Abstract
This chapter presents the rationale and potential advantages of treating social anxiety disorder (SAD) in schools. School-based programs provide increased access to evidence-based treatment for youth in need, and interventions for SAD may benefit from delivery in an ecologically valid context in which many feared situations occur. Two interventions for adolescents with SAD designed specifically for school-based delivery, the original Intervención en Adolescentes con Fobia Social: Therapy for Adolescents with Social Phobia (IAFS; Garcia-Lopez (2000, 2007) and Skills for Academic and Social Success (SASS; Masia et al. 1999) are described. This chapter focuses on considerations and adaptations necessary for school-based interventions to fit into the school environment. We emphasize how such programs capitalize on the school environment to implement effective exposures and practice social skills. The chapter concludes with a discussion of the methods and challenges associated with the long-term sustainability of offering interventions in schools, including the use of existing school personnel to implement evidence-based interventions. Future directions of school-based interventions for youth with SAD are discussed.
Author Note
This work was supported by an NIMH grant awarded to Dr. Masia Warner, Grant R01MH081881.
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Social anxiety disorder (SAD) is the most impairing anxiety disorder among adolescents, impacting an estimated 9.1 % during their lifetime (Merikangas et al. 2010). The social discomfort and avoidance experienced by youngsters with SAD is associated with limited friendships, missed social opportunities (e.g., school clubs and sports teams), peer victimization (Garcia-Lopez et al. 2011; Ranta et al. 2013, 2009), and hardship executing class requirements (e.g., verbal presentations, class participation). These difficulties can lead to loneliness, academic difficulties, dysphoric mood, and an overall lower quality of life (Beidel et al. 1999; Grover et al. 2007; Katzelnick et al. 2001; Wittchen et al. 1999).
Given the high prevalence and impairment associated with SAD, several clinic-based efficacious psychological (Beidel et al. 1998; Heimberg and Becker 2002; Ledley et al. 2009) and pharmacological (Walkup et al. 2008) treatments have been developed and evaluated (see Chap. 9 by Guerry et al.). Yet, the majority of socially anxious adolescents remain unlikely to receive mental health services (Colognori et al. 2012; Kashdan and Herbert 2001; Wittchen et al. 1999). A large epidemiological study found that only 12 % of adolescents with SAD received treatment (Merikangas et al. 2010). Excepting substance use, this was the lowest rate of service utilization among psychiatric disorders in adolescents.
Unfortunately, this problem is indicative of a larger public health crisis regarding the failure to provide mental health services to affected youngsters. Common barriers to care include stigma, cost, and transportation. In addition, families are often unaware of where to seek treatment, and not surprisingly, fewer than 20 % obtaining services receive evidence-based intervention (Collins et al. 2004; Lim et al. 2012; Wahl 2012). Schools play a central role in addressing the unmet mental health needs of youth. Providing intervention within schools minimizes the considerable burdens associated with accessing treatment in the community. In a study of 2,488 ninth graders, students referred for school services were twice as likely to receive help as those referred to community providers (Husky et al. 2011). In addition, there is considerable evidence that school-based services enhance access for minority and economically disadvantaged youth (Angold et al. 2002; Catron et al. 1998; Juszczak et al. 2003; Kataoka et al. 2007). Clearly, the educational sector provides an avenue for reaching the majority of children in need of intervention.
Beyond these advantages, schools are uniquely poised to address challenges specific to treating SAD. First, worries about stigma (e.g., being labeled as having a “problem”) are likely magnified in socially anxious youth because of their severe sensitivity to negative evaluation. Thus, they may have heightened reluctance to disclose social difficulties. For example, Colognori and colleagues (2012) found that, of 270 adolescents reporting elevated social anxiety, 40 % had never informed an adult about their distress. Unlike externalizing disorders, which are clearly observable without self-disclosure, parents and school personnel often have difficulty identifying anxiety (Horwitz et al. 1998; Layne et al. 2006; Wren et al. 2003; Wu et al. 1999). In addition, even when key adults recognize that teenagers are extremely shy, their behaviors may be misunderstood as a personality style that does not require intervention. Schools can readily address these barriers to improve the recognition of SAD. For example, a brief SAD questionnaire could be added to routine school screenings, or students might be educated about anxiety in health classes and provided a chance to self-refer. (For more details on screening and assessment in SAD, refer to Chap. 6 by Garcia-Lopez, Salvador and De Los Reyes.) Further supporting identification, teachers and school counselors could receive training to enhance detection of more subtle avoidance behaviors.
