68 0.77∗∗ .168 Read aloud anxietya 2.72 1.29 2.03 0.97∗∗ .080 CBCL: internalizing 66.40 8.62 48.36 11.62∗∗ .438 CBCL: externalizing 49.43 9.42 49.04 10.05 .000 KGAS 5.61 0.73 8.70 0.46∗∗ .853 Role play anxietya 2.40 0.85 2.02 0.86∗ .049 Role play effectivenessb

2.43 0.95 2.84 0.84∗ .051

Read aloud anxietya 2.02 0.68 1.58 0.71∗∗ .094 Read aloud effectivenessb

2.69 0.81 3.23 0.80∗∗ .101

Role play speech latencyc

2.36 2.35 0.99 0.82∗∗ .124

aLower scores indicate less anxiety. bLower scores indicate less skill. cMean scores are indicated in seconds. ∗p < .05. ∗∗p < .01.

was at the 50th percentile based on published norms. There- fore, although higher than the normal control group, not all of the adolescents scored in the clinically significant range for depression. Finally, social phobic adolescents scored sig- nificantly higher on the EPQ-J neuroticism scale (p < .001) but significantly lower on the extraversion scale (p < .001). Mean scores for adolescents with social phobia were in the clinically significant range according to published norms.

Parents of adolescents with social phobia endorsed sig- nificantly more internalizing behaviors on the CBCL than did the parents of normal control adolescents (p < .001; see Table 3). There was no group difference on the CBCL externalizing subscale scores.

Group differences on self- and parent-reports were cor- roborated by clinicians, who rated social phobic adolescents as significantly more impaired in their overall functioning than normal controls based on K-GAS scores (p < .001). In fact, the overall K-GAS score of 5.61 for adolescents with social phobia indicates that the disorder exerted substantial interference with every day functioning.

Behavioral assessment of social and performance skill

Independent observers blind to group status rated social pho- bic adolescents as significantly more anxious (p < .01) and

significantly less effective in their presentation (p < .01) than normal control adolescents during the read-aloud task. Likewise, social phobic adolescents were significantly more anxious (p < .05) and significantly less skilled during the role play interactions (p < .05). Additionally, social phobic adolescents had significantly longer speech latencies during the role play task (p < .01). Consistently, social phobic ado- lescents rated themselves as more anxious during both the role play scenes (p < .001) and the read aloud performance task (p < .01).

Effects of gender and race

A 2 (race; Caucasian vs. African American) × 2 (gender) multivariate analysis of variance (MANOVA) examining all of the above variables did not reveal significant main effects for gender or race or a significant interaction for race x gender interaction.

Discussion

This study examines the psychopathology of adolescent so- cial phobia using a sample composed entirely of adolescents and including a comparison to adolescents with no disorder. The results indicate that adolescents with social phobia ex- hibit significant psychopathology across various domains of functioning. They not only experience significantly greater social distress, but also higher levels of dysphoria and depres- sion, loneliness, neuroticism and introversion, in comparison to adolescents without disorders. They also exhibit signifi- cant patterns of social avoidance, poor social skills and a range of comorbid conditions.

When compared to published results for pre-adolescents with social phobia, there appears to be a more pervasive pat- tern of fear and avoidance and higher social distress (Beidel et al., 1999; Spence et al., 1999). For example, using the same diagnostic interview, only 35% of potentiallly distress- ing social situations were endorsed as at least moderately distressing by at least 50% of preadolescent children (Beidel et al., 1999). However, in this study, 100% of the situations were endorsed as at least moderately distressing by at least 50% of the adolescent sample. Similarly, there is a substan- tial percentage of adolescents who avoid social encounters. Because this study did not include a pre-adolescent group, the comparison should be interpreted cautiously. However, it appears that despite their identical diagnoses, adolescents experience a much more pervasive pattern of distress and avoidance than younger children.

The available figures for the percentage of adolescents with social phobia who met generalized subtype are vari- able; 33–45.5% of those in epidemiological samples met the generalized criteria (Hofmann et al., 1999; Wittchen et al.,

Springer

52 J Psychopathol Behav Assess (2007) 29:47–54

1999), whereas in this investigation, 92% met criteria for the generalized subtype. One obvious reason for these disparate rates is the different populations from which the samples were drawn (community vs. clinical). Additionally, in one investigation (Wittchen et al., 1999), test anxiety was in- cluded as a social phobia, a situation inconsistent with the current DSM-IV criteria. A large number of adolescents in that study endorsed only testing fears and therefore were clas- sified as non-generalized social phobics. Eliminating those adolescents from the sample would undoubtedly change the percentage of those with the generalized subtype. Addition- ally, it is important to note that clinically, many individuals seeking treatment often present with only one specific com- plaint, yet a thorough diagnostic interview reveals a more pervasive pattern of distress (e.g., Beidel & Turner, 1998). Thus, it is likely that among a clinic sample, the percent- age of adolescents with the generalized subtype is higher than that found for epidemiological samples, perhaps reflect- ing the more severe impairment seen in a treatment-seeking sample.

Interestingly, the percentage of adolescents with social phobia who had a comorbid diagnosis (57%) is very similar to that found for other adolescent samples (Clark et al., 1995; DeWit, MacDonald, & Offord, 1999; Essau et al., 1999). The pattern of comorbidity was somewhat different, how- ever. In contrast to other investigations (Clark et al., 1995; DeWit et al., 1999), fewer externalizing disorders were found among this clinic sample. Similarly, externalizing symptoms were not significantly higher among those with social pho- bia when compared to children with no psychiatric disorder based on CBCL scores. These differences may have been due to sampling and/or recruitment strategies.

GAD was the most common secondary (comorbid) dis- order in this sample and the rate (31.7%) was similar to the rate found for adults (e.g., Turner, Beidel, Borden, Stanley, & Jacob, 1991). Generalized anxiety disorder (GAD) is de- fined as excessive worry and anxious apprehension about a number of events or activities and the worry is difficult to control. Worry requires the ability to consider the future, a cognitive skill that may not necessarily be developed in all preadolescent children (see Alfano, Beidel, & Turner, 2002 for a discussion of this issue). Thus, GAD as a comorbid disorder in those with social phobia may emerge in concert with cognitive maturity.

On the other hand, selective mutism (SM) was much less common among adolescents (1.6%) than the rate reported for younger children (8%, Beidel et al., 1999). As noted (Beidel & Turner, 1998; Yeganeh, Beidel, Turner, Pina, & Silverman, 2004), SM may be conceptualized as an avoid- ance strategy used by children and adolescents with social phobia to deal with their high levels of distress. As children mature, they may find different ways to deal with stress. Be- havioral avoidance strategies also evolve and become more

subtle with increasing age. For example, among children undergoing stressful medical procedures, overt fear behav- iors (crying, screaming, expressing verbal anxiety, needing physical restraint) were more common among younger chil- dren. Adolescents were more likely to use subtle expressions of distress such as groaning, flinching, and muscle tension (Katz, Kellerman, & Sigel, 1980; LeBaron & Zeltzer, 1984). Although the youth in that investigation did not necessarily have an anxiety disorder, the data do suggest the emergence of different patterns of anxious behaviors in preadolescent and adolescent children. Data from this investigation suggest that behavioral avoidance, in the form of selective mutism, may be replaced by different behavioral strategies consis- tent with the adolescents’ more sophisticated physical and cognitive maturity.

There were no differences in clinical presentation based on gender or race (Caucasian vs. African American adoles- cents). Thus, consistent with previous investigations (Beidel et al., 1999; Spence et al., 1999), the clinical presentation of adolescent social phobia is consistent across these demo- graphic variables, although further investigations including adolescents from other racial and ethnic groups are needed.

As is consistent with the extant child and adult literature, adolescents with social phobia exhibit substantial social skill deficits when compared to age-matched peers with no psy- chiatric disorder. These deficits were evident to individuals blind to diagnostic group and existed in both one-on-one social interactions and a read-aloud task. In addition to rat- ings of high anxiety and low skill, adolescents with social phobia also had longer speech latencies. Delayed speech in response to comments from others is characteristic of be- haviorally inhibited children (Kagan, Reznick, & Snidman, 1987), a temperamental style evident at a very early age. The current study does not make a determination of whether these speech latencies preceded the development of social phobia, but several recent investigations have reported that childhood behavioral inhibition is associated with adolescent general- ized social anxiety (Schwartz, Snidman, & Kagan, 1999) and adolescent social phobia (Hayward et al., 1998). Higher rates of behavioral inhibition were not related to more spe- cific fears, separation anxiety disorder, or performance anxi- ety (Schwartz et al., 1999), suggesting some predispositional specificity of behavioral inhibition for social phobia.

This investigation is not without limitations. This is one of the largest reported clinical samples for a study of the psychopathology of adolescents with social phobia. How- ever, this was a treatment-seeking sample and thus might not be representative of all adolescents with this disorder. Sec- ond, although the associated treatment protocol allowed for a wide-range of comorbid diagnoses, children with behav- iors suggesting the existence of comorbid conduct disorder, oppositional disorder, primary attention deficit-hyperactivity disorder or significant depression were screened out during

Springer

J Psychopathol Behav Assess (2007) 29:47–54 53

an initial telephone interview. Thus, comorbidity rates for those disorders may be an underestimate of those found in the general population. Third, the sample of African-American adolescents with social phobia is low and children repre- senting other racial or ethnic minority groups were virtually non-existent. Thus, conclusions regarding clinical presenta- tions in non-Caucasian groups require further investigation. Finally, there may be some concern that the study design did not include a psychiatric control group. However, the purpose of this study was to determine the impact of adoles- cent social phobia upon social and emotional functioning, a subject that heretofore has not been adequately addressed. There is no attempt to draw any unique conclusions about the impact of social phobia upon adolescent behavior or to state that social phobia is the only precipitant of impaired adolescent functioning. In short, the study design is appro- priate for the purpose of the investigation: to investigate the psychopathology of adolescent social phobia.

Despite these limitations, this is the first investigation specifically to (a) examine the psychopathology of adoles- cent social phobia using a broad-based assessment strategy, (b) include a comparison to a normal control group, and (c) include a behavioral assessment. This latter component ap- pears particularly important inasmuch as it revealed deficits in the area of social skill, deficits that would be less eas- ily identified based solely on self-report of emotional state. The identification of these deficits has implications for the comprehensive treatment of this disorder. Specifically, inter- ventions that focus solely on decreasing social anxiety may not address these skill deficits. Without increasing social skills, attempts to decrease social anxiety ultimately might be ineffective inasmuch as adolescents still will not “know what to say” (i.e., they will not possess the skills neces- sary for effective social interaction). Such multi-component interventions, combining social skills training and anxiety reduction procedures (e.g., Beidel, Turner, & Morris, 2000; Spence, Donovan, & Brechman-Touissant, 2000) have been demonstrated to be efficacious for children and adolescents up to age 14. Currently, a randomized controlled trial exam- ining the utility of one such multi-component intervention for adolescents ages 13–17 is underway (Beidel, Turner, Sallee, & Ammerman, 2004).

Acknowledgement This research report was supported by funding from NIMH grant #MH60332 to the first, second, and fourth author.

References

Achenbach, T. (1991). Manual for the Child Behavioral Checklists/4– 18 and 1991 Profile. Burlington: University of Vermont.

Alfano, C., Beidel, D. C., & Turner, S. M. (2002). Considering cognition in childhood anxiety disorders: Conceptual, methodological and

developmental considerations. Clinical Psychology Review, 22, 1209–1238.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, (4th ed.) (DSM-IV). Washington, DC: American Psychiatric Association.

Asher, S., & Wheeler, V. (1985). Children’s loneliness: A comparison of rejected and neglected peer status. Journal of Consulting and Clinical Psychology, 53, 500–505.

Ballenger, J. C., Davidson, J., Lecrubrier, Y., Nutt, D., Bobes, J., Beidel, D. C., Ono, Y., & Westenberg, H. (1998). Consensus statement on social anxiety disorder from the international consensus group on depression and anxiety. Journal of Clinical Psychiatry, 59, 54– 60.

Beidel, D. C., & Turner, S. M. (1998). Shy children, phobic adults: The nature and treatment of social phobia. Washington, DC: American Psychological Association Books.

Beidel, D. C., Turner, S. M., & Morris, T. L. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 73–79.

Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology of childhood social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 643–650.

Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treat- ment of childhood social phobia. Journal of Consulting and Clin- ical Psychology, 68, 1072–1080.

Beidel, D. C., Turner, S. M., Sallee, F. R., & Ammerman, R. T. (2004). Treatment of childhood social phobia. Unpublished manuscript, University of Maryland.

Clark, D. B., Bukstein, O., Smith, M., Kaczynski, N., Mezzich, J. A., & Donovan, J. (1995). Identifying anxiety disorders in adoles- cents hospitalized for alcohol abuse or dependence. Psychiatric Services, 46, 618–620.

DeWit, D., MacDonald, K., & Offord, D. (1999). Childhood stress and symptoms of drug dependence in adolescence and early adulthood: Social phobia as a mediator. American Journal of Orthopsychiatry, 69, 61–72.

Essau, C., Conradt, J., & Petermann, F. (1999). Frequency and comor- bidity of social phobia and social fears in adolescents. Behaviour Research and Therapy, 37, 831–843.

Eysenck, H. J., & Eysenck, S. (1975). Eysenck Personality Question- naire (Junior & Adult) Manual. San Diego, CA: Educational and Industrial Testing Service.

Francis, G., Last, C. G., & Strauss, C. C. (1992). Avoidant disorder and social phobia in children and adolescents. Journal of the Amer- ican Academy of Child and Adolescent Psychiatry, 31, 1086– 1089.

Hayward, C., Killen, J., Kraemer, H. C., & Taylor, C. (1998). Linking self-reported childhood behavioral inhibition to adolescent social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1308–1316.

Hofmann, S., Albano, A. M., Heimberg, R. G., Tracey, S., Chorpita, B., & Barlow, D. H. (1999). Subtypes of social phobia in adolescents. Depression and Anxiety, 9, 15–18.

Hollingshead, A. (1957). Two factor index of social position. New Haven, CT: Yale Station.

