Sie sind auf Seite 1von 16

Journal of Abnormal Child Psychology, Vol. 33, No. 6, December 2005, pp.

707–722 (
C 2005)

DOI: 10.1007/s10802-005-7649-z

School-Based Intervention for Adolescents with Social

Anxiety Disorder: Results of a Controlled Study

Carrie Masia-Warner,1,4 Rachel G. Klein,1 Heather C. Dent,2 Paige H. Fisher,1

Jose Alvir,1 Anne Marie Albano,1 and Mary Guardino3

Received June 18, 2003; revision received July 19, 2004; accepted August 15, 2004

Social anxiety disorder, whose onset peaks in adolescence, is associated with significant impairment.
Despite the availability of effective treatments, few affected youth receive services. Transporting
interventions into schools may circumvent barriers to treatment. The efficacy of a school-based
intervention for social anxiety disorder was examined in a randomized wait-list control trial of 35
adolescents (26 females). Independent evaluators, blind to treatment condition, evaluated partici-
pants at preintervention, postintervention, and 9 months later. Adolescents in the intervention group
demonstrated significantly greater reductions than controls in social anxiety and avoidance, as well as
significantly improved overall functioning. In addition, 67% of treated subjects, compared to 6% of
wait-list participants, no longer met criteria for social phobia following treatment. Findings support
the possible efficacy of school-based intervention for facilitating access to treatment for socially
anxious adolescents.

KEY WORDS: social anxiety; adolescents; school intervention; behavior therapy.

Social anxiety disorder, whose onset peaks in ado- 1985; Pine, Cohen, Gurley, Brook, & Ma, 1998; Schneier,
lescence, is associated with significant impairment (e.g., Johnson, Hornig, Liebowitz, & Weissman, 1992; Turner,
few friends, loneliness, depressed mood, disturbances in Beidel, Dancu, & Keys, 1986; Wittchen et al., 1999).
school performance, difficulty with interpersonal relation- Recognition of the significance of social phobia in
ships) (Albano, 1995; Beidel, Turner, & Morris, 1999; youth has led to the development of three clinic-based
Wittchen, Stein, & Kessler, 1999). Epidemiological re- treatments designed specifically for children and adoles-
search suggests that social phobia in youth is common cents. Spence (1995) developed Social Skills Training:
(see Klein & Pine, 2002). Prevalence rates are particularly Enhancing Social Competence in Children and Adoles-
high for adolescents, ranging from 4 to 9% (Verhulst, van cents (SST), a program emphasizing social skills training
der Ende, Ferdinand, & Kasius, 1997; Wittchen et al., and exposures, but also including problem-solving, cog-
1999). Studies of social phobia in clinical and epidemio- nitive restructuring, and relaxation techniques. The 12-
logical samples have found stability into adulthood, and week program consists of weekly hour-long group ses-
suggest that social phobia may contribute to increased sions, followed by a 30-min practice of learned social
risk for suicide attempts, alcohol use, inability to work, skills in a simulated environment. In a trial evaluating
depression, and severe social restrictions (Essau, Conradt, SST, clinic children, ages 7–14, were assigned to either
& Petermann, 1999; Liebowitz, Gorman, Fryer, & Klein, child-focused SST (n = 19), SST plus parent involvement
(n = 17), or a waiting list (n = 14) (Spence, Donovan,
1 New York University Child Study Center, NYU School of Medicine, & Brechman-Toussaint, 2000). At posttreatment, signif-
New York. icantly more children who received SST alone, or SST
2 Psychology Department, University of Denver, Denver, Colorado.
3 Freedom from Fear, Staten Island, New York.
with parent involvement, no longer met diagnostic cri-
4 Address all correspondence to Carrie Masia-Warner, NYU Child Study teria for social phobia compared to the wait-list con-
Center, 215 Lexington Avenue, 13th floor, New York 10016; e-mail: trol group (WLC), 58%, 87.5%, and 7%, respectively. In addition, compared to the WLC, both treatment groups

C 2005 Springer Science+Business Media, Inc.
708 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