In addition to facilitating increased recognition and referral, implementing intervention in schools affords opportunities to enrich treatment quality for SAD. For one, given that social evaluation fears are at the core of SAD, group treatment is particularly suitable and has been shown to be efficacious (Heimberg and Becker 2002). Supporting this notion, recent research has shown that, relative to other anxiety disorders in youth, SAD is less likely to respond to individual cognitive-behavioral therapy (CBT) (Ginsburg et al. 2011). Moreover, it is becoming increasingly accepted that social skills training may be necessary for maximal treatment benefits (Alfano et al. 2006; Kendall et al. 2012; Mesa et al. 2014). Learning new social skills is more feasible in a group format that includes peers for practicing skills and providing feedback. Whereas forming groups in clinics is challenging because of limited numbers of clients with similar diagnoses and varying schedules, schools are conducive to developing groups and routinely implement group programs. For these reasons, group interventions for SAD fit well into the school environment.
Finally, because many feared situations occur at school, school-based interventions provide an ecologically valid context for treatment. That is, implementing intervention at school affords opportunities to help adolescents enter into commonly avoided situations (e.g., eating in cafeteria, speaking with school personnel) and to practice skills in realistic contexts with a variety of individuals (e.g., teacher, coach). Thus, intervention delivered in school blends the treatment setting with the natural environment, which may improve the effectiveness of existing empirically based clinic treatments.
Based on the potential advantages of delivering treatment for SAD within the school environment, two interventions for adolescents have been specifically designed for school-based implementation and evaluated in schools. These include a program developed in Spain, the original Intervención en Adolescentes con Fobia Social: Therapy for Adolescents with Social Phobia (IAFS; Garcia-Lopez 2000, 2007), and one in the United States, Skills for Academic and Social Success (SASS; Masia et al. 1999). Both IAFS and SASS were developed from empirically supported, clinic-based treatments. IAFS was adapted from the adolescent Spanish version (SET-Asv; Olivares et al. 1998) of Social Effectiveness Therapy (SET; Turner et al. 1994 ) and Cognitive-Behavioral Group Therapy for Adolescents (CBGT-A; Albano et al. 1991). SASS was primarily based on the child format of SET (SET-C; Beidel et al. 2000), which emphasizes behavioral exposure and social skills training. A full description of these clinic-based treatments and their empirical support can be found in Chap. 13.
Considerations in Conducting School-Based Interventions for SAD in Adolescents
Due to the complexity of disseminating evidence-based treatments to community settings, several implementation frameworks have been developed (see Damschroder et al. 2009; Fixsen et al. 2005; Han and Weiss 2005; Meyers et al. 2012), all of which highlight the importance of ensuring fit between the intervention and the setting. SET-Asv, SET-C, and CBGT-A are intensive treatments, consisting of numerous sessions of long duration. For example, SET-C involves 24 sessions lasting 90 min each (12 social skills groups followed by planned social activities and 12 individual exposure sessions). Therefore, adapting clinic-based treatments to fit into the school environment required extensive changes.
Addressing School Priorities
When adapting a clinic-based intervention for the school setting, modifications are necessary to improve the program’s acceptability to school administrators and staff. Naturally, the top priorities for schools are academic instruction and student performance. Although school personnel understand the potential benefit of addressing SAD, they are concerned about the loss of instructional time associated with implementing the intervention. In order to address this, the potential benefits of each session must be carefully weighed against the cost of lost instructional time. Minimizing individual sessions may be one valuable approach. Consistent with this, SASS contains only two brief individual meetings, and weekly individual sessions in IAFS are optional. Instead, SASS and IAFS rely primarily on a group format because of its clinical relevance for treating SAD and routine use in schools (e.g., clubs, drug prevention, peer leadership; Foster et al. 2005; Kelly and Lueck 2011). In addition, it is helpful for the length of school-based interventions to fit within one academic semester without excessive class absences. Accordingly, length of the original IAFS is 12, 90-min group sessions that are scheduled using one school hour (60 min) and a break period (30 min). SASS includes 12 group meetings shortened to fit within one academic period or approximately 40 min. To avoid repeated disruption of any single academic subject, SASS group times (e.g., class periods) are rotated so that students never miss the same class more than twice throughout the program.