Inderbitzen, H., Walters, K., & Bukowski, A. (1997). The role of social anxiety in adolescent peer relations: Differences among sociomet- ric status groups and rejected subgroups. Journal of Clinical Child Psychology, 26, 338–348.

Kagan, J., Reznick, J., & Snidman, N. (1987). The physiology and psy- chology of behavioral inhibition in children. Child Development, 58, 1459–1473.

Kashdan, T., & Herbert, J. (2001). Social anxiety disorder in childhood and adolescence: Current status and future

Springer

54 J Psychopathol Behav Assess (2007) 29:47–54

directions. Clinical Child and Family Psychology Review, 4, 37– 62.

Katz, E., Kellerman, J., & Siegel, S. (1980). Behavioral distress in chil- dren with cancer undergoing medical procedures: Developmental considerations. Journal of Consulting and Clinical Psychology, 48, 356–365.

Kovacs, M. (1992). Children’s Depression Inventory Manual. Toronto, Ontario, Canada: Multi-Health Systems, Inc.

La Greca, A., & Lopez, N. (1998). Social anxiety among adolescents: Linkages with peer relations and friendships. Journal of Abnormal Child Psychology, 26, 83–94.

Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1992). DSM-III- R anxiety disorders in children: Sociodemographic and clinical characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1070–1076.

LeBaron, S., & Zeltzer, L. (1984). Assessment of acute pain and anx- iety in children and adolescents by self-reports, observer reports, and a behavioral checklist. Journal of Consulting and Clinical Psychology, 52, 729–738.

Lewinsohn, P., Hops, H., Roberts, R., Seeley, J., & Andrews, J. (1993). Adolescent psychopathology: I. Prevalence and incidence of de- pression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 10, 133–144.

Liebowitz, M., Gorman, J., Fyer, A., & Klein, D. (1985). Social Pho- bia: Review of a neglected anxiety disorder. Archives of General Psychiatry, 42, 729–736.

Ollendick, T., & King, N. (1998). Empirically supported treatments for children with phobic and anxiety disorders: Current status. Journal of Clinical Child Psychology, 27, 156–167.

Regier, D., Rae, D., Narrow, W., Kaelber, C., & Schatzberg, A. (1998). Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry, 173, 24–28.

Schwartz, C., Snidman, N., & Kagan, J. (1999). Adolescent social anxi- ety as an outcome of inhibited temperament in childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1008–1015.

Shaffer, D., Gould, M., Brasic, J., Abrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983). A Children’s Global Assessment

Scale (K-GAS). Archives of General Psychiatry, 40, 1228– 1231.

Silverman, W. K., & Albano, A. M. (1996). The anxiety disorders interview schedule for children (ADIS-C/P). San Antonio, TX: Psychological Corporation.

Spence, S., Donovan, C., & Brechman-Toussaint, M. (1999). Social skills, social outcomes, and cognitive features of childhood social phobia. Journal of Abnormal Psychology, 108, 211–221.

Spence, S., Donovan, C., & Brechman-Toussaint, M. (2000). The treat- ment of childhood social phobia: The effectiveness of a social skills training-based, cognitive-behavioural intervention, with and without parental involvement. Journal of Child Psychology and Psychiatry, 41, 713–726.

Strauss, C. C., & Last, C. (1993). Social and simple phobias in children. Journal of Anxiety Disorders, 7, 141–152.

Turk, C., Heimberg, R. G., & Hope, D. A. (2001). Social anxiety dis- order. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders, (3rd ed.). New York, NY: Guilford, pp 114–153.

Turner, S. M., & Beidel, D. C. (1989). Social phobia: Clinical syndrome, diagnosis, and comorbidity. Clinical Psychology Review, 9, 3–18.

Turner, S. M., Beidel, D. C., Borden, J. W., Stanley, M. A., & Jacob, R. G. (1991). Social phobia: Axis I and Axis II correlates. Journal of Abnormal Psychology, 100, 102–106.

Velting, O., & Albano, A. M. (2001). Current trends in the under- standing and treatment of social phobia in youth. Journal of Child Psychology & Psychiatry & Allied Disciplines, 42, 127–140.

Vernberg, E., Abwender, D., Ewell, K., & Beery, S. (1992). Social anxiety and peer relationships in early adolescence: A prospective analysis. Journal of Clinical Child Psychology, 21, 189–196.

Wittchen, H., Stein, M., & Kessler, R. (1999). Social fears and so- cial phobia in a community sample of adolescents and young adults: Prevalence, risk factors and co-morbidity. Psychological Medicine, 29, 309–323.

Yeganeh, R., Beidel, D. C., Turner, S. M., Pina, A., & Silverman, W. (2003). Clinical distinctions between selective mutism and social phobia: An investigation of childhood psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1069–1075.

Springer

Building a World-Class Mental Health Care System for America

This is an exciting time for mental health in America. The scientific revolution in men- tal health over the past 25 years has given us a deeper understanding of the brain and its effect on human behavior and develop- ment. This research has established once and for all that mental health is an inseparable part of overall physical health and well- being. Thanks to the hard work of mental health professionals such as psychologists, we have many more innovative treatments and services that work.

Our progress in research and treatment is complemented by significant advancements in mental health policy. Just over the past few years alone, we have seen greater in- vestments in state and community mental health services and the publication of the landmark Surgeon General’s Report on Mental Health—the most comprehensive review of mental health ever produced. We have seen significant progress on mental health parity: National mental health parity legislation was signed into law; more than 30 states have adopted parity laws; and more and more forward-thinking employ- ers, including the nation’s largest employer, the federal government, are beginning to pro- vide parity for their employees. In addition, we are seeing steady changes in (he public’s perception and acceptance of mental health.

However, even with all of this progress, our work is far from over. Recent school shootings and other acts of violence have sounded a wake-up call to the nation about the mental health needs of our children. Con- sider this fact: Of the one in five children with a diagnosable mental disorder, less than one third actually receive services. We have to address the severe shortage of children’s mental health services and mental health professionals that is facing too many of our communities, confront insurance discrimi- nation, and support parents who are strug-

gling to meet the mental health needs of their children.

As 1 travel around the country, one of the greatest frustrations I hear from parents is that they cannot find the kind of services their children need. Al and I once met a mother in our home state of Tennessee who was forced to give up custody of her daugh- ter to the state when her insurance coverage ran out. This is a horrible dilemma facing too many parents with sick children. For many rural communities and isolated urban communities, treatment and services are sim- ply not available, and other communities are experiencing a severe shortage in specialized services for children and adolescents. We, as adults, must better serve our children.

Thus, if we are serious about giving our children a good start in life, we have to in- vest in community mental health services. We must expand programs such as the Na- tional Health Service Corps that bring men- tal health professionals to underserved com- munities, and we must find creative ways to attract more people to mental health pro- fessions and specialties that serve high-need communities in a culturally sensitive man- ner. In addition, we need to make greater use of the Internet and advanced technology to deliver mental health services. And, as we expand access to treatment and services, we must ensure that our nation’s mental health system reflects our diversity and responds to the needs of all our people.

Schools have become one of the largest providers of mental health services to chil- dren. However, many of our schools do not have enough resources or support to meet this demand. School counselors, with long waiting lists of kids who need help, are over- worked and often cut off from the wider mental health community. Furthermore, teachers need more training to spot children in trouble and get them help early.

That is why I believe we need to put more mental health professionals in schools, give teachers and school staff training to recog- nize the warning signs of mental illness and behavioral problems, and build stronger re- lationships between schools and community mental health and social service providers. I am proud that the Administration’s Safe Schools/Healthy Students initiative has helped communities create comprehensive school safety and children’s health strate- gies involving everyone—from schools and parents to law enforcement and the local mental health system. We need to expand this initiative and encourage communities all across the country to adapt model strate- gies to their own needs. Preliminary find- ings from a Yale University School of Medi- cine study showed a significant increase in the number of children admitted to hospital emergency departments because of a psychiatric-related emergency (Harby, K. [2000, May 17]. Childhood psychiatric emer- gencies on the rise. Reuters Health News- wire. Report on a study by Yale University School of Medicine pediatric emergency specialist Dr. K. Santucci). I also believe the mental health professional community such as psychologists, social workers, and other counselors should find creative ways to sup- port the schools and families in (heir com- munity. This could mean creating support systems for school counselors and teachers, involving graduate students in community programs, asking the business community to get involved, or creating stronger links between researchers and community-based providers. These steps would help fill the gaps and deliver quality services to children and families in need.

As we continue to address the acute short- age of children’s mental health profession- als, services, and emergency bed space, we must also address the enduring problem of discrimination against mental illness by many of our nation’s health plans. This bla- tant form of discrimination denies people the treatment they need and the coverage they deserve to remain healthy. Several stud- ies and surveys show that the cost of men- tal health parity is minimal while the ben-

Prnfesionnl Psychology: Research and Pmclire, 2UOO. Veil, 31. No. 5,467^68 Copyrighl 2000 by the American Psychological Association, Inc. 0733-7l)28/(XV$5.(» DOI: I0.ln37//0735.7(l28.3].5.467

467

468 NEWS FROM WASHINGTON, DC

efits to people are just and humane. We need

to build on the progress we have made on

parity by guaranteeing health coverage and

mental health parity for every child in

America. We cannot fail to meet the chal-

lenge of ensuring that mental illness and

physical illness are treated equally by every

health plan for everyone in America.

I am always moved by the struggle facing

the parents of children with mental illness.

Imagine their emotional pain as they face

the challenge of raising their kids with so

little support. With conditions such as au-

tism, schizophrenia, bipolar disorder, and

depression, it is often difficult to get an ac-

curate diagnosis, and once you have a diag-

nosis, many unanswered questions remain

about appropriate treatments and medica-

tion. All of these parents struggle with the

financial and time burdens of caring for chil-

dren with special needs.

One of the greatest challenges facing these

parents is helping their children get the treat-

ment they need while holding down a job to

make ends meet. These mothers and fathers

often have to take time off from work to

take their children to appointments, attend

parental and family therapy sessions, re-

spond to emergencies at school, or support

their children through a crisis. Not being there

for their children not only could hurt their

children’s recovery and development, but in

some cases the parents can be cited for ne-

glect as well. When children need hospital-

ization, another element of stress is added

to family life.

Unfortunately, many of these parents find

themselves unable to take time out of their

workday, whereas many others are forced

to choose between helping their children and

keeping their jobs. No parent should ever

have to make this difficult decision. Several

years ago, I founded a child and family ad-

vocacy organization called Tennessee Voices

for Children, which hears from parents all

across the state who are facing these diffi-

culties. One mother moving from welfare

to work was raising a son with bipolar dis-

order. She was often called to school to

address her son’s behavior in class. Her em-

ployers did not have flexible leave policies,

and she was ultimately fired from her job.

She lost four jobs in 2 years and eventually

returned to welfare.

Does it not make more sense to support

her as she cares for her child and goes to

work? Although there are many parents who

face this stark reality, there are many em-

ployers who are working to find creative

and reasonable solutions that help employ-

ees balance their responsibilities at home

and at work. Tennessee Voices for Children

worked with one family with a teenage son

who had just returned from a residential

treatment program. The mother could not

leave her son at home alone and decided to

bring him to work after school. This ar-

rangement soon proved difficult for her son

and her employer, and the mother feared

she would lose herjob. With mediation, the

employer agreed to allow the mother to leave

work in the early afternoon, take her son

home, and finish her day’s work using a

company computer from home. In another

case, the father of a child threatening sui-

cide was able to create a flexible work sched-

ule with his employer. While his wife

worked during the day, the father stayed at

home to be with their son. In the evening,

after the mother came home, the father went

into work for a few hours in the evening to

keep up with any pressing matters. It was

not easy, but it worked.

We need more of these kinds of flexible

arrangements. We need to help employers

better understand the needs of parents of

children with mental illness and help parents

and employers understand how our nation’s

family leave laws apply to mental illness

just as they apply to other illnesses.

Because of the limits in private health care

plans and public mental health services, some

parents of children with severe menial il l-

ness face an even more difficult decision—

whether to give up custody of their children

so they can get the intensive services they

need.

Consider the dilemma of this typical par-

ent. A mother has a daughter with severe

attention deficit hyperactivily disorder who

has been causing problems at school. Over

time, the daughter’s disruptive behavior es-

calates, and she has several stays in psychi-

atric hospitals. Each time her daughter is

hospitalized, the mother is told that no men-

tal health services are available in her com-

munity. Desperate, the mother turns to the

child welfare system and gives up custody

of her daughter in hopes that her daughter

will finally get treatment (Bazelon Center

for Mental Health Law. [2000, March]. Re-

linquishing Custody, p. 10).

No parent should have to choose between

custody and care. That is why we must work

aggressively to find commonsense solutions

that help these families stay together and get

the services they need.

In this period of unprecedented prosper-

ity, now is the time for us to work together

and find lasting solutions that create the kind

of world-class mental health care system that

helps people live up to their fullest poten-

tial. It is good for our families. It is good for

our communities. And, it is the right thing

to do.

V

Journal of Child and Family Studies, Vol. 15, No. 3, June 2006 ( C© 2006), pp. 287–301 DOI: 10.1007/s10826-006-9021-5

Investigating the Impact of Strength-Based Assessment on Youth with Emotional or Behavioral Disorders

Kathleen F. Cox, Ph.D., L.C.S.W1,2

Published online: 4 May 2006

The trend toward adopting a strengths approach to mental health practice with children and adolescents amounts to a paradigm shift from an emphasis on diag- nosing disorders to tapping child capacities and assets toward the achievement of treatment goals. While the potential value and challenges associated with this shift has received ample attention in the literature, minimal research has been conducted to assess the benefits and barriers related to the use of strength-based strategies with youth. Utilizing an experimental design, this author examined the impact of strength-based assessment using the Behavioral and Emotional Rat- ing Scale (BERS) with seriously emotionally or behaviorally disturbed children and adolescents. Results revealed that child functioning outcomes were signifi- cantly better for youth who received BERS-guided assessment versus the usual deficit-based assessment protocol only when the treating therapist reported an ori- entation toward service that reflects highly strength-based attitudes and practices. Furthermore, high adherence to the strength-based assessment protocol was asso- ciated with significantly higher parent satisfaction with services and lower rates of missed appointments. These findings highlight the importance of accounting for practitioner effects and treatment fidelity in future studies of strength-based practice effectiveness.

