Changing the Course of Social Anxiety in Adolescence: What Works, Why, and for Whom

Social anxiety is characterized by emotional reactivity to social events in which individuals believes they can be subject to the scrutiny of others. Although normative during adolescence, along with the growing importance attributed to acceptance and integration with peers, it can come to fulfill criteria for social anxiety disorder (SAD; McNeil, 2010), which is an intense and disabling experience for adolescents (Rao et al., 2007). SAD refers to excessive and persistent fear of being evaluated in social interactions, also with peers, which leads to those situations being faced with high levels of suffering or, if possible, avoided (APA, 2013). If not subject to specialized intervention, SAD usually has a chronic course and is associated with the emergence of other psychiatric disorders (Essau et al., 2004). In Portugal, it is estimated about 8% of adolescents in the community meet criteria for SAD, including intense anxiety and frequent avoidance of social situations, as well as severe impairment of academic and social functioning and quality of life. Most of these adolescents (roughly 94%) did not seek or were referred to specialized intervention (Vagos et al., 2021), which points to the importance of offering acceptable, practical, and effective forms of intervention for PAS.

With adults, the treatment of choice for SAD is Cognitive Therapy (CT; Mavranezouli et al., 2015) derived from the model by Clark and Wells (1995). This model proposes that social anxiety is maintained by cognitive biases (i.e., negative automatic thinking and self-focused attention) that support the practice of safety or avoidance behaviors, so that the intervention is aimed at making the focus of attention more flexible in order to be able to invest in and be exposed to social situations and extract evidence from them that may help adjust one's own thoughts and social expectations. Based on a review of evidence of the presence of various components of this model also in adolescents, Leigh and Clark (2018) propose that it could be applicable to the understanding and intervention in SAD in adolescents, contributing to better therapeutic results. In fact, previous work supports the therapeutic effectiveness (Leigh et al., 2021; Leigh & Clark, 2016) and applicability of this approach in different contexts (Creswell et al., 2021; Leigh et al., 2021).

While cognitive therapy focuses on modifying the cognitive content elicited by self-focused attention during social events as a means of preventing safety and/or avoidance behaviors in these situations (Clark & Wells, 1995), third-generation therapies (i.e., Compassion-focused Therapy - CFT and Acceptance and Commitment Therapy - ACT) emphasize the modification of the way the person relates to these cognitive contents. CFT proposes that this relationship be based on a compassionate attitude, given that psychopathology is based on a relationship with one's own internal experiences that is excessively critical and punishing, also in children and adolescents (Carona et al., 2017). There is previous evidence pointing to the association between self-compassion and social anxiety in adults (Werner et al., 2012) and adolescents (Gill et al., 2012), as well as to the effectiveness of CFT for SAD in adults (Boersma al., 2018; Gharraee et al., 2018). As for ACTC, its application with adolescents is also conceived, assuming that psychopathology results from an avoidant relationship with ones' own negative internal experiences (Hallibturton & Cooper, 2015). Still, along with the scant evidence linking its core constructs (i.e., psychological flexibility) to social anxiety, research on the efficacy of this intervention for SAD is scarce, although pointing to promising results with adults (Dalrymple, & Herbert, 2007; Khoramnia et al., 2020; Ossman et al., 2006). The applicability of these therapies to SAD in adolescence remains to be elucidated.

In view of the above, evidence on the efficacy of the therapeutic offer for SAD in adolescence is still scarce. So, it is relevant to explore the therapeutic results of CT, CFT and ACT, as well as to explore the mechanisms by which each one enables change and with whom it can be most effective. Previous research has pointed to the importance of changing core constructs in the CBT intervention with adults with SAD (e.g., Santoft et al., 2019), but evidence regarding the therapeutic approaches under study is scarce. In addition, and considering the relevance of the intervention being adjusted to the characteristics of the person receiving the intervention (Beck et al., 2010), it is important to explore the moderators of therapeutic change, namely with regard to the severity of symptoms within what is proposed to be the main psychological vulnerability for each of the approaches under analysis.

The present work used a parallel clinical trial methodology (although different parallel conditions were collected sequentially over time) to assess the efficacy of three therapeutic approaches (i.e., CT, CFT and ACT) with adolescents with SAD, compared to a waiting list control group, and using four data collection times (i.e., pre-intervention/time 0, post-intervention/time 1, 12-weeks follow-up/time3, and 24-month follow-up/time 4). All participants included in the waiting-list control group were offered the opportunity to receive psychological intervention, after the waiting period. All procedures involved in this study (i.e., sampling, data collection to assess the efficacy of the intervention, and implementation of the intervention) were implemented after a positive position from the Ethics Committee of the institution hosting the investigation, authorization from the General Directorate of Education on the data collection protocol to be implemented, partnership with national secondary schools, authorization of legal guardians of adolescents, and consent of the adolescents themselves. Furthermore, this investigation complied with all applicable ethical and deontological requirements.