To further address the schools’ main objectives, it is essential that school-based programs explicitly target social avoidance that interferes with academic performance or engagement in the school community. The original IAFS contains a social skills module using unknown peers to practice initiating and maintaining conversations with same and opposite-sex teenagers. IAFS also has an intensive focus on public speaking, a skill essential to school performance. Similarly, SASS emphasizes improving skills such as participating in class, asking teachers for help, joining school activities, and speaking to school personnel such as principals, teachers, and counselors. In addition, school personnel are enlisted to assist students as they practice skills, and thus they readily observe treatment effects. Clearly, these situations are central to treating SAD, but targeting them directly in schools has the added benefit of facilitating collaboration and support from school administrators and personnel.
Delivery of the Intervention by School Personnel
Schools are more likely to adopt interventions that benefit their students and can be implemented and sustained utilizing the schools’ existing resources (Atkins et al. 2003; Shediac-Rizkallah and Bone 1998). In the United States, frontline school practitioners (e.g., school psychologists and social workers) and school guidance counselors are key providers of services for youth (Lyon et al. 2011a, b; Ryan and Masia Warner 2012). In addition, school counselors’ familiarity with the student population, school culture, and available school resources may enable them to easily relate to the students, anticipate concerns, and use the school environment effectively to optimize treatment gains. Therefore, our aim for SASS was to develop an intervention that could be feasibly delivered by school counselors. A group format was considered more viable for school counselors given their time burdens. In addition, the SASS manual was written to accommodate individuals without specialized training in CBT. Specifically, we used nontechnical language whenever possible and included detailed session scripts, as well as session outlines and checklists to help with executing groups and prioritizing session tasks.
Capitalizing on the School Environment
Given the severe reduction in treatment dose necessary to facilitate school delivery, SASS and IAFS aim to enhance their clinical impact by capitalizing on the natural advantages of treating SAD in the school community, namely, increased accessibility to parents and school peers (Ryan and Masia Warner 2012). SASS involves parents by holding two parent meetings at school. Garcia-Lopez et al. (2014) have developed a parent module, Intervención en Familias & Adolescentes con Fobia Social; Therapy for Families and Adolescents with Social Phobia (IFAFS; Garcia-Lopez et al. 2011b), to accompany the IAFS school-based treatment. In addition, both programs utilize school peers to assist with the implementation of exposures, and peer assistants also attend SASS social events with group members in the community. Finally, school-based exposures are designed to take advantage of the school context by utilizing real-life school situations (e.g., meeting with a teacher for clarification of academic material, approaching a peer in the library or cafeteria).
Developmental Adaptations for Adolescents
To create interventions appropriate for adolescents in schools, modifications to the core skills were required. Given that negative self-talk is more frequent among teenagers than children with SAD (Alfano et al. 2006), both IAFS and SASS added cognitive restructuring or realistic thinking. In addition, the social skills curriculum was adapted to include more advanced content (e.g., extending invitations, assertiveness) and include typical adolescent social challenges at school (e.g., joining a group in the school cafeteria).
Several of the considerations that have been discussed clearly shaped the development and implementation of the school-based programs for SAD. In the next section of this chapter, we describe IAFS and SASS and their treatment outcome data.