KEY WORDS: strength-based assessment; children’s mental health; practitioner orientation.

Recent mental health policies, including the Children’s System of Care ini- tiative (Stroul & Friedman, 1994) and California’s Mental Health Services Act (2005), have promoted the use of a strength-based approach to treatment for children and adolescents. This promulgation of strength-based service delivery is

1Clinical Director, EMQ Children and Family Services, Sacramento, CA. 2Correspondence should be directed to Kathleen F. Cox, EMQ Children and Family Services, 8801 Folsom Blvd., Sacramento, CA 95825; e-mail: [email protected].

287

1062-1024/06/0600-0287/1 C© 2006 Springer Science+Business Media, Inc.

288 Cox

founded on the premise that even the most troubled youth have unique talents, skills, and other resources that can be marshaled in the service of recovery and development. The recognition of such capacities by mental health practitioners is thought to convey a sense of genuine respect for the client, resulting in heightened motivation toward the attainment of enduring change (Weick, 1992; Weick & Chamberlain, 2002). Thus, a strengths orientation is viewed as a less stigmatizing approach to children’s mental health treatment than models focused on deficits and pathology.

Strength-based assessment, the cornerstone of strengths-focused practice, broadens the scope of traditional mental health assessment protocols that empha- size the identification of youth problems, symptoms, and impairments. As defined by Epstein & Sharma (1998, p. 3), strengths-based assessment is:

The measurement of those emotional and behavioral skills, competencies and characteristics that create a sense of personal accomplishment; contribute to satisfying relationships with family members, peers and adults; enhance one’s ability to deal with adversity and stress; and promote one’s personal, social, and academic development.

Consistent with this definition, the Behavioral and Emotional Rating Scale (BERS; Epstein & Sharma, 1998) assesses child strengths within the dimensions of: interpersonal capacity, family involvement, intrapersonal competence, school functioning, and affective ability. Scoring of this instrument produces an overall strengths quotient and standard subscale scores within each of these domains. The BERS is recommended by its developers as a tool for use in mental health clinics, schools, and social service agencies due to its potential for: engaging chil- dren in service planning, facilitating parent-professional collaboration, increasing youth motivation, identifying strengths and weaknesses for intervention, and doc- umenting progress toward skill mastery. Evidence in support of these purported advantages of strength-based assessment is scarce, however. There is considerable research documenting the sound psychometric properties of the BERS (Epstein, Harniss, Pearson, & Ryser, 1999; Epstein, Nordness, Nelson, & Hertzog, 2002; Epstein & Sharma, 1998; Friedman, Friedman, & Weaver, 2003; Friedman, Leone, & Friedman, 1999; Reid, Epstein, Pastor, & Ryser, 2000; Trout, Ryan, LaVigne, & Epstein, 2003; Walrath, Mandell, Holden, & Santiago, 2004) but none demon- strating its contribution to treatment outcomes with emotionally and behaviorally disturbed children and adolescents.

The literature does recognize the challenge inherent in the adoption of such strength-focused protocols in mental health settings. In fact, much has been written on the “tenacious attachment” of human service providers to deficit oriented beliefs and attitudes—a bond that inhibits their embrace of strength-based strategies and methods (Blundo, 2001; Saleebey, 2002). Theorists have also discussed the misconceptions that pervade social service settings regarding the purpose and principles of the strengths approach (Graybeal, 2001; Saleebey, 1996). However, the author is aware of no research to date that systematically studies the impact of

Strength-Based Assessment with Children and Adolescents 289

such contextual factors in promoting or impeding successful implementation of strength-based practices.

In recognition of these gaps, this study sought to advance knowledge of the benefits and barriers associated with the incorporation of BERS-guided assessment into mental health service delivery. A primary aim was to assess the proximal and distal outcomes attributable to strength-based assessment with seriously emotion- ally or behaviorally disturbed youth. Secondly, practitioners’ beliefs and attitudes regarding strength-based practice were explored. Finally, the relationship between strength-focused views/practices on the part of participating therapists and mental health treatment outcomes was examined.

METHOD

Study Participants

The sample consisted of eighty-four youth who were requesting or receiving psychotherapy services from a public mental health agency in Northern California. These children ranged in age from 5 to 18 years, with 77% above the age of 11 years. A majority were male (66%), while approximately 86% were Caucasion, 8% were of mixed race, 2% were African-American, 2% were Asian-American, and 1% were Latino. All of these youth held at least one mental health diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994).

Participating therapists included 3 licensed clinical psychologists, 4 psy- chology interns (master’s level psychologists), 3 licensed clinical social workers, 1 licensed marriage and family therapist, 2 master’s level social workers, and 1 M.S.W. student. The level of experience of these practitioners in the mental health field varied greatly, ranging from 1 to 30 years (M = 12.72, SD = 9.1). All were familiar with the principles of strength-based practice as a result of their attendance at a 2-hour training overview on this topic provided by the investigator just prior to the onset of the study.

Study Design

A pretest-posttest randomized block design was used for this investigation in which assignment of subjects to assessment conditions was performed separately for new intake clients and on-going outpatient therapy clients. An experimental design was selected due to its capacity to control for threats to internal validity (Bickman, 1992). Blocking was performed in order to allow for an efficient ex- amination of the degree to which intake and on-going cases differed as to impact of the experimental protocol on treatment outcomes.

290 Cox

Subjects assigned to the experimental condition received strength-based as- sessment, as produced by the Behavioral and Emotional Rating Scale (BERS), in addition to the usual diagnostic assessment. The youth’s caregiver (parent or guardian) was asked by the investigator to complete this measure along with the other pretest instruments. The primary therapist was subsequently given a copy of the BERS results including: ratings for individual BERS items, standardized subscale scores, strengths quotient, answers to open-ended questions regarding specific strengths and resources of the child, written interpretations and recom- mendations. This clinician was encouraged to share these results with the youth and parent during the process of service planning and/or intervention formulation.

Participants assigned to the control group received the usual format for mental health assessment. Based on client interview, an admission assessment form was also completed by the intake clinician, yielding information in the following areas: presenting problems, symptoms, health conditions, desired changes, risk factors, psychiatric history, and mental status. This initial evaluation culminated with the provision of a mental health diagnosis included in the DSM-IV. On-going assessment information was documented in clinical progress notes and service plans, the latter completed on an annual basis.

Measures

Child Functioning

Outcomes with respect to child symptomatology and functioning were as- sessed from the perspective of the youth, caregiver, and primary therapist using the following instruments. First, the Child Behavior Checklist (CBCL; Achenbach, 1991a) was completed by the parent or guardian at study enrollment and again at 6-months post enrollment. This measure consists of 118 items that require the respondent to rate the child’s behavioral, emotional, and social problems using a Likert-type scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true). Scoring produces a Total Problems score as well as raw scores within two broad-band groupings of syndromes (Internalizing and Externalizing Problems) that are displayed in relation to percentiles and T scores based on a nationally representative sample of children of the subject’s gender and age. The CBCL has been found to have very good psychometric properties, including in- ternal consistency, test-retest reliability and discriminant validity (Achenbach & Rescorla, 2001). Second, the Youth Self-Report (YSR; Achenbach, 1991b) was completed by the youth at enrollment and the 6-month follow-up. This measure utilizes a format that is parallel to the CBCL, with scoring also producing Inter- nalizing and Externalizing Problem scores, as well as a Total Problem score. Like the CBCL, the YSR has demonstrated sound psychometric properties (Achenbach & Rescorla, 2001). Lastly, the Child and Adolescent Functional Assessment Scale

Strength-Based Assessment with Children and Adolescents 291

(Hodges, 1990) was completed by the primary therapist at pre-test and post-test. This instrument measures the negative effects of problem behaviors and symp- toms on child functioning across a variety of real-life domains (i.e. School, Home, Community, Behavior Toward Others, Moods/Emotions, Self-Harmful Behaviors, Substance Use, Thinking). Subscale scores in these dimensions are summed to produce a total CAFAS score, with a higher value indicating more severe impair- ment. The CAFAS has demonstrated high inter-rater reliability (Hodges & Wong, 1996; Pernice, Gust, & Hodges, 1997), as well as adequate internal consistency (Hodges, Doucette-Gates, & Liao, 1999; Hodges & Wong, 1996) and discriminant validity (Hodges et al., 1999; Hodges & Wong, 1996).

Parent Satisfaction

Consistent with the strengths model emphasis on parent-professional collabo- ration (Epstein & Sharma, 1998), the parent or guardians’ satisfaction with services was also deemed an important dependent variable in this study. Thus, the eighth version of the Client Satisfaction Scale (CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) was administered to the parent or guardian at 6-months post- enrollment. This 8-item instrument provides a unidimensional self-report measure of an individual’s satisfaction with a specific health or human service received. The CSQ-8 has enjoyed widespread use by investigators and administrators for program planning and evaluation and has been found to have desirable psycho- metric properties, including internal reliability and construct validity (Attkisson & Greenfield, 1999).

Service Measures

Based on the hypothesis that clients motivated through a focus on strengths would be less inclined to miss therapy appointments and/or discontinue services prematurely, treatment retention was selected as a proximal outcome for this investigation. This dependent variable was operationalized as: (1) the percentage of therapy appointments either missed or cancelled over the 6-month study period and (2) the presence or lack of presence of an unplanned termination of services (treatment drop-out). Additionally, adherence to the strength-based assessment protocol was assessed through a review of experimental case records. Written service plans and clinical progress notes were examined at the 6-month follow-up for evidence of therapist-guided discussion of BERS results with client and/or parent.

Measure of Therapist Orientation

To assess the influence of therapist orientation on treatment outcomes at the client and service level, a questionnaire (referred to as the Clinician

292 Cox

Survey) was devised by the investigator and administered to participating thera- pists at the close of the study. The first section of this measure includes open-ended questions that inquire as to the therapist’s view of the strengths and limitations of the BERS. Multiple-choice questions in the next two sections of the survey were informed through a review of the literature pertaining to the philosophy and principles characterizing strength-based practice. The first of these sections taps the clinician’s attitudes and beliefs regarding mental health practice. Three of 12 items ask the therapist to indicate the extent to which they agree (strongly agree, agree, not sure, disagree, or strongly disagree) with statements that are consistent with the strengths-perspective. The remaining 9 items request that the therapist indicate the level of their agreement with statements that are in- consistent with a strengths-orientation. In tabulating this data, the investigator assigned the following values to responses to the statements reflecting a strengths- focus: strongly agree = 2, agree = 1, not sure = 0, disagree = −1, strongly dis- agree = −2. The values were reversed for statements inconsistent with a strengths perspective. By summing the response values in this section, a score was ob- tained for each clinician within the domain labeled as Therapist Perspective. In the second section of multiple choice questions, clinicians are asked to indicate the extent to which they had utilized certain interventions during the study pe- riod (very often, often, occasionally, rarely, or never). Half of 12 items reflect interventions typical of strengths-based practice. The other 6 items in this section refer to interventions that are more consistent with a deficit-based approach. For the responses to items reflecting strengths-focused practice, the response values were assigned as follows: very often = 2, often = 1, occasionally = 0, rarely = −1, never = −2. Summation of these response values produced a score labeled as In- terventions Used. The scores for Therapist Perspective and Interventions Used were then summed to produce a Strength-Based Orientation (SBO) score for each therapist. These SBO scores were collapsed to form an ordinal level variable, with values assigned as low, medium, and high in relation to strength-focused orientation.

RESULTS

Preliminary Analyses

I initially examined whether groups (intake versus on-going therapy clients; experimental versus control subjects) differed in demographic characteristics and impairment level at study enrollment. Independent t-tests and chi square tests showed no between-groups differences in age, gender, or Total Problem scores on the CBCL, YSR and CAFAS at pre-test.

Strength-Based Assessment with Children and Adolescents 293

Child Functioning Outcomes

Repeated measures ANOVA’s conducted on the CBCL, YSR and CAFAS data collected at baseline and the 6-month follow-up revealed main effects for time on all measures except the YSR Externalizing Problems scale and the CAFAS scores measuring impairment in Community Role Performance, Substance Use, and Thinking. Pre-post reductions in problem behaviors and symptomatology for the total study sample emerged on the CBCL Total Problems scale (F = 23.75, df = 1, p = .000), CBCL Externalizing Problems scale (F = 9.76, df = 1, p = .003), CBCL Internalizing Problems scale (F = 26.83, df = 1, p = .000), YSR Total Prob- lems scale (F = 5.48, df = 1, p = .022), YSR Internalizing Problems scale (F = 5.00, df = 1, p = .029), and CAFAS domains of Total Functioning (F = 20.55, df = 1, p = .000), School Role Performance (F = 13.35, df = 1, p = .000), Home Role Performance (F = 6.28, df = 1, p = .014), Behavior (F = 15.14, df = 1, p = .000), Moods (F = 4.37, df = 1, p = .040), Self-Harm (F = 8.45, df = 1, p = .005).

Analysis of data for differences in child functioning attributable to condition or case type revealed no significant group effects. Additionally, no significant interactions between the impact of time and treatment condition were observed on any measure, thus disconfirming the hypothesis that youth provided strength- based assessment would make greater gains in functioning over the 6-month study period. With respect to interactions between the impact of time and case type, only one proved significant. On the CAFAS dimension of Self-Harm, a significant time × case type interaction was detected (F = 5.36, df = 1, p = .023). Intake clients showed a greater reduction in self-harmful tendencies over the study period than on-going clients. This result was likely due to the greater difficulty evidenced by intake youth in this domain of functioning at baseline, with a mean CAFAS score of 7.22 (SD = 10.31), as contrasted with 3.10 (SD = 7.15) for on- going clients. No significant interactions were found between time, condition, and case type. Overall, these findings indicated that intake and on-going therapy clients did not differ substantially with respect to the impact of strength-based assessment on child functioning outcomes.

A second series of repeated measures analyses of variance was performed to assess the main and interaction effects attributable to the therapists’ orientation toward strength-based practice, as assessed using the SBO measure within the Clinician Survey. While no main effects emerged for therapist orientation, a sig- nificant interaction was found between therapist SBO score, condition, and time on the CBCL Total Problems score (F = 3.99, df = 2, p = .023) and the CBCL In- ternalizing Scale (F = 4.54, df = 2, p = .014). On both measures, the experimental clients of highly strength-based therapists made greater improvements in function- ing over time than the control clients of these clinicians. A series of Wilcoxon sign rank tests confirmed that for experimental clients, only those with therapists

294 Cox

scoring high in strengths orientation made significant pre-post gains on the ba- sis of the CBCL Total Problems scale (Z = −2.20, p = .028), CBCL Internal- izing Problems scale (Z = −2.09, p = .037), and CBCL Externalizing Problems scale (Z = −2.32, p = .020). Conversely, the control subjects of therapists scoring medium or low with respect to strengths orientation improved to a greater extent on both scales than their experimental counterparts. For these clients, only those with a therapist scoring medium or low in strengths-orientation made significant pre- post gains, as measured by the CBCL Total Problems scale (Z = −2.46, p = .014; Z = −2.02, p = .044, respectively) and the CBCL Internalizing Problems scale (Z = −2.94, p = .003; Z = −2.26, p = .024, respectively).

The CAFAS data reflected a slightly different view of the impact of therapist orientation. For both experimental and control clients, only those with a therapist scoring medium with respect to a strengths orientation made significant pre-post gains, as assessed by the CAFAS Total Problems score (Z = −2.86, p = .004; Z = −2.73, p = .006, respectively). This finding may, however, be due to the higher level of impairment demonstrated by these clients at baseline on this measure (F = 4.19, df = 78, p = .019). Clients with a therapist scoring medium in strength- based orientation had a mean CAFAS Total Problems score of 105.79 (SD = 39.1) at study enrollment, while those with a clinician scoring high or low in SBO had mean scores of 78.75 (SD = 44.1) and 77.89 (SD = 47.2), respectively. Tables I and II present an overview of the nonparametric test results confirming the differing child functioning outcomes on the basis of the therapist’s orientation toward strength-based practice.

Parent Satisfaction

The mean CSQ-8 score for study participants at follow-up was 27.06 (SD = 13.29), just slightly below the norm-group mean for this instrument of 27.09 (SD = 4.01) (Nguyen, Attkisson, & Stegner, 1983). Parent satisfaction for experimental subjects (M = 27.68; SD = 5.05) was higher than that for control subjects (M = 26.48; SD = 4.9), although the difference between treatment groups on this measure was not significant. Further analysis of the parent satisfaction data focused on the difference in CSQ-8 scores between cases in which discussion of BERS results with clients and/or parents was documented in case records versus those in which such documentation was not present, including control cases. (As will be discussed below, a distinction between experimental cases on the basis of adherence to this element of the BERS assessment protocol is important.) The Kruscal-Wallis test revealed a significant difference between these groups on the CSQ-8 (χ2 = 4.63, df = 1, p = .031), with cases in which BERS discussion was documented evidencing higher parent satisfaction scores (M = 29.05, SD = 3.05) than those in which such discussion of youth strengths was not noted (M = 26.29, SD = 5.41).

Strength-Based Assessment with Children and Adolescents 295

Ta bl

e I.

M ea

n Pr

e- Po

st D

if fe

re nc

es by

T he

ra pi

st St

re ng

th -B

as ed

O ri

en ta

tio n

Sc or

e fo

r E

xp er

im en

ta lC

as es

H ig

h M

ed iu

m L

ow

SB 0

Sc or

e N

M Z

p N

M Z

p N

M Z

p

C B

C L

To ta

lP ro

bl em

s 12

7. 08

−2 .2

0 .0

28 ∗

14 1.

57 −1

.3 4

.1 81

10 2.

30 −.

77 .4

44 In

te rn

al iz

in g

12 8.

00 −2

.0 9

.0 37

∗ 14

1. 93

−1 .8

2 .0

68 10

1. 80

−. 67

.0 74

E xt

er na

liz in

g 12

6. 83

−2 .3

2 .0

20 ∗

14 .9

3 −.

63 .5

29 10

.4 0

−. 36

.7 21

Y SR T

ot al

Pr ob

le m

s 7

−. 43

.0 0

1. 00

16 3.

88 −1

.6 6

.0 98

7 5.

71 −1

.3 6

.1 76

In te

rn al

iz in

g 7

1. 29

−. 43

.6 70

16 2.

06 −.

47 .6

37 7

5. 14

−1 .3

6 .1

76 E

xt er

na liz

in g

7 −1

.0 −.

11 .9

17 16

2. 56

−1 .3

5 .1

78 7

3. 29

−1 .0

5 .2

93

C A

FA S

To ta

lP ro

bl em

s 12

13 .3

3 −.

68 .4

99 16

25 .6

3 −2

.8 6

.0 04

∗ 9

30 .0

0 −1

.3 3

.1 82

∗ p <

.0 5.

296 Cox

Ta bl

e II

. M

ea n

Pr e-

Po st

D if

fe re

nc es

by T

he ra

pi st

St re

ng th

-B as

ed O

ri en

ta tio

n Sc

or e

fo r

C on

tr ol

C as

es

H ig

h M

ed iu

m L

ow

SB 0

Sc or

e N

M Z

p N

M Z

p N

M Z

p

C B

C L

To ta

lP ro

bl em

s 11

2. 18

−. 97

.3 32

19 4.

16 −2

.4 6

.0 14

∗ 9

10 .6

7 −2

.0 2

.0 44

∗ In

te rn

al iz

in g

11 2.

45 −1

.1 1

.2 65

19 5.

58 −2

.9 4

.0 03

∗ 9

12 .4

4 −2

.2 6

.0 24

∗ E

xt er

na liz

in g

11 1.

73 −.

94 .3

47 19

2. 95

−1 .4

6 .1

44 9

8. 22

−1 .6

0 .1

09

Y SR T

ot al

Pr ob

le m

s 9

1. 11

−. 68

.4 97

18 1.

06 −.

78 .4

37 7

4. 71

−. 93

.3 51

In te

rn al

iz in

g 9

−. 11

.0 00

1. 00

18 1.

22 −.

44 .6

63 7

9. 29

−1 .7

8 .0

75 E

xt er

na liz

in g

9 .4

4 −.

36 .7

22 18

−. 39

−. 22

.8 26

7 −1

.2 9

−. 42

.6 72

C A

FA S

To ta

lP ro

bl em

s 12

5. 00

−. 85

.3 94

19 20

.5 3

−2 .7

3 .0

06 ∗

7 20

.0 0

−1 .0

5 .2

92

∗ p <

.0 5.

Strength-Based Assessment with Children and Adolescents 297

Treatment Retention

Unplanned or premature termination of services occurred in 20% of the total cases in the study sample. A lower percentage of experimental cases ended prematurely (16%) than control cases (37%), but the between group difference here was not significant. Similarly, a lower premature termination percentage was found for cases in which discussion of BERS results with the client and/or parent was documented (9%) than those in which this notation was not present in case records, including control cases (25%).

The percentage of scheduled appointments missed by participants over the 6-month study period ranged from 0 % to 67% (M = 13%). While experimental subjects evidenced, on average, a lower percentage of missed appointments than their control counterparts (10.4%; 14.5%, respectively), these groups did not differ significantly on this service variable. A significant difference in the percentage of missed appointments was found, however, between cases in which BERS dis- cussion with clients was documented and those in which this notation was absent from case records (χ2 = 4.72, df = 1, p = .03). The former group had a lower mean percentage of appointments cancelled or not attended (8%) than the latter (14%).

DISCUSSION

The purpose of this study was two-fold: (1) test the effectiveness of strength- based assessment, as performed using the Behavioral and Emotional Rating Scale (BERS) and (2) explore the impact of therapist orientation toward strength-based practice on proximal and distal outcomes. Results of the experiment revealed that youth receiving strength-based assessment did not make significantly greater gains in functioning than those receiving the usual deficit-focused assessment pro- tocol. This “no difference” finding is not surprising, given that major studies of children’s mental health system reform (Bickman, 1996; Bickman, Sommerfelt, Firth, & Douglas, 1997) and of promising clinic-based treatment interventions (Weisz, Weiss, & Donenberg, 1992) have failed to demonstrate substantial effects on child and adolescent functioning. Of particular interest in the present investiga- tion, is that therapist orientation toward strength-focused service (encompassing attitudes and reported use of strength-based intervention) modified the impact of assessment type on parent reported changes in child symptomotology and functional impairment over time. Youth provided BERS assessment demonstrated statistically significant treatment gains (as measured by the CBCL) when, and only when, they received services from a highly strengths-oriented therapist. In con- trast, children provided the traditional assessment protocol evidenced such gains when, and only when, they received services from a provider scoring medium or low in strengths-orientation. This finding suggests that the therapeutic process is benefited by the use of a standardized strength-based assessment measure only

298 Cox

when providers value the data it generates. It falls short of confirming that youth with serious emotional or behavioral disturbance make greater improvements in treatment when provided strengths-based assessment.

Along with this practitioner effect, fidelity or adherence to the experimen- tal protocol emerged as an important intervening variable in this investigation. Treatment fidelity has been defined as “confirmation that the manipulation of the independent variable occurred as planned” (Moncher & Prinz, 1991, p. 247). The assessment of fidelity in the present project, conducted primarily through record review, revealed that the BERS was administered to the parent or guardian of all experimental subjects, scored and returned to the clinician with a complete pro- file of standard scores and written recommendations for treatment. Additionally, monthly meetings were held over a 4-month period with participating therapists for the purpose of discussing BERS results and exploring interventions that could be used to build on child strengths identified. However, only 56% of the experimental case records contained notation indicating that the BERS results were discussed with the client and/or parent in session for purposes of treatment planning or intervention. Not surprisingly, the therapist’s orientation toward strength-based practice appeared to have some bearing on the likelihood of this disclosure oc- curring, with highly strength-based clinicians sharing BERS results with 67% of their experimental clients and therapists scoring moderate or low in strengths orientation doing so with a lower proportion (58% and 40%, respectively). These findings beg the question as to whether experimental subjects would have demon- strated significantly greater child functioning outcomes than their control group counterparts, had their therapists more consistently incorporated BERS results into service planning and delivery. Further research utilizing enhanced implementation controls is needed to further explore this question.

The significance of adherence levels was apparent in data pertaining to parent satisfaction and treatment retention. Analysis revealed that subjects assigned to the experimental condition (for whom it’s clear only that administration of the BERS took place) did not differ significantly from control subjects on either de- pendent variable. However, youth for whom BERS results were not only obtained by the investigator but also shared in treatment sessions by the clinician (hereto- fore referred to as the High BERS Adherence Group) did differ significantly on these variables from youth for whom BERS data was either not gathered or not discussed. This latter group of subjects (heretofore referred to as the No/Low BERS Adherence Group) included those in the control group, as well as those in the experimental group for whom documented disclosure of BERS results with client/parent, a prescribed element of the strength-based assessment protocol, did not occur. The formation of the No/Low BERS Adherence Group on an a priori basis was founded on the premise that subjects for whom BERS results were not disclosed in session had an experience with the therapeutic process that was more similar to that of control clients than to experimental clients for whom BERS

Strength-Based Assessment with Children and Adolescents 299

results were incorporated into the treatment process. Results revealed that the High BERS Adherence Group did evidence significantly greater parent satisfaction and significantly lower rates of missed appointments than the No/Low BERS Adher- ence Group. These findings indicate that the BERS must not only be administered to parents, but scored and utilized in the process of treatment in order for improve- ments in parent satisfaction and treatment retention to occur. They also imply that the adoption of such strength-based assessment tools by mental health programs does little to enhance child and family engagement if practitioners fail to recognize their worth or integrate the information they produce over the course of treatment.

It should be recognized, however, that the faithful incorporation of strength- focused protocols in settings dominated by the medical model presents with nu- merous challenges. The professional language used in such service settings centers on disease and disorder, diverting attention away from client capacities (Goldstein, 1992). Reimbursement structures often require practitioners to define problems as personal pathology, thus reinforcing an emphasis on client deficits (Graybeal, 2001). Misunderstanding abounds on the part of administrators and clinicians alike regarding the nature and scope of strengths-based practice. The assertion prevails, as was reflected in therapist comments obtained by the Clinician Survey, that the strengths perspective is naı̈ve or simplistic and downplays real mental health disorders (Saleebey, 1996).

Staff development efforts are sorely needed that assist children’s mental health therapists in viewing clients through a different lens, one that recognizes their resilience and potential. Blundo (2001) notes that such a “re-vision” can be quite difficult for some providers to attain in that it requires them to adopt new frames of reference. Such frames are said to contain constructed meanings that they share with others in their profession. When asked to alter these, some may find it easier to “attach a small aside to an existing frame” rather than make a substantial shift in their perceptions and practices (p. 299). This tendency was apparent in the present study when providers accommodated the administration of the BERS for their clients but failed to utilize the results in a meaningful way. In order to avoid this dilution of strengths-based protocols, providers must be recruited for future effectiveness research that are prepared to make a more fundamental shift in their approach to treatment with children and families.

The findings of this study must be considered in light of its limitations. First, the SBO measure developed for this project demonstrated promise as a tool for assessing the degree to which providers embrace the attitudes and practices con- sistent with the strengths approach. However, its psychometric properties have not been the focus of examination. Further research is needed to determine the validity and reliability of this measure. Second, the external validity of this investigation is limited by the lack of ethnic diversity of the sample. Because the study was performed in a rural region with a sample heavily dominated by Caucasion youth, it is unclear if the results can be extended to ethnically diverse populations and/or

300 Cox

urban settings. Another methodological limitation pertains to the process of ran- dom assignment utilized. Because it was not feasible at the study site to randomly assign subjects to therapists, they were assigned instead to treatment conditions in which all participating therapists carried cases. In other words, clinicians were crossed with conditions and therefore provided services to both experimental and control clients. This aspect of the research design elevated the risk for diffusion, or the spread of treatment effects from experimental to control groups. To guard against this threat to internal validity in future experimental studies, therapists should be nested within treatment conditions. While this method will not control for all practitioner effects, it could potentially increase treatment integrity. For in- stance, therapists might be assessed regarding their attitudes toward the strengths perspective (possibly using this study’s SBO measure), and those who appear most strength-oriented could be recruited as providers for the experimental con- dition. With on-going therapist training and fidelity controls, this methodological change should result in enhanced capability for the detection of treatment effects attributable to strength-based assessment.