Evidence-Based School Interventions for SAD
Intervención en Adolescentes con Fobia Social: Therapy for Adolescents with Social Phobia (IAFS)
The original IAFS (Garcia-Lopez 2000, 2007) consists of 12 weekly group sessions, each 90 min in length in approximately 4 months (due to vacations and exams). Groups vary from 4 people to 8 people. Techniques include psychoeducation, self-esteem bibliotherapy, cognitive restructuring, social skills, exposure, and relapse prevention. During group sessions, exposures are carried out utilizing unknown school peers as co-therapists who interact with the participants. Targeted social situations include beginning and maintaining conversations with persons of the same or opposite sex and speaking in public in front of group members and therapists. A feature unique to IAFS is that exposure tasks are video recorded. Video feedback is then used to help students learn from exposures, detect safety behaviors, and establish a more realistic self-image. Participants and other group members provide feedback on speeches that is compared with students’ objective performance from video recordings. Along with group sessions, weekly individual counseling sessions are offered in which a range of issues can be discussed. These optional individual meetings can be used to prepare exposure practice or review concepts presented during group sessions.
Evaluating IAFS
The original IAFS (Garcia-Lopez 2000, 2007) has been compared to the Spanish translations of two efficacious clinic-based treatments for SAD, SET-Asv (Olivares et al. 1998), and CBGT-A (Albano et al. 1991). Fifty-nine adolescents (mean age = 15.92, range 15–17 years) with a diagnosis of SAD received IAFS (n = 15), CBGT-A (n = 15), or SET-Asv (n = 14). Treatment groups were compared to a no-treatment control (n = 15) that included a random sample of students who refused intervention. The program was conducted during the school day by two therapists with a minimum of 2 years’ experience who received supervision by a licensed psychologist.
Immediately following intervention, results showed superiority of all treatments relative to the no-treatment control. Students who received intervention reported decreased social anxiety and avoidance, reduced fear of public speaking, improved self-esteem, and a decrease in the number of feared social situations. Clinical improvements were largely maintained one year following treatment completion, with some possible advantages to IAFS on outcomes pertaining to social avoidance using self-reports (Olivares et al. 2002) and Corpus Linguistics methodology (Garcia-Lopez et al. 2011a). Effect sizes were large for all interventions compared to the no-treatment control immediately after treatment at one year follow-up. (Garcia-Lopez et al. 2002). To understand long-term impact, Garcia-Lopez and colleagues (2006) also conducted a 5-year follow-up of 25 participants who had received an active treatment in the initial study (n = 44). Although the study had a modest sample size, results demonstrated that treatment gains were maintained equally across interventions over 5 years. Clinical and effect size significance suggest the possibility of IAFS may have more robust long-term durability (see Garcia-Lopez et al. 2006).
In a second trial, Garcia-Lopez and colleagues (2014) evaluated the clinical benefits of including parents in the treatment of adolescents with SAD. The original IAFS was compared with IAFS plus a parent module (IFAFS) (Garcia-Lopez et al. 2011b) in a sample of 52 families. IFAFS consists of five, two-hour group sessions for parents that target expressed emotion (EE), as a previous study revealed that high EE is associated with less positive treatment outcomes in adolescents with social phobia (Garcia-Lopez et al. 2009). Parent sessions include psychoeducation about SAD and the role of expressed emotion in their children’s symptomatology, communication skills to replace the use of rejection, criticism and hostile verbal comments, and contingency management training aimed at teaching strategies to better manage children’s SAD. Parent sessions were conducted by two clinical psychologists with extensive experience in parent training. Adolescents aged 14–18 years (mean age = 15.92) with parents exhibiting high EE were randomly assigned to either IAFS (n = 32) or IAFS plus IFAFS (n = 20). Findings revealed that adding a parent component to IAFS enhanced its clinical benefits and may be a promising approach for treating adolescents with SAD if parents exhibit high levels of EE. Taken together, these trials support the efficacy of IFAFS when delivered by trained psychologists in the school setting.
Skills for Academic and Social Success (SASS)
The SASS intervention (Masia et al. 1999) consists of 12 weekly group sessions, two group booster sessions, and two brief individual meetings. Additionally, four weekend social events that include prosocial peers, called peer assistants, provide real-world exposures and skills generalization. Parents attend two group meetings during which they receive psychoeducation regarding SAD and learn techniques to address their child’s anxiety. Teachers can participate in two optional meetings in which they learn about SAD and the program and receive instruction to help students practice classroom exposures. The program is designed to be flexible to accommodate the school calendar (e.g., vacations and exams) and typically spans about 3 months. Treatment groups are small (4–6 students) and can be facilitated by one or two group leaders. Each SASS component is discussed in the sections that follow, with an emphasis on how to capitalize on the school environment to implement and practice skills.