ACKNOWLEDGMENTS

The author gratefully acknowledges the advisement of Ferol Mennen, Ph.D., Devon Brooks, Ph.D., and Niraj Verma, Ph.D., of the University of Southern California, in the development of this research project. This study was also supported by the administration of Shasta County Mental Health in Redding, California.

REFERENCES

Achenbach, T. M. (1991a). Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington: University of Vermont, Department of Psychiatry.

Achenbach, T. M. (1991b). Manual for the Youth Self-Report and 1991 profile. Burlington: University of Vermont, Department of Psychiatry.

Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school- age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Attkisson, C. C., & Greenfield, T. K. (1999). The UCSF client satisfaction scales: The Client Satis- faction Questionnaire-8. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (2nd ed., pp. 1333–1346). Mahwah, New Jersey: Lawrence Erlbaum Associates.

Bickman, L. (1992). Designing outcome evaluations for children’s mental health services: Improving internal validity. In L. Bickman & D. J. Rog (Eds.), Evaluating mental health services for children, (pp. 57–68). San Fransicso: Jossey-Bass Publications.

Bickman, L. (1996). A managed continuum of care: More is not always better. American Psychologist, 51, 689–701.

Bickman, L., Sommerfelt, W. T., Firth, J., & Douglas, S. (1997). The Stark County Evaluation Project: Baseline results of a randomized experiment. In T. C. Nixon & D. A. Northrop (Eds.), Evaluating

Strength-Based Assessment with Children and Adolescents 301

mental health services: How do programs for children “work” in the real world? (pp. 231–258). Newbury Park, CA: Sage Publications.

Blundo, R. (2001). Learning strengths-based practice: Challenging our personal and professional frames. Families in Society: The Journal of Contemporary Human Services, 82, 296–304.

Epstein, M. H., Harniss, M. K., Pearson, N., & Ryser, G. (1999). The Behavioral and Emotional Rating Scale: Test-retest and inter-rater reliability. Journal of Child and Family Studies, 8, 369–377.

Epstein, M. H., Nordness, P. D., Nelson, J. R., & Hertzog, M. (2002). Convergent validity of the be- havioral and emotional rating scale with primary grade-level students. Topics in Early Childhood Special Education, 22, 114–121.

Epstein, M. H., & Sharma, J. M. (1998). Behavioral and emotional rating scale. Austin, TX: Pro-Ed. Friedman, K. A., Leone, P. E., & Friedman, P. F. (1999). Strengths-based assessment of children with

SED: Consistency of reporting by teachers and parents. Journal of Child and Family Studies, 8, 169–180.

Friedman, P., Friedman, K. A., & Weaver, V. (2003). Strength-based assessment of African-American adolescents with behavioral disorders. Perceptual and Motor Skills, 96, 667–673.

Goldstein, H. (1992). Victors or victims: Contrasting views of clients in social work practice. In D. Saleebey (Ed.), The strengths perspective in social work practice (pp. 27–38). New York: Longman Publishing Group.

Graybeal, C. (2001). Strengths-based social work assessment: Transforming the dominant paradigm. Families in Society: The Journal of Contemporary Human Services, 82, 233–242.

Hodges, K. (1990). Child and adolescent functional assessment scales. Nashville, TN: Vanderbilt Child Mental Health Services Evaluation Project.

Hodges, K., Doucette-Gates, A., & Liao, Q. (1999). The relationship between the Child and Adolescent Functional Assessment Scale (CAFAS) and indicators of functioning. Journal of Child and Family Studies, 8, 109–122.

Hodges, K., & Wong, M. M. (1996). Psychometric characteristics of a multi-dimensional Assessment Scale. Journal of Child and Family Studies, 5, 445–467.

Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2, 197–207.

Mental Health Services Act, 1 Ca., Welfare & Institutions Code, S 5878.1 (2005). Moncher, F. J., & Prinz, R. J. (1991). Treatment fidelity in outcome studies. Clinical Psychology

Review, 11, 247–266. Nguyen, T. D., Attkisson, C. C., & Stegner, B. L. (1983). Assessment of patient satisfaction: Develop-

ment and refinement of a Service Evaluation Questionnaire. Evaluation and Program Planning, 4, 139–150.

Reid, R., Epstein, M. H., Pastor, D. A., & Ryser, G. R. (2000). Strengths-based assessment differences across students with LD and EBD. Remedial and Special Education, 21, 346–355.

Saleebey, D. (1996). The strengths perspective in social work practice: Extensions and cautions. Social Work, 41, 296–305.

Saleebey, D. (2002). The strengths perspective in social work practice (3rd ed.). New York: Longman Publishing Group.

Stroul, B. A., & Friedman, R. M. (1994). A system of care for children and youth with severe emotional disturbance. Washington, DC: Georgetown University, Child and Adolescent Service System Program (CASSP) Technical Assistance Center.

Trout, A. L., Ryan, J. B., La Vigne, S. P., & Epstein, M. H. (2003). Behavioral and emotional rating scale: Two studies of convergent validity. Journal of Child and Family Studies, 12, 399–410.

Walrath, C. M., Mandell, D. S., Holden, E. W., & Santiago, R. L. (2004). Assessing the strengths of children referred for community-based mental health services. Mental Health Services Research, 1, 1–8.

Weick, A. (1992). Building a strengths perspective for social work. In D. Saleebey (Ed.), The strengths perspective in social work practice (pp. 18–26). New York: Longman Publishing Group.

Weick, A., & Chamberlain, R. (2002). Putting problems in their place: Further explorations in the strengths perspective. In D. Saleebey (Ed.), The strength perspective in social work practice, (pp. 95–105). New York: Longman Publishing Group.

Weisz, J. R., Weiss, B., & Donenberg, G. R. (1992). The lab versus clinic: Effects of child and adolescent psychotherapy. American Psychologist, 47, 1578–1585.

Journal of Consulting and Clinical Psychology 2000, Vol. 68, No. 6, 1072-1080

Copyright 2000 by the American Psychological Association, inc. 0022-006X/00/S5.00 DOT: 10.1037//0022-006X.68.6.1072

Behavioral Treatment of Childhood Social Phobia

Deborah C. Beidel and Samuel M. Turner University of Maryland

Tracy L. Morris West Virginia University

Sixty-seven children (ages 8 and 12) with social phobia were randomized to either a behavioral treatment program designed to enhance social skills and decrease social anxiety (Social Effectiveness Therapy for Children, SET-C) or an active, but nonspecific intervention (Testbusters). Children treated with SET-C were significantly more improved across multiple dimensions, including enhanced social skill, reduced social fear and anxiety, decreased associated psychopathology, and increased social interaction. Further- more, 67% of the SET-C group participants did not meet diagnostic criteria for social phobia at posttreatment compared with 5% of those in the Testbusters group. Treatment gains were maintained at 6-month follow-up. The results are discussed in terms of treatment of preadolescent children with social phobia and the durability of treatment effects.

Although social phobia had been considered an early onset disorder beginning in middle to late adolescence (e.g., Turner, Beidel, Dancu, & Keys, 1986), the syndrome has been diagnosed in children as early as age 8 (Beidel & Turner, 1988). The Diag- nostic and Statistical Manual of Mental Disorders (4th ed.; DSM- IV; American Psychiatric Association, 1994) included develop- mentally sensitive descriptors of social phobia in children for the first time.

Extant data reveal that the syndrome in children is very similar to that found in adults (Beidel & Turner, 1998). For example, youth with social phobia fear speaking, reading, eating, or writing in public; going to parties; using public restrooms; speaking to authority figures; and interactions in informal social situations (Beidel, Turner, & Morris, 1999). Unstructured peer interactions (e.g., playing games with other children, joining in activities at recess, or riding bicycles with a friend) are the most frequent distressing events, occurring as often as every other day (Beidel, Turner, & Morris, 1999). Emotional reactions can be quite severe and include headaches or stomach aches, occasional panic attacks, crying, and behavioral avoidance. Children with social phobia also suffer from higher levels of general anxiety, dysphoria, and de- pression. They report loneliness, few friends, a very restricted range of social relationships, and demonstrate deficient social skills (Beidel, Turner, & Morris, 1999). Sometimes oppositional and school refusal behaviors can occur, and in adolescents, alcohol and other substance abuse have been reported (Clark, 1993). Thus,

Deborah C. Beidel and Samuel M. Turner, Maryland Center for Anxiety Disorders, Department of Psychology, University of Maryland; Tracy L. Morris, Department of Psychology, West Virginia University.

This research was supported by Grant MH53703 from the National Institute of Mental Health. We thank Jennifer Berkes, Frank Beylotte, Kasey Hamlin, Jonathan Long, Gene Perine, and Jeff Randall for their assistance in conducting the study.

Correspondence concerning this article should be addressed to Deborah C. Beidel, Maryland Center for Anxiety Disorders, Department of Psy- chology, University of Maryland, College Park, Maryland 20742.

even in childhood, social phobia can have a significant impact on emotional, social, and academic functioning.

Although the clinical presentation and detrimental effects of social phobia in childhood are becoming clearer, to date there have been only six studies that have addressed the treatment of this disorder in children. However, in five of those studies, children with social fears were included among larger samples of children with various anxiety disorders (Barrett, Dadds, Rapee, & Ryan, 1996; Kendall, 1994; Kendall et al., 1997; Silverman, Kurtines, Ginsburg, Weems, Lumpkin, & Carmichael, 1999; Silverman, Kurtines, Ginsburg, Weems, Rabian, & Serafmi, 1999). Addition- ally, several of these studies used the DSM-III-R (3rd ed., rev; American Psychiatric Association, 1987) diagnosis of avoidant disorder of childhood, which, with the publication of the DSM-IV, has been subsumed under social phobia. In the first reported study (Kendall, 1994), a group receiving cognitive-behavior therapy (CBT) was compared with a wait-list control group. A few chil- dren who had avoidant disorder were included in the sample of children with anxiety disorders. At posttreatment, those who re- ceived CBT had significantly lower general anxiety and enhanced coping abilities. Parents’ ratings of anxiety/depression and social competence also improved, but teacher ratings did not change. Finally, a total behavioral observational score differentiated the treatment and control groups. A replication study (Kendall et al., 1997) reported a similar outcome for children with various anxiety disorders, again including some with avoidant disorder. Fifty-three percent of all treated children no longer met diagnostic criteria at posttreatment compared with 6% of the wait-list control group. Treatment outcome did not differ by diagnostic group. Barrett et al. (1996) reported a positive treatment outcome for a very similar CBT program for Australian youth with various anxiety disorders, including 27% with social phobia. Silverman, Kurtines, Ginsburg, Weems, Lumpkin, and Carmichael (1999) reported that a group cognitive-behavioral treatment for children with social phobia, overanxious disorder, or generalized anxiety disorder was more effective than a wait-list control condition. However, Silverman, Kurtines, Ginsburg, Weems, Rabian, and Serafmi (1999) did not find posttreatment differences among a contingency management

1072

BEHAVIORAL TREATMENT OF CHILDHOOD SOCIAL PHOBIA 1073

program, a self-control program, or an educational support group for children with various types of phobias, among which were a few children with social phobia.

Although children with avoidant disorder or social phobia were reported as improved in these studies, for several reasons, the results must be considered preliminary. First, only 18-19% of the samples (Kendall, 1994; Kendall et al., 1997) had avoidant disor- der. Neither sample included children with clearly documented social phobia. Even with substantial overlap between avoidant disorder and social phobia, the small number of subjects precludes drawing strong conclusions regarding the treatment’s specific ef- ficacy for avoidant disorder or, by extrapolation, social phobia. Second, the active treatment was compared with a wait-list control group, a less stringent comparison than an attention-placebo or nonspecific treatment group. Similar concerns exist with the Bar- rett et al. (1996) study. Specifically, although 27% of the children in the Barrett et al. study had social phobia, the outcome was not reported separately by diagnostic group (although there was a general statement that the treatment appeared equally efficacious across diagnoses). Silverman and colleagues (Silverman, Kurtines, Ginsburg, Weems, Lumpkin, & Carmichael, 1999; Silverman, Kurtines, Ginsburg, Weems, Rabian, & Serafini, 1999) also in- cluded mixed diagnostic groups. Finally, none of these studies included specific measures that assessed social anxiety or phobia. Thus, although the findings reported to date have implications for the treatment of social phobia, there is a need for studies that address childhood social phobia specifically.

Only one study has reported the results of a treatment program specifically for social phobia patients who were not adults. The intervention, cognitive-behavior group therapy for adolescents (CBGT-A), consisted of psychoeducation, cognitive restructuring, skill building, and exposure (Albano, DiBartolo, Heimberg, & Barlow, 1995). Five adolescents were treated over a 3-month period using a single-case design. At posttreatment, social phobia had decreased to subclinical levels in 4 of 5 adolescents, and at 1-year follow-up, 4 adolescents did not meet criteria for social phobia. A recent, randomized, controlled trial of 27 adolescents treated with either CBGT or CBGT plus four sessions of parental involvement did not reveal any significant differences at posttreat- ment (Tracy et al., 1998). However, this initial report did not address the outcome of the third cell included in the randomized trial, which was a wait-list control group (A. M. Albano, personal communication, January 30, 2000). Thus, whether the improve- ment in these two groups was significantly greater than a no- treatment control group has yet to be determined.

In summary, although several studies have included children with social fears or social phobia in their sample, to date there is only one reported controlled trial of psychosocial treatment with nonadult social phobics (adolescents) with DSM-IV social phobia. All of these studies have used cognitive restructuring and more traditional behavioral procedures such as exposure. However, a recent study of the psychopathology of social phobia in children indicates that they suffer social skill deficits (Beidel, Turner, & Morris, 1999), suggesting a need to address skill deficits in this population. Furthermore, because social phobia can be diagnosed at least as early as age 8, interventions designed for preadolescent children are needed. This study reports the results of a multifaceted behavioral treatment for childhood social phobia.

Method

Subjects

One hundred two children between the ages of 8 and 12 were screened for the study at the Anxiety Prevention and Treatment Center of the Medical University of South Carolina. Participants were drawn from those seeking treatment in the clinic, referrals from other professionals, referrals from the schools, and responders to advertisements indicating the avail- ability of a treatment program for “shy” children. Parents and children were interviewed (together for younger children and separately for older chil- dren) with the Anxiety Disorders Interview Schedule for Children (ADIS-C; Silverman & Albano, 1997) by either Deborah C. Beidel or Samuel M. Turner. When children were interviewed separately from their parents, data were combined from the interviews to derive a final diagno- sis. The ADIS-C is a semistructured interview designed to assist the clinician in the determination of DSM-IV Axis I diagnoses. Twenty-five percent of the interviews were videotaped and independently rated by a second clinician. Interrater reliability for a diagnosis of social phobia was K = .85. Other diagnoses were made too infrequently for the calculation of kappa coefficients.

Among those interviewed, 24 (24%) did not meet study inclusion criteria. That is, they did not have a primary diagnosis of social phobia or their social fears were at a subclinical level. An additional 11 (11%) were excluded for administrative reasons (i.e., did not return to complete pre- treatment assessment). Thus, 67 (66% of those referred) were admitted to the protocol. All children who were randomized met criteria for a primary diagnosis of social phobia. All children expressed fears of interpersonal interactions as well as fears in public performance situations. Thus, all children would be classified as the generalized subtype. In addition, 41% had a comorbid diagnosis, most of which were other anxiety disorders. Comorbid diagnoses included panic disorder (n = 1), generalized anxiety disorder (n = 5), specific phobia (« = 3), obsessive-compulsive disorder (n = 2), separation anxiety disorder (n = 4), adjustment disorder with depressed mood (n = 1), selective mutism (n = 4), and attention deficit hyperactivity disorder (n = 8).

Thirty-six children were randomly assigned to Social Effectiveness Therapy for Children (SET-C) and 31 to the nonspecific treatment control group (Testbusters). Children with additional comorbid disorders were equally distributed across the two groups. Treatment groups were started when 4 to 6 children within the specified age ranges (8-10 or 10-12) were admitted to the study. Assignment to treatment condition (i.e., SET-C or Testbusters) for each cohort was accomplished by a predetermined ran- domization schedule. Seven subjects (6 assigned to Testbusters and 1 to SET-C) did not attend the first session, citing an inability to adhere to the treatment protocol. However, parents and children did not know to which group they had been assigned until after the first session. Thus, this differential entry rate does not appear to be the result of a difference in treatment credibility. Ten subjects (16%) dropped out of treatment (5 from SET-C and 5 from Testbusters, all citing inability to commit to twice-per- week appointments). Demographic data for those children who completed the study are depicted in Table 1.

An analysis of demographic and pretreatment variables indicated that there were no significant differences between the dropouts and completers with the exception of age and scores on the Loneliness Scale (LS; Asher & Wheeler, 1985). Those who dropped out were younger, M = 9.5 years (SD = 1.8) versus M = 10.5 years (SD = 1.5), ?(60) = 2.06, p < .05, and had lower scores (were less lonely) on the LS, M = 35.1 (SD = 10.1) versus M = 43.0 (SD = 11.6), <(60) = 2.09, p < .05. Among the 50 participants who completed the study, 30 completed the SET-C protocol, and 20 completed the Testbusters protocol (75% of those beginning treat- ment completed the study). In Table 2, mean scores and standard devia- tions on demographic and pretreatment variables are presented for the dropouts and completers.

1074 BEIDEL, TURNER, AND MORRIS

Table 1 Demographic Characteristics of Study Completers

Characteristic

Age (years)” Raceb

White African American Hispanic Biracial

Gender” Boys Girls

IQ score” Clinical severity”

SET-C (n = 30)

10.5 (1.6)

18(60%) 8 (27%) 3 (7%) 2 (7%)

14 (47%) 16(53%)

105.1 (15.9) 5.5 (0.9)

Testbusters (n = 20)

10.6(1.4)

17(85%) 3 (15%) 0 (0%) 0 (0%)

6 (30%) 14 (70%)

106.6(18.4) 5.6(1.3)

Entire sample (n = 50)

10.5(1.5)

35 (70%) 11(22%) 2 (4%) 2 (4%)

20 (40%) 30 (60%)

105.7(16.7) 5.6(1.1)

Note. SET-C = Social Effectiveness Therapy for Children. ” Values are means (and standard deviations). b Values are frequencies (and percentages).

Measures

The assessment strategy, administered at pretreatment, posttreatment, and 6-month follow-up, included self-report inventories, parent ratings, independent evaluator ratings, daily diary ratings, and ratings of skill and anxiety in two behavioral tasks: role-play scenes and reading aloud before a group.

Self-Report Inventories

These included the Children’s Depression Inventory (GDI; Kovacs, 1985), Eysenck Personality Inventory (EPI; Eysenck & Eysenck, 1968), LS (Asher & Wheeler, 1985), Social Phobia and Anxiety Inventory for Chil- dren (SPAI-C; Beidel, Turner, & Morris, 1995), and the State-Trait Anx- iety Inventory for Children (STAI-C; Spielberger, 1973).

Parental Report

Parents completed the Child Behavior Checklist (CBCL; Achenbach, 1991). The Internalizing scale was used in the analysis.

Independent Evaluator Ratings

At pretreatment, the clinician administering the ADIS-C also completed the Children’s Global Assessment Scale (K-GAS; Shaffer et al., 1983). The K-GAS is a 10-item rating scale used to assess children’s academic, social, or occupational functioning. At posttreatment and follow-up, a PhD-level clinician unaware of the child’s treatment group completed the ADIS-C and the K-GAS. Interrater reliability for the K-GAS was r = .85.

Behavioral Assessment of Social Phobia

Each child participated in two tasks to measure social skill and anxiety. Independent observers who were unaware of the child’s group assignment used Likert scales to make ratings of skill and anxiety. Effectiveness was rated on a 5-point scale where 1 = completely ineffective and 5 = very effective. Ratings of anxiety were made with a 4-point scale where 1 = very relaxed and 4 = very nervous. In addition, children rated their anxiety by using a 5-point pictorial Likert scale where 1 = very relaxed and 5 = very anxious or distressed. Twenty-five percent of all assessments were rated independently by a second rater to determine interrater reliability (Pear- son’s r). Interrater reliability was r = .89 for skill and r = .87 for anxiety. The order of task presentation was determined randomly. The specific tasks are described below.

Social skills assessment. Children were aware of the evaluative nature of the task and were given standard behavioral assertiveness test instruc- tions (e.g., to respond as if the scene were really happening). Prior to the initiation of the task, the children completed a practice scene to make sure that they understood the instructions. Children engaged in five role-plays with a same-age peer trained to respond in a friendly, but neutral, fashion. Role-play scene content included starting a conversation with an unfamiliar child, offering to help another child, giving a compliment, receiving a compliment, and responding assertively to the inappropriate behavior of another child.

Read-aloud task. Children read aloud the story of Jack and the Bean- stalk in front of a small group (at least 1 of whom was a same-age peer) for 10 min.

Daily Diary

The daily diary was used to assess the frequency of engagement in various social situations. In addition, children recorded their response to the situation, which was categorized by an independent evaluator as pos- itive (“I told myself not to be nervous, it would be OK”), negative (“I refused to go to the party”), or neutral (“I did what I was told”). Interrater reliability was K = .97. In addition, children rated their distress in each particular social encounter with the 5-point rating scale described above. Children completed the diary for a 2-week period at pretreatment, post- treatment, and 6-month follow-up. Although instructed to complete the diary every day, the mean number of recorded days was 11.4. Because of some variability in number of days recorded, frequency of events and frequency of coping responses were calculated as percentages (number of events divided by number of days recorded). Ratings of distress were averaged across all situations recorded.

Table 2 Frequencies or Means (and Standard Deviations) for Dropouts and Completers

Variable

Demographic Age Gender (% female) Race (% Caucasian) Comorbidty (% with comorbid

diagnosis) IQ score

Pretreatment CBCL Internalizing scale Children’s Depression Inventory EPI Extraversion EPI Neuroticism Children’s Global Assessment

Scale Loneliness Scale STAI-C State STAI-C Trait Reading anxiety Reading effectiveness Reading self-rating Speech latency Social skills anxiety Social skills effectiveness Social skills self-rating

Completers (n = 50)

10.5(1.5) 60% 70%

46% 105.7(16.7)

69.0(7.1) 10.7 (7.0) 11.9(4.9) 10.1 (5.2)

5.7 (0.8) 43.0(11.6) 32.2 (8.7) 38.1 (7.5) 2.7(1.0) 2.8(1.2) 3.3(1.4) 4.2(3.1) 3.0 (0.9) 2.1(1.1) 3.2(1.4)

Dropouts (« = 10)

9.5(1.8) 42% 58%

29% 100(12.8)

64.4(9.1) 11.2(10.8) 12.8 (5.7) 9.5 (5.5)

5.6 (0.5) 35.1 (10.1) 33.8(10.1) 35.5 (9.2) 2.5 (0.7) 2.2(1.0) 3.3(1.5) 3.3(3.1) 2.5 (0.7) 2.2(1.1) 3.6(1.4)

P

.05

.05

Note. CBCL = Child Behavior Checklist; EPI = Eysenck Personality Inventory; STAI-C = State-Trait Anxiety Inventory for Children.

BEHAVIORAL TREATMENT OF CHILDHOOD SOCIAL PHOBIA 1075

Treatment

SET-C

SET-C (Beidel, Turner, & Morris, 1998) is a multifaceted behavioral treatment modeled after a successful program used for adult social phobics (Turner, Beidel, & Cooley-Quille, 1997). SET-C is comprehensive and structured to address various dimensions of the syndrome as it exists in young children, including reduction of social anxiety and fear, improve- ment in social skill and interpersonal functioning, and increase in partici- pation in social activities. The components include Child and Parent Education, Social Skills Training and Peer Generalization Experiences, and In Vivo Exposure. The last three components are conducted simulta- neously. A component of the child program (SET-C) not included in the adult program is the Peer Generalization component (see below). Social Skills Training was conducted in small groups of 4 to 6 children with sessions lasting approximately 60 min. Peer Generalization sessions were 90 min. In Vivo Exposure was conducted in individual sessions averaging 60 min in length. Treatment was provided twice weekly (one group session and one individual session) over a 12-week period of time.

Educational session. The one-session Educational component in- cluded providing information about social phobia in children, the specifics of the SET-C treatment, and an opportunity for parents and children to ask questions.

Social Skills Training. As noted in the introduction, children with social phobia exhibit substantial social skills deficits (Beidel, Turner, & Morris, 1999). Thus, a Social Skills Training component was considered necessary as part of the treatment package. The content of the Social Skills Training sessions included greetings and introductions, starting conversa- tions, maintaining conversations, listening and remembering skills, skills for joining groups, positive assertion, negative assertion, and telephone skills. One skill was taught each week by using instruction, modeling, behavioral rehearsal, and corrective feedback. Children were assigned homework based on that week’s content.

Peer Generalization session. Because prior Social Skills Training pro- grams for socially isolated children indicated that generalization to natu- ralistic settings did not occur spontaneously (see Beidel & Turner, 1998, for a review), specific Peer Generalization programming was included. Thus, immediately following each Social Skills Training session, the children joined a group of nonanxious peers in a 90-min group activity. Examples of group activities included bowling, pizza parties, flying kites, or in-line skating. A different activity occurred each week and always included lunch. The Peer Generalization sessions provided an opportunity to practice acquired social skills in a natural setting and with children who did not have social phobia. Activities were unstructured to mimic chil- dren’s usual interactions. Peers were recruited through newspaper adver- tisements. Although a formal diagnostic interview was not conducted, children were interviewed clinically by either Deborah C. Beidel or Samuel M. Turner and did not evidence any Axis I disorders. In addition, they had to demonstrate good social skills (i.e., they completed the social skills assessment with no difficulty) and have a desire to work with shy children. Finally, they had to score in the nonanxious range on the SPAI-C and have a parental rating below 70 on the CBCL Internalizing scale. Different peers were used throughout the 12-week program to ensure opportunities to interact with a variety of different children. The number of peers used in each session matched the number of peers in the group (i.e., if there were 5 children in the group, 5 peers were included in the Peer Generalization session).

In Vivo Exposure. In addition to the skills training, children partici- pated in a once per week individual exposure session using activities specifically constructed to address their unique pattern of social fears. Among adult populations, exposure-based interventions have been docu- mented to be the most effective for the treatment of social phobia. Exam- ples of exposure activities included reading in front of a group, playing a game with peers, acting out plays in front of an audience, or taking tests at

the blackboard while being observed by others. One item was presented each week. The child participated in the activity until elicited anxiety dissipated, with session length averaging 60 min (range = 45-75 min). Sessions were longer in the initial phase of treatment and shorter at the end. Children were able to participate fully in all tasks presented to them.

Testbusters

Testbusters (Beidel, Turner, & Taylor-Ferreira, 1999) is a study-skills and test-taking strategy program designed specifically for children between the ages of 8 and 12. Testbusters has face validity as a control condition inasmuch as anxiety during test taking is a common complaint of children with social phobia (Beidel, Turner, & Taylor-Ferreira, 1999) and the children in this study. Skills addressed in the Testbusters program include establishing good study habits, the development of a study contract, in- struction in the Survey, Question, Read, Review, and Recite (SQ3R) method of study skills (Carmen & Adams, 1972), test-taking preparation, and specific instructions in how to answer multiple-choice, matching, and fill-in-the-blank questions. Reviewing test-taking mistakes is also part of the program. In this study, Testbusters was conducted twice weekly with one individual and one group session (to parallel the SET-C program). Skills were introduced in the group session where children were required to read aloud in front of the group from the Testbusters manual and discuss their experiences with the topic being addressed during that session. Children were provided with opportunities to practice the skill in the group setting by using standardized materials appropriate for their age. In the individual session, children met with the therapist who reviewed the skills presented in the group session and provided the children with additional opportunities to practice using their own academic materials. In addition, they had to practice the skills everyday for 30 min by means of a study contract.