School Group Sessions
The 12 groups last one class period or about 40 min. They cover five core components: (a) psychoeducation, (b) realistic thinking, (c) social skills training, (d) exposure, and (e) relapse prevention.
Psychoeducation
The first group informs students about the structure of the program and provides an overview of the cognitive-behavioral model of SAD. Given socially anxious adolescents’ heightened social evaluative concerns coupled with specific worries about attending a group with classmates that is run by a school counselor, considerable time is dedicated to confidentiality.
Realistic Thinking
The second group session focuses on realistic thinking, primarily adapted from Ronald Rapee’s (1998) book Overcoming Shyness and Social Phobia. Students are taught to identify negative expectations (e.g., I will sound boring) and to use specific questions to evaluate them more realistically (e.g., How many times has this happened in the past? How do I feel when I see others in similar situations?). Engaging in this process with school peers can be valuable because students’ negative predictions are often related to school situations that they may have in common (e.g., certain teachers or coaches). These strategies of identifying and challenging thoughts are practiced and revisited throughout the program.
Social Skills Training
Compared to 12 social skills sessions in SET-C, SASS contains four. Of the 12, we chose four skills we considered most essential for enhancing adolescent social experiences including: (a) initiating conversations, (b) maintaining conversations and establishing friendships, (c) listening and remembering, and (d) assertiveness. In the initiating conversations session, students learn how to identify opportunities for interactions and tips for starting a conversation (e.g., comment on something you have in common or on something going on around you). Conducting these groups in schools with school peers often creates natural opportunities for conversation starters about well-known eccentric teachers, cafeteria food, or frustrating locker assignments. In the second skills group, students are taught strategies to sustain conversations as well as how to appropriately switch topics. This session also teaches group members how to invite peers to get together outside of school (e.g., to go to a movie, hang out). Group members often express interfering beliefs about the need to know peers very well before an invitation is considered acceptable. Having other teenagers challenge these assumptions can be valuable in providing more realistic socially acceptable norms. In addition, it is valuable to have other group members generate ideas for extending social invitations that are relevant to their school culture (e.g., school performances, sporting events).
The third skills session is listening and remembering. Some of the difficulty that socially anxious individuals have maintaining conversations is due to limitations in fully attending to the conversation at hand. Such impairment may be partially related to worries about what to say next or evaluative concerns (e.g., I will sound boring). This session trains students to fully engage in conversations by attending to what others are saying and how to use this information to maintain conversations. The final social skills session focuses on how to be assertive with others. Working on these behaviors at school can be particularly potent because relevant situations often arise in the school environment. For example, we may facilitate having students speak with teachers about various classroom difficulties (e.g., getting an unfair grade). Group members may also be asked to make complaints about school policies or schedules to school administrators or staff. Finally, group participants often support each other and problem-solve typical school incidents such as other students requesting to copy homework or cheat on an exam. These are just a few of the examples that make integrating this treatment into the school setting so compelling.
There are a few specific recommendations for teaching social skills to socially anxious teenagers. First, shy students often look unfriendly or unapproachable because of their nonverbal behaviors (e.g., tense expressions, avoidance of eye contact). Therefore, all skills groups focus on shaping and reinforcing behaviors consistent with appearing friendly and confident (e.g., engaged and relaxed body positioning, smiling). The majority of session time should be dedicated to helping students incorporate constructive feedback such as speaking louder or smiling and role-playing the skill repeatedly until improvement is observed. In addition, because socially anxious individuals often depend on a single way to initiate conversations (e.g., commenting on the weather), we attempt to train conversational flexibility. Through repeated practice, students are asked to generate different statements in similar situations. Other group members are encouraged to offer alternatives.