The structure of Testbusters mimicked many crucial elements of the SET-C program, and over 80% of the children in this study reported at least moderate anxiety in testing situations. Children received two sessions per week (one group and one individual session) as did the SET-C group. Testbusters did not have a peer generalization component, but both groups had homework assignments. Finally, children in Testbusters were required to perform in front of the other children in the group (reading aloud and answering questions). Because well-validated measures of treatment cred- ibility for children did not exist at the start of the study, credibility ratings were not used in this study. However, dropout rates were equivalent across the two groups, suggesting equal credibility. Thus, the Testbusters program provided a strong test of the efficacy of SET-C by equivalent amounts of therapist attention, and the group sessions required the children to partic- ipate in performance and social interactions, although not in the program- matic fashion found in the SET-C group.

Results

There were no differences on demographic (age, IQ, comorbid- ity status, race, or gender) or clinical severity (K-GAS scores or ADIS-C clinical severity ratings) variables at pretreatment. Treat- ment outcome was analyzed with repeated measures multivariate analyses of variance (MANOVAs) where time represented the within-subject factor. Because of a few instances of missing data, there is a slight variation in the number of subjects included in the analysis. Measures were grouped according to the following de- pendent variable classifications: those assessing social phobia, those assessing other aspects of psychopathology, those assessing social skill and performance, and those assessing self-reported distress in social interactions. Significant multivariate effects were followed by repeated measures univariate tests where time was the

1076 BEIDEL, TURNER, AND MORRIS

repeated measure. Pre- and posttreatment means and standard deviations are presented in Table 3.

Social Phobia

Included in this analysis was the EPI Extroversion scale, the SPAI-C, and clinician ratings (K-GAS and ADIS-C severity rat- ing). The intercorrelations among the various measures ranged from r = .426 to .846. All were statistically significant atp < .01. The results of the MANOVA indicated that there was a significant multivariate Time X Group interaction, F(7, 36) = 7.89, p < .005. Follow-up univariate analyses indicated significant Group X Time interactions for all of these variables: EPI Extraversion scale, F(l, 45) = 6.41, p < .01; SPAI-C total score, F(l, 45) = 13.89, p < .001; K-GAS severity score, F(l, 45) = 47.51, p < .0005; and ADIS-C severity rating, F(l, 45) = 15.25,;? < .0005. In each case, significant improvement occurred in the group treated with SET-C.

Other Aspects of Psychopathology

Included in this analysis were the CBCL Internalizing scale, GDI, LS, EPI Neuroticism scale, and the STAI-C State and Trait subscales. Intercorrelations among the self-report measures in- cluded in this category ranged from r = .21 to .55. All were statistically significant at the .05 level or higher. The correlations between the CBCL Internalizing scale and the child’s self-report measures were lower (r = .06-.24). These lower correlations might be expected given that the information is coming from two

different sources. Nevertheless, the CBCL Internalizing scale was included in this analysis as it assesses a broad range of psychopa- thology. The overall MANOVA was significant, F(l 1, 33) = 2.10, p < .05. With respect to the univariate tests, there were significant Time X Group interactions on the EPI Neuroticism scale, F(l, 45) = 7.37, p < .01, and the CBCL Internalizing scale, F(l, 45) = 436, p < .01. In each case, greater improvement was noted in the group that received SET-C. In addition, there were signifi- cant effects for time on the LS, F(l, 45) = 10.63, p < .005; the STAI-C State subscale, F(l, 45) = 4.07, p < .05; and the STAI-C Trait subscale, F(l, 45) = 20.22, p < .0005; indicating significant pre- to posttreatment improvement. There were no significant main or interaction effects for the GDI, although there was a trend toward a Time X Group interaction (p < .07).

Observer Assessment of Social Skill and Performance

Included in this analysis were the independent observers’ ratings of skill and anxiety during the role-play and read-aloud tasks. Intercorrelations among the variables ranged from r = .486 to .781, and all were significant at p < .01. The overall repeated measures MANOVA revealed a significant Time X Group inter- action, F(7, 35) = 2.52, p < .05. There was also a significant univariate Time X Group interaction for the observer rating of skill during the role-play task, F(l, 45) = 15.77, p < .0005, indicating that those treated with SET-C were judged to be signif- icantly more skilled at posttreatment. There was a similar trend for

Table 3 Pre- and Posttreatment Means (and Standard Deviations) for the SET-C and Testbusters Groups

SET-C (n = 30) Testbusters (n = 20)

Variable Pre Post Pre Post Effect

Social phobia EPI Extroversion K-GAS ADIS-C severity rating SPAI-C

Other aspects of psychopathology CBCL Internalizing CDI EPI Neuroticism Loneliness Scale STAI-C State STAI-C Trait

Social and performance skill Role-play effectiveness” Role-play anxietyb

Read-aloud effectiveness Read-aloud anxiety

Self-ratings of frequency and distress in social interactions Stressful events (% of days) Negative coping (% of events) Self-report of anxiety Role-play self-rating6

Read-aloud self-rating”

11.4(4.9) 6.0 (0.7) 5.5 (1.0)

26.8 (8.8)

68.4 (7.2) 9.5 (8.4)

10.2 (5.5) 42.0(11.5) 29.6 (10.3) 30.3 (8.4)

2.0(1.1) 2.9 (0.9) 3.0(1.3) 2.5(1.0)

0.8 (0.3) 0.7 (0.2) 3.3(1.1) 3.4(1.3) 3.7(1.4)

14.6 (5.2) 7.5(1.2) 1.3(1.9)

16.0(9.1)

60.2(8.1) 6.3 (6.5) 7.7 (4.0)

35.3 (10.5) 28.4 (6.2) 30.1 (5.8)

2.8(1.1) 2.5 (0.7) 3.7(1.3) 2.1 (0.9)

0.3 (0.4) 0.3 (0.2) 2.6 (0.9) 4.0(1.1) 4.2 (1.0)

11.8(6.4) 5.5(1.1) 5.6(1.2)

25.9(10.2)

70.3 (8.3) 11.1 (13.8) 9.5 (5.5)

44.6(12.2) 31.1 (7.8) 35.6(7.4)

2.5(1.2) 2.9 (0.9) 2.9(1.2) 2.7(1.0)

0.7 (0.4) 0.8 (0.3) 3.2(1.2) 3.1(1.4) 3.2(1.2)

11.2(5.2)* 5.9 (0.9)*** 5.1 (1.8)***

24.2 (8.9)***

67.0 (6.9)* 12.6(7.2) 11.1(4.9)** 41.5(12.7)** 28.5 (7.3)*** 34.7 (8.0)***

2.5(1.0)*** 2.9 (0.9)* 3.1 (1.2)** 2.6(1.0)

0.5 (0.6) 0.4 (0.2) 3.0(1.0) 3.6(1.0) 4.1(1.3)

T X G TX G T X G T X G

T X G

T X G T T T

T X G T T

T X G

Note. SET-C = Social Effectiveness Therapy for Children; EPI = Eysenck Personality Inventory; K-GAS = Children’s Global Assessment Scale; ADIS-C = Anxiety Disorders Interview Schedule for Children; SPAI-C = Social Phobia and Anxiety Inventory for Children; CBCL = Child Behavior Checklist; CDI = Children’s Depression Inventory; STAI-C = State-Trait Anxiety Inventory for Children; T = time; G = group. a Higher scores indicate more skill. b Lower scores indicate less anxiety. c Higher scores indicate less anxiety. *p<.01. **p < .005. ***p < .001.

BEHAVIORAL TREATMENT OF CHILDHOOD SOCIAL PHOBIA 1077

the read-aloud effectiveness score (/?<< .07). In addition, there was a significant main effect for time for effectiveness during the read-aloud task, F(l, 45) = 8.17, p < .01, and observer rating of anxiety during the role-play task, F(l, 45) = 4.16,p < .05. In each case, posttreatment ratings were lower (better) than at pretreat- ment. There were no main effects for the observer ratings of anxiety during the read-aloud task.

Self-Assessment of Interaction and Distress During Social Interactions

Included in this analysis were the percentage of days that a stressful event occurred, the percentage of negative coping behav- iors, ratings of distress when stressful events occurred, and self- ratings of distress during the role-play and read-aloud tasks. Inter- correlations among the variables ranged from r = .23 to .63. With the exception of r = .23 (percentage of negative coping strategies and rating of distress on the diary), all were significant alp < .05. The repeated measures MANOVA did not reveal a significant Time X Group interaction. Therefore, no further analyses were conducted.

Effect Sizes

Effect sizes (d) were calculated for all variables used in this study and are presented in Table 4. As depicted, effect sizes were calculated for both groups for 19 variables. With the exception of the STAI-C State and Trait Anxiety subscales and two self-ratings

Table 4 Effect Sizes for All Dependent Variables

Variable SET-C Testbusters

Social phobia EPI Extroversion 0.59 0.13 K-GAS 1.31 0.49 ADIS-C severity rating 2.30 0.30 SPAI-C 1.24 0.22

Other aspects of psychopathology CBCL Internalizing 1.12 0.44 CDI 0.49 0.11 EPI Neuroticism 0.54 0.27 Loneliness Scale 0.69 0.29 STAI-C State 0.30 0.33 STAI-C Trait 0.65 0.73

Social and performance skill Role-play effectiveness 0.54 0.00 Role-play anxiety 1.02 0.21 Read-aloud effectiveness 0.76 0.14 Read-aloud anxiety 0.38 0.11

Self-ratings of frequency and distress in social interactions

Stressful events (% of days) 0.54 0.37 Negative coping (% of events) 0.39 0.11 Self-report of anxiety 0.20 0.27 Role-play self-rating 0.55 0.40 Read-aloud self-rating 0.52 0.78

Note. SET-C = Social Effectiveness Therapy for Children; EPI = Ey- senck Personality Inventory; K-GAS = Children’s Global Assessment Scale; ADIS-C = Anxiety Disorders Interview Schedule for Children; SPAI-C = Social Phobia and Anxiety Inventory for Children; CBCL = Children’s Behavior Checklist; CDI = Children’s Depression Inventory; STAI-C = State-Trait Anxiety Inventory for Children.

of anxiety, effect sizes were larger for the SET-C group than for the Testbusters group. In most instances, effect sizes for the SET-C group were in the moderate to large range, whereas the effect sizes for the Testbusters group were in the small to moderate ranges.

Clinical Significance and Responder Status

The clinical significance of these changes was determined by examining the percentage of subjects in each group who no longer met DSM-IV criteria for social phobia. Among the SET-C group, 67% no longer met criteria compared with 5% for the Testbusters group, ^(1, N = 44) = 17.34, p < .0001. Similarly, responder status was defined a priori as those children who at posttreatment scored less than 18 on the SPAI-C (a score previously established as the cutoff for social phobia) and a rating by the independent evaluator of 8 or 9 on the K-GAS (indicating very minimal or no functional impairment). Only children who met both of these criteria were considered to be responders. When the conservative responder criteria were applied at posttreatment, 53% of the SET-C group met criteria compared with 5% for the Testbusters group, ^(1, N = 44) = 10.41, p < .001.

Another way of determining clinical significance is to compare outcome data on treated individuals with data from a normative sample. For this particular investigation, we determined the per- centage of children treated with SET-C whose posttreatment and follow-up scores fell below a score of 18. This value had been previously determined as a valid cutoff score for the diagnosis of social phobia (Beidel et al., 1995). At posttreatment, 63% of children in the treated group had SPAI-C scores that were less than 18. At follow-up, 82% of those children treated with SET-C had SPAI-C scores below 18.

Relationship of Demographic Variables to Outcome

Data were analyzed to determine whether there were differential treatment effects based on race, gender, age (<10 years or S:10 years) or presence or absence of a comorbid diagnosis. The results were analyzed with independent sample t tests with a Bonferroni correction to control for experimentwise error rate (.05/19 com- parisons equals p < .0026). The results indicated that treatment outcome for SET-C did not differ on the basis of any of these three variables.

6-Month Follow-Vp

Only 1 child treated with Testbusters was considered to be a responder at posttreatment. Therefore, the children treated with Testbusters were removed from the protocol and were not avail- able for follow-up analysis. Twenty-two children (73%) originally treated with SET-C completed the 6-month follow-up. Three dropped out during follow-up, and the relocation of the research program to the University of Maryland precluded follow-up on the last 5 completers. Results were analyzed with a one-way repeated measures analysis of variance, with time (pretreatment, posttreat- ment, and 6-month follow-up) as the repeated measure. The pre- treatment, posttreatment, and 6-month follow-up means are pre- sented in Table 5.