Facing Your Fears
Whereas SET-C contains 12 individual, 90-min exposures, SASS was reduced to five group exposure sessions, referred to as facing-your-fear sessions. Given the personalized nature of fear hierarchies, we recommend that they be completed during an individual session (see below). Hierarchies should include some exposure situations that can be readily executed in the school environment. Students are often sent to public areas (e.g., cafeteria, library) to interact with peers or school staff. For example, they may ask a teacher for help or make school announcements on the loudspeaker. In addition, the school auditorium can be used for students to practice speeches with school personnel attending as an audience. Students may also practice intentionally dropping their books in a crowded hallway or entering a classroom late. Conducting exposure within various parts of the school environment also reduces typical resistance, because leaders are available to provide real-time coaching and immediate feedback. In addition, performing realistic tasks in the school environment can produce natural positive consequences (e.g., a student is invited to sit with a peer in the library after initiating a conversation) that may result in more immediate gains and generalization of treatment effects.
Relapse Prevention
The final group is designed to help students consolidate gains and create a realistic plan for continuing progress. Each group member gives a speech about his or her experience in the program, which serves as an exposure exercise and termination activity.
Booster Sessions
Two group booster sessions occur monthly for 2 months after termination. The purpose is to monitor progress, discuss barriers to continued improvement, and highlight additional ways to strengthen peer relationships and engagement in social activities. Additional exposures can also be conducted during boosters.
Social Events
SASS includes four 90-min social events, reduced from 12 in SET-C, that are held on weekends in community settings. Group leaders, participants, and peer assistants from the students’ schools (see next section) attend these events. Activities include bowling, a picnic, laser tag, board games, billiards, miniature golf, rollerblading, ceramics, cooking, and rock climbing. These events provide unique benefits because they offer opportunities to partake in social activities without close friends, practice conversational skills, and perform in front of others. We also use these events to challenge students to take risks in a safer social environment, such as ordering food for the group or asking to be on a peer’s team. In planning social events, we start with structured activities such as bowling and progress to unstructured ones (e.g., a pizza party) that require more self-reliance to engage with others.
Peer Assistants
Similar to SET-C, prosocial peers are recruited to attend the social events with group participants. The SASS program benefits from the ability to enroll school peers to assist with social events. The primary role of peer assistants is to create a positive climate at social events by engaging group members in conversation and integrating reluctant participants into activities. In addition, peer assistants may help encourage resistant students to attend the initial social event by coordinating arrival times. However, because peer assistants are in the same schools as program participants, careful selection is essential. The optimal strategy is to use students who have previously completed the SASS program because they are sensitive to the concerns of group members. When this method is not feasible, we recommend asking school counselors for nominations of good-natured, mature, and friendly students.
Individual Sessions
SASS includes two brief individual sessions about 20 min in length. Often the first meeting is used to develop an individualized fear hierarchy. These meetings also allow for tailored cognitive restructuring, review of specific social skills, or individual exposures. Finally, group leaders try to better understand personal issues that may be interfering with group participation or program progress.
Parent Meetings
Two meetings were added to SASS to provide parents with psychoeducation about SAD, orient them to the program, and offer strategies to support their child’s participation and progress. The first parent meeting occurs within the first 3 weeks of SASS. Group leaders provide psychoeducation about SAD and information about the rationale and structure of the program. Presenting SASS as a way to prevent long-term difficulties such as transitioning to college can increase buy-in from parents. The second meeting is more directive, highlighting common yet unhelpful parental reactions to children’s anxiety and providing suggestions for more constructive strategies (Rapee et al. 2008). Parents are encouraged to foster their children’s autonomy and self-efficacy by supporting them to approach anxiety-provoking situations.
Evaluating SASS
SASS was first evaluated in an open pilot study to demonstrate the feasibility of conducting the program in schools (Masia et al. 2001). Based on its potential benefits, this pilot work was followed by two randomized controlled trials evaluating the efficacy of SASS for adolescents, ages 13–17, with SAD. The first study (n = 35) comparing SASS to a waiting list demonstrated that SASS was superior in reducing the rate and severity of SAD and enhancing functioning as noted by blinded evaluator, as well as parent and adolescent ratings (Masia Warner et al. 2005). To test the specific efficacy of SASS, a second trial (n = 36) compared SASS to a credible control that omitted its core components (e.g., social skills training, exposure) but was matched in its overall structure including four social events without peer assistants. The attention control consisted of psychoeducation about SAD, relaxation, and support. Immediately after treatment, only 7 % in the attention control versus 82 % of participants in SASS were rated as treatment responders by blind independent evaluators. In addition, 59 % of the SASS group no longer had a diagnosis of SAD relative to 0 % of the control. SASS was also superior to the attention control 6 months following the end of the program (Masia Warner et al. 2007).
Findings of both studies support the efficacy of SASS when delivered by clinical psychologists with training in CBT. As described above, other studies of school-based intervention for SAD have shown positive effects when implemented by research psychologists (Garcia-Lopez et al. 2002; Olivares et al. 2002). This work has been important in enhancing access to evidence-based treatments and demonstrating effectiveness in community settings. However, reliance on specialized psychologists to implement interventions in schools will ultimately limit wide-scale dissemination and implementation. To achieve sustainable school-based programs, responsibility must be transferred to school personnel. However, it is uncertain whether treatment delivery by community providers will be effective.
To this aim, studies have evaluated whether school-based providers (e.g., social workers, counselors) can effectively implement evidence-based interventions for various anxiety disorders (e.g., Ginsburg et al. 2008; Rapee 2000). Specific to SAD, a recent Canadian study by Miller and colleagues (2011) trained teachers and adolescent peer counselors to conduct SASS with 27 socially anxious high school students who were nominated by school personnel or self-referred. Students showed a reduction in anxiety and depression symptoms as well as behavioral avoidance following SASS. Masia Warner and colleagues (2014) recently completed a randomized controlled trial of 136 adolescents with SAD that compared SASS delivered by school counselors to SASS delivered by psychologists and to a nonspecific school counseling program (NIMH R01MH081881). Preliminary results reveal that students receiving SASS led by school counselors or specialized psychologists, relative to those who participated in the nonspecific intervention, showed significant reductions in SAD severity and higher rates of treatment response (Masia Warner et al. 2014). Based on this limited research, the approach of training school-based providers appears promising but raises questions about the types of delivery models that will support competent treatment implementation in schools.
Future Directions
School-based intervention has been shown to be an effective approach for treating SAD in adolescents in several countries. However, a main challenge to the success of school-based treatments is their sustainability following the removal of external support from highly specialized psychologists or grant funding. Thus, the next crucial step for our field is to obtain a better understanding of how to support competent implementation of school-based interventions utilizing resources that already exist within schools. Identifying feasible solutions will likely vary by country based on societal values, differing school structures, and availability and educational backgrounds of various school professionals. The Canadian study (Miller et al. 2011), for example, used teachers and adolescent peers to implement the SASS program, while the American trial (Masia Warner et al. 2014) used school counselors. From our perspective, it would be challenging to convince school administrators in the United States to permit teachers to devote resources to implementing a program like SASS, given the current political climate that evaluates schools based on students’ achievement on national standardized tests. When selecting appropriate school personnel to deliver an intervention, it is important to consider competing demands that will take priority over mental health programming. Schools that can commit to protecting identified personnel’s time for providing socio-emotional programming like SASS or IAFS, and possibly reducing administrative (e.g., making student schedules) or other nonessential responsibilities, will likely have greater success in long-term sustainability of these interventions.