Overall, the results indicated that significant improvement oc- curred from pretreatment to posttreatment and that this improve-

1078 BEIDEL, TURNER, AND MORRIS

Table 5 Analysis of Posttreatment to 6-Month Follow-Up for SET-C Means (and Standard Deviations)

Variable

Social phobia K-GAS ADIS-C severity rating EPI Extroversion Social Phobia and Anxiety Inventory

Other aspects of psychopathology CBCL Internalizing GDI EPI Neuroticism Loneliness Scale STAI-C State STAI-C Trait

Social skills and performance Social skills task

Effectiveness Anxiety Speech latency Self-rating of anxiety

Read-aloud task Effectiveness Anxiety Self-rating of anxiety

Daily diary ratings Stressful events (% of days) Negative coping (% of days) Self-report of anxiety

Pre

5.8 (0.7) 5.6(1.1)

11.3(4.3) 28.2 (8.3)

68.1 (7.3) 11.1(5.3) 10.6 (5.0) 42.1 (12.0) 32.5 (5.4) 37.1 (7.5)

2.0(1.0) 2.9 (0.8) 4.0(3.1) 3.3(1.3)

2.8(1.1) 2.6 (0.9) 3.4 (0.9)

0.6 (0.2) 0.8 (0.4) 3.9 (2.4)

Post

8.0(1.2) 1.1(1.8)

14.8 (4.8) 15.8(8.0)

60.4 (7.9) 6.4(6.1) 7.3 (3.2)

34.8 (10.8) 28.0 (6.3) 35.7 (5.8)

2.8(1.1) 2.4 (0.7) 2.8(1.9) 4.1 (0.7)

3.7(1.1) 2.2 (0.7) 4.2 (0.7)

0.3 (0.3) 0.3 (0.2) 2.6(2.1)

6-month follow-up

8.3*a (0.7) 0.6* (1.1)

17.6*” (3.4) 12.1* (8.0)

58.4** (9.6) 3.0* (3.5) 7.0* (4.7)

30.5(11.2) 28.2* (5.3) 32.0* (5.8)

2.7* (1.0) 2.5 (0.6) 2.6* (1.5) 4.6* (0.7)

3.7* (1.0) 2.3 (0.9) 4.4* (1.3)

0.4* (0.2) 0.3 (0.2) 2.0* (1.5)

Effect

Pre vs. post Pre vs. post Pre vs. post Pre vs. post

Pre vs. post Pre vs. follow-up Pre vs. post

Pre vs. post Pre vs. follow-up

Pre vs. post

Pre vs. follow-up Pre vs. follow-up

Pre vs. post

Pre vs. follow-up

Pre vs. post

Pre vs. follow-up

Note. SET = C = Social Effectiveness Therapy for Children; K-GAS = Children’s Global Assessment Scale; ADIS-C = Anxiety Disorders Interview Schedule for Children; EPI = Eysenck Personality Inventory; CBCL = Child Behavior Checklist; CDI = Children’s Depression Inventory; STAI-C = State-Trait Anxiety Inventory for Children. a Higher scores on these measures represent improvement. *p < .01.

ment was maintained at 6-month follow-up. In particular, SPAI-C scores at follow-up not only were below the cutoff for social phobia but were also not significantly different from scores of normal children (see Beidel et al., 1995, for SPAI-C norms). Among treatment responders, only 1 child showed evidence of relapse (a 6% relapse rate) at the 6-month follow-up, and in fact, 2 children who did not meet responder criteria at posttreatment did so at the 6-month follow-up. Of those who completed the 6-month follow-up, the percentage who no longer met diagnostic criteria following treatment rose to 85%.

Discussion

The study reported here is the first to date to report the results of a controlled trial of behavioral treatment for social phobia in preadolescent children. Previous studies included children and adolescents with social phobia among a larger sample of children with a range of anxiety disorders. The treatment, SET-C, which combines social skills training, peer generalization experiences, and exposure, produced significant improvement across various domains of functioning. Specifically, statistically significant im- provement was noted in social phobic fear, general anxiety and distress, social skill and performance, and functioning in daily social encounters. Thus, the children were less anxious in social situations, showed less avoidance, were more skillful in their social interactions, and engaged in more social discourse. This

improvement was evident not only to the child but also to the parent and independent evaluators who either rated the child’s clinical status or skill in social encounters.

The outcome was clinically as well as statistically significant. First, the group mean for SPAI-C scores of the SET-C group at posttreatment was below the cutoff previously established as in- dicative for social phobia (Beidel et al., 1995), effectively moving 63% of the children into the range reported by children who do not meet diagnostic criteria for social phobia. Second, 67% of the SET-C treated group no longer met diagnostic criteria, and 52% were judged to be treatment responders (compared with 5% and 5%, respectively, of those treated with Testbusters). Third, the effect sizes for the SET-C group were large for each domain examined, illustrating that the treatment has a broad impact on the clinical syndrome of social phobia. Finally, at follow-up, SPAI-C scores were even lower, suggesting that children continued to make improvements during this 6-month period.

In a previous study (Beidel, Turner, & Morris, 1999), we re- ported that there were no differences in the clinical presentation of social phobia with respect to gender or race (African American vs. Caucasian). In this study, treatment response within the SET-C group, based on these variables, was examined along with the additional variables of age (<10 years vs. 10-12 years) and comorbid conditions. No differences were found for race, gender, age, or presence or absence of comorbid conditions. It might be

BEHAVIORAL TREATMENT OF CHILDHOOD SOCIAL PHOBIA 1079

argued that the smaller sample sizes resulting from parsing the SET-C group in this fashion may have reduced power such that it would be impossible to detect differences. However, mean scores for these subgroups were equivalent across the various measures, suggesting that power might not be an issue. In any event, the data suggest that SET-C treatment is equally efficacious for African American and Caucasian children and that it is efficacious whether or not comorbid conditions are present. Nevertheless, these issues will need to be addressed with larger samples.

Treatment gains were maintained over a 6-month follow-up period. Although 6 months is a relatively short period of time to examine the durability of treatment effects, careful perusal of the data indicate that there appeared to be continued improvement during this period. Although it is impossible to determine from the design of this study why this might have happened, one reason might be that the children had acquired a set of skills and could continue to use those skills even after the active treatment had ended. Furthermore, interviews with parents and children at the follow-up assessment indicated that children were engaging in social activities such as running for student council, joining ath- letic teams, and playing with “friends.” Thus, there appeared to be qualitative as well as quantitative improvement. Obviously, further long-term follow-up is needed to better gauge the durability of this intervention, and it would be particularly interesting and informa- tive to follow preadolescent children through the age of greatest risk for the onset of the disorder (i.e., mid-adolescence). A study of this type using this sample is currently underway.

The findings reported here are particularly encouraging because the experimental treatment (SET-C) was compared with an active, but nonspecific, control treatment. This is an important issue because a previous treatment when compared with attention- placebo control groups did not show significant differences (Sil- verman, Kurtines, Ginsburg, Weems, Rabian, & Serafmi, 1999). On the other hand, treatments compared with wait-list control groups have shown differences (Kendall, 1994; Kendall et al., 1997; Silverman, Kurtines, Ginsburg, Weems, Lumpkin, & Car- michael, 1999).

In addressing the state of the literature regarding psychosocial treatment of anxiety disorders in children, Turner and Heiser (1999) reported that there were nine randomized controlled trials, seven of which used a form of cognitive-behavior therapy. Some of these studies (Barrett et al., 1996; Kendall, 1994; Kendall et al., 1997; King et al., 1998; Silverman, Kurtines, Ginbsburg, Weems, Lumpkin, & Carmichael, 1999) compared active interventions with a wait-list control group. In each case, the active intervention worked better than nothing at all. Another group (Last, Hansen, & Franco, 1998; Silverman, Kurtines, Ginsburg, Weems, Rabian, & Serafini, 1999) compared their interventions with an attention- placebo control group. In each of these cases, there was no differ- ence between the active intervention and the attention-placebo control group.

A more recent report that was not included in the Turner and Heiser (1999) review, Tracey et al. (1998), compared a psycho- social intervention (CBGT-A) for adolescent social phobia to CBGT-A plus four sessions of parental involvement. There was no difference favoring the addition of parent involvement. One limi- tation of this report is that the comparison with a third cell in the study, a wait-list control group, was not reported. Therefore, it is unclear whether the reported within-treatment differences were

superior to no treatment. However, the data reported in this inves- tigation clearly indicate that the treatment used in this study (SET-C) was statistically superior to the active, nonspecific com- parison group (Testbusters). Although children receiving Testbust- ers also were (a) seen twice per week for 12 weeks, (b) were assigned daily homework assignments, and (c) engaged in group activities that were very similar to the exposure sessions for those treated with SET-C (reading in front of a group, writing on the blackboard, and reciting aloud), they did not show significant improvement. There was no peer generalization component in the Testbusters condition, but it is unlikely that this one particular difference could explain the results of this study. That Testbusters indeed is a potent intervention is attested to by the fact that approximately 20% of the children with social phobia who were treated with Testbusters achieved honor roll status for the first time after completing the Testbusters program. Thus, this is the first study, to our knowledge, to report a difference in treatment out- come between an active treatment group and a control condition (other than a wait-list control) for childhood anxiety disorders and, more specifically, for social phobia.

The assessments conducted in this study included some by those unaware of the child’s treatment assignment (e.g., independent raters unaware of group membership) or even treatment status (e.g., pretreatment or posttreatment independent evaluator ratings). An additional strategy often used in the assessment of child psy- chopathology is the use of teacher ratings, which provide another source of independent information. We attempted to include teacher ratings in this study, but compliance was only about 50%. Furthermore, some children completed the treatment program dur- ing the summer, and teachers were not available to complete the ratings. However, the use of independent evaluators to make clinical ratings as well as behavioral raters unaware of treatment condition or phase of the assessment makes up for this potential limitation.

Some may view the lack of follow-up data for the Testbusters condition as a significant limitation of this study. Although there might be some scientific advantage to following children “untreat- ed” for an additional 6 months, it is our opinion that this is outweighed by .the ethics of not providing a promising treatment for children with a severe and chronic disorder (Beidel, Turner, & Morris, 1999; Davidson, 1993). Finally, SET-C consists of several components, and we are unable to state definitively if any indi- vidual aspect of the program was particularly effective or ineffec- tive. Furthermore, because of the limited age range used in this study, it is unclear whether the particular combination of social skills training, peer generalization, and individualized exposure would be equally suited for adolescents. For example, exposure might be conducted differently depending on the patient’s age, and, clearly, the content of social skills training would be different for younger and older children. However, the treatment from which SET-C is derived (SET) was developed for adults. This suggests that similar treatments are useful for the treatment of social phobia across various age groups. After reviewing the extant literature, Beidel and Turner (1998) concluded that a program encompassing exposure and social skills training was most effica- cious for adult social phobics, and this appears to apply to young children as well.

1080 BEIDEL, TURNER, AND MORRIS

References

Achenbach, T. M. (1991). Manual for the Child Behavioral Checklists/ 4-18 and 199J Profile. Burlington: University of Vermont.

Albano, A. M., DiBartolo, P. M., Heimberg, R. G., & Barlow, D. H. (1995). Children and adolescents: Assessment and treatment. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 387-425). New York: Guilford Press.

American Psychiatric Association. (1987). Diagnostic and statistical man- ual of mental disorders (3rd ed., rev.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical man- ual of mental disorders (4th ed.). Washington, DC: Author.

Asher, S. R., & Wheeler, V. A. (1985). Children’s loneliness: A compar- ison of rejected and neglected peer status. Journal of Consulting and Clinical Psychology, 53, 500-505.

Barrett, P. M., Dadds, M. R., Rapee, R. M., & Ryan, S. M. (1996). Family intervention for childhood anxiety: A controlled trial. Journal of Con- sulting and Clinical Psychology, 64, 333-342.

Beidel, D. C., & Turner, S. M. (1988). Comorbidity of test anxiety and other anxiety disorders in children. Journal of Abnormal Child Psychol- ogy, 16, 275-287.

Beidel, D. C., & Turner, S. M. (1998). Shy children, phobic adults: The nature and treatment of social phobia. Washington, DC: American Psychological Association.

Beidel, D. C., Turner, S. M., & Morris, T. L. (1995). A new instrument to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, I, 73-79.

Beidel, D. C., Turner, S. M., & Morris, T. L. (1998). Social Effectiveness Therapy for Children: A treatment manual. Unpublished manuscript, Medical University of South Carolina.

Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology of childhood social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 643-650.

Beidel, D. C., Turner, S. M., & Taylor-Ferreira, J. C. (1999). Teaching study-skills and test-taking strategies to elementary school children: The Testbusters program. Behavior Modification, 23, 630-646.

Carmen, R. A., & Adams, R. W. J. (1972). Study skills: A student’s guide for survival. New York: Wiley.

Clark, D. B. (1993, March). Assessment of social anxiety in adolescents. Paper presented at the Anxiety Disorders Association of America An- nual Convention, Charleston, SC.

Davidson, J. R. T. (1993, March) Childhood histories of adult social phobics. Paper presented at the Anxiety Disorders Association of Amer- ica Annual Convention, Charleston, SC.

Eysenck, H. J., & Eysenck, S. B. G. (1968). Manual for the Junior Eysenck Personality Inventory. San Diego, CA: Educational and Industrial Test- ing Service.

Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychol- ogy, 62, 100-110.

Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam- Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Con- sulting and Clinical Psychology, 65, 366-380.

King, N. J., Tonge, B. J., Hyene, D., Pritchard, M., Rollings, S., Young, D., Myerson, N., & Ollendick, T. H. (1998). Cognitive-behavioral treatment of school-refusing children: A controlled evaluation. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 395-403.

Kovacs, M. (1985). The Children’s Depression Inventory (GDI). Psycho- pharmacology, 21, 995-998.

Last, C. G., Hansen, C., & Franco, N., (1998). Cognitive-behavioral treatment of school phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 404-411.

Shaffer, D., Gould, M. S., Brasic, J., Abrosini, P., Fisher, P., Bird, H., & Aluwahlia S. (1983). A Children’s Global Assessment Scale (K-GAS). Archives of General Psychiatry, 40, 1228-1231.

Silverman, W., & Albano, A. M. (1997). The Anxiety Disorders Interview Schedule for Children (ADIS-C/P). San Antonio, TX: Psychological Corporation.

Silverman, W., Kurtines, W. M., Ginsburg, G. S. Weems, C. F., Lumpkin, P. W., & Carmichael, D. H. (1999). Treating anxiety disorders in children with group cognitive behavior therapy: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 995-1003.

Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Rabian, B., & Serafini, L. T. (1999). Contingency management, self-control, and education support in the treatment of childhood phobic disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychol- ogy, 67, 675-687.

Spielberger, C. (1973). STAI-C preliminary manual. Palo Alto, CA: Con- sulting Psychologists Press.

Tracey, S. A., Mattis, S. G., Chorpita, B. F., Albano, A. M., Heimberg, R. G., & Barlow, D. H. (1998, November). Cognitive-behavioral group treatment of social phobia in adolescents: Preliminary examination of the contribution of parental involvement. Poster presented at the Asso- ciation for Advancement of Behavior Therapy Annual Convention, Washington, DC.

Turner, S. M., Beidel, D. C., & Cooley-Quille, M. R. (1997). Social effectiveness therapy: A program for overcoming social anxiety and social phobia. Toronto, Ontario, Canada: Multi-Health Systems.

Turner, S. M., Beidel, D. C., Dancu, C. V., & Keys, D. (1986). Psycho- pathology of social phobia and its relationship to avoidant personality disorder. Journal of Abnormal Psychology, 95, 389-394.

Turner, S. M., & Heiser, N. (1999). Current status of psychological interventions for childhood anxiety disorders. Anxiety disorders in youth: Current problems, future solutions [Conference monograph]. Rockville, MD: Anxiety Disorders Association of America.