Central to supporting services provided by existing school personnel will be gaining a clearer understanding of the training and consultation strategies required to promote robust program quality, although strategies may vary based on the diverse backgrounds and roles of school professionals identified as potential implementers. Overall, previous efforts to train community-based clinicians have shown that providing manuals, expert workshops, or Web-based training improves therapists’ attitudes and knowledge but has minimal impact on actual skill (Beidas et al. 2009; Chagnon et al. 2007; Dimeff et al. 2009; Sholomskas and Carroll 2006). For skill acquisition, ongoing feedback and coaching is essential (Mannix et al. 2006; Miller et al. 2004; Sholomskas et al. 2005). Han and Weiss (2005) suggest a rigorous consultation model to promote high-quality implementation skills that include (1) direct observation of implementation, (2) feedback and partnering on resolving issues, (3) modeling of program techniques, and (4) attending to student improvements and connecting them to program use. Our previously mentioned controlled trial of SASS implemented by school counselors (Masia Warner et al. 2014) was among the initial attempts to train school personnel to independently conduct a specialized treatment; therefore, we developed a comprehensive training and consultation approach consistent with Han and Weiss’ (2005) recommendations. SASS training consisted of (1) receipt of a treatment manual, (2) attendance at a five-hour interactive workshop coled by the treatment developer and a postdoctoral level psychologist, and (3) coleading a twelve-session SASS training group with a CBT-trained postdoctoral fellow with ongoing performance feedback. This initial training was followed by independent implementation of the SASS program with weekly individual consultation for one school period (40 min). While this training and consultation model yielded promising results (Masia Warner et al. 2014), it may be too resource intensive to be sustainable and cost-effective in the long term. On the other hand, this model may be necessary for school personnel who tend to have minimal mental health training, such as teachers. The field is in its infancy regarding how to support and sustain high-quality implementation of evidence-based interventions by school providers and would benefit from further research in this area across countries and cultures.
Another avenue for identifying feasible methods of training frontline school professionals involves evidence-based decision making about the program content and quality of implementation necessary to produce positive student outcomes. Most SAD interventions contain multiple treatment components (e.g., cognitive reappraisal, exposure, multiple social skills), yet we have not examined which of these are essential. Identifying active ingredients will inform which strategies should receive emphasis when training school personnel. This approach would also likely reduce program length by eliminating time spent on nonessential skills, an advancement that would further enhance intervention fit with the school environment. Information is also lacking regarding what level of treatment quality is sufficient to produce positive student outcomes. Examining links between treatment elements, program quality, and clinical outcomes will help determine critical treatment features and priorities for training (Masia Warner et al. 2013). Such research advances have the potential to result in more empirically informed approaches to training and consultation that may be effective, yet less labor intensive.
Finally, we must address methods to support the maintenance of skills over time as well as ways to train new school personnel. One option may be a “train the trainer” or pyramid model (Demchak and Browder 1990), in which one school personnel would be intensively trained to deliver the intervention and then provide training and consultation to his or her colleagues. Other variations might include initial training by experts followed by on-site consultation by school personnel with program experience or peer group supervision. Maintaining support for the program and protecting against turnover of trained staff may also be strengthened by the development of Learning Collaboratives (Cohen and Mannarino 2008). Such learning collaboratives would consist of trained school personnel across school districts with the goal of supporting training and supervisory capabilities as well as the viability and effectiveness of the program.
Conclusion
SAD is highly prevalent and impairing in adolescents, yet severely undertreated. Schools play an important role in addressing the unmet mental health needs of socially anxious youth. School-based intervention may be particularly beneficial to adolescents with SAD because the school environment supports a group modality and provides a rich context for practicing skills and conducting exposures. Based on these positive features, two SAD interventions (IAFS and SASS) have been specifically designed for the school setting and have demonstrated effectiveness when implemented by specialized psychologists. SASS has also shown to be effective when delivered by school counselors with rigorous training and consultation. This approach appears promising, yet we know little about the type of training and consultation necessary to sustain high-quality treatment delivery by school-based providers with varying educational background and resources. A better understanding of crucial intervention ingredients, as well as streamlining program content, should allow for more efficient procedures such as training school providers intensively in fewer core techniques. These strategies may be a better fit for the time constraints of the educational sector while still promoting quality delivery of efficacious interventions by school personnel to the many youngsters in need of services.
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Warner, C.M., Colognori, D., Brice, C., Sanchez, A. (2015). School-Based Interventions for Adolescents with Social Anxiety Disorder. In: Ranta, K., La Greca, A., Garcia-Lopez, LJ., Marttunen, M. (eds) Social Anxiety and Phobia in Adolescents. Springer, Cham. https://doi.org/10.1007/978-3-319-16703-9_12
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