demonstrated significantly greater reductions in children’s ing to the Surgeon General’s 1999 report on mental health,
self-reports of social and general anxiety and increases 6–9 million youngsters with emotional problems are not
in parent reports of their children’s social skills. Both receiving the help they require (U.S. Department of Health
treatment groups maintained relative gains at 12-month and Human Services, 1999). There is growing recognition
follow-up. Outcomes for SST treatment with and without that community mental health centers and other standard
parent involvement did not differ significantly at any point. sites for service delivery are insufficient for ameliorat-
Social Effectiveness Therapy for Children (SET-C: ing this situation (Weist, 1999). Waiting lists are often
Beidel, Turner, & Morris, 1998) is a 12-week treatment, long, no-show and drop-out rates are high, youngsters are
designed for children ages 8–12, that consists of 24 ses- often reluctant to receive services in these settings, and
sions focused on behavioral exposure and social skills research has failed to support the effectiveness of com-
training. Two sessions, an individual exposure session and munity treatment (Weist, 1999; Weisz, Donenberg, Han,
a social skills training group, are conducted weekly. So- & Weiss, 1995).
cial skills groups are followed by peer generalization so- The failure to provide treatment to youth represents
cial activities with outgoing, unfamiliar peers. Beidel and a major public health concern. Incorporating effective
colleagues (Beidel, Turner, & Morris, 2000) compared interventions into schools may help to circumvent this
SET-C, to a control intervention, Testbusters, a program problem. In fact, the majority of the small percentage of
that includes study-skills and test-taking strategies but children who do obtain services, receive them at school
does not address social anxiety. Children in the SET-C (Burns et al., 1995; Burns & Hoagwood, 2002; Farmer,
program (n = 30), compared to those in the control group Stangl, Burns, Costello, & Angold, 1999; Hoagwood &
(n = 20), demonstrated significant decreases in symp- Erwin, 1997; Leaf et al., 1996; Staghezza-Jaramillo, Bird,
toms and improved functioning. In addition, 67% of the Gould, & Canino, 1995). Consistent with this finding, the
SET-C treated group no longer met diagnostic criteria for U.S. Surgeon General’s report designates schools as a
social phobia compared to only 5% of the control group. key setting for identifying and addressing mental health
Treatment gains were maintained at 6-month follow-up. concerns in youth (U.S. Department of Health and Human
These treatment differences are particularly impressive Services, 1999).
given the contrast with an attention rather than a wait-list This proposed solution for increasing healthcare ac-
control. cess is based on several observations. First, schools pro-
A more cognitively oriented approach to treatment, vide unparalleled access to youth (Adelman & Taylor,
Cognitive-Behavioral Group Therapy for Adolescents 1999; Weist, 1997), and therefore, represent a single loca-
(CGBT-A: Albano, Marten, Holt, Heimberg, & Barlow, tion through which the majority can be reached (Anglin,
1995), consists of 16, 90-min group sessions that in- 2003). Second, school programs reduce barriers to treat-
clude psychoeducation, cognitive restructuring, problem- ment such as cost and transportation (Catron, Harris, &
solving, social skills, and behavioral exposure. A con- Weiss, 1998). In a study of children with depressive and
trolled study of socially phobic adolescent girls compared disruptive disorders (Wu et al., 1999), children’s use of
CBGT-A to a wait-list control group (Hayward et al., school-based services, compared to community mental
2000). Significant reductions in clinician-rated interfer- health services, was less influenced by demographic and
ence scores were obtained in the CBGT-A group (n = 11) parental factors, indicating that the school setting may
compared with the wait-list control (n = 22). At posttreat- offer opportunities that would not be otherwise available.
ment, 45% of the treated group no longer met criteria for Third, schools provide increased opportunity for preven-
social phobia compared to 5% of the untreated group. tion and early identification and intervention, which may
The treated group reported significantly decreased social prevent the development of serious secondary dysfunction
phobia symptoms on the Social Phobia and Anxiety In- (Weist, 1999).
ventory, but their scores were still in the clinical range. At In addition, children and families may avoid seek-
1-year follow-up, groups no longer differed. ing help partly due to the stigma associated with mental
Despite the availability of promising clinic-based health treatment. Offering services in a familiar setting
programs, socially anxious adolescents are rarely referred like schools may make treatment more acceptable (Catron
(Kashdan & Herbert, 2001) and are unlikely to receive & Weiss, 1994; Weist, 1999) since many children already
treatment (Essau et al., 1999; Wittchen et al., 1999). This receive school-based services for nonmental health con-
problem is consistent with a larger literature document- cerns. This is especially important for adolescents, who
ing a considerable gap between youth who are in need are reluctant to seek help and are an underserved pop-
of treatment and those who actually receive any mental ulation (Laitinen-Krispijn, van der Ende, Wierdsma, &
healthcare (Burns et al., 1995; Leaf et al., 1996). Accord- Verhulst, 1999; Verhulst & van der Ende, 1997), perhaps
School-Based Intervention for Social Anxiety 709

because of age-related worries about stigma or being la- atic evaluation and their effectiveness is largely unknown
beled abnormal (HoganBruen, Clauss-Ehlers, Nelson, & (Adelman & Taylor, 1998; Hoagwood & Erwin, 1997;
Faenza, 2003). Leff, Power, Manz, Costigan, & Nabors, 2001; Power,
Moreover, partnering with schools creates opportu- Manz, & Leff, 2003; Rones & Hoagwood, 2000). A recent
nities to educate and support school personnel and parents review of research on school-based mental health services
in identifying mental health issues and making appropri- found that only 47 of 337 published program evaluations
ate referrals for treatment. This is particularly relevant for used adequate designs for testing effectiveness. Some pos-
social anxiety for several reasons: (1) students with so- itive effects were found for programs addressing depres-
cial anxiety are often overlooked, most likely due to their sion, conduct and emotional problems, and substance use
quiet, compliant manner, (2) it is common for adults to (see Rones and Hoagwood, 2000 for a review). Over-
underestimate the adversity associated with problems ex- all, however, few studies target specific psychiatric disor-
perienced by socially anxious youth, and (3) few teachers ders, utilize methodological controls, or implement well-
and parents believe that social anxiety requires treatment articulated interventions and standard outcome measures
even when they recognize extreme shyness or nervous- (Hoagwood & Erwin, 1997). In addition, no scientifically
ness (Masia, Klein, Storch, & Corda, 2001; Pandey et al., rigorous studies of school-based prevention or interven-
2003), and they expect that youngsters will “grow out” tion programs for anxiety were found. Since anxiety dis-
of their anxiety (HoganBruen et al., 2003). In addition, orders are among the most common mental disorders in
parents frequently consult teachers about their children’s children and adolescents (Costello & Angold, 1995; Klein
problems (Cohen, Kasen, Brook, & Struening, 1991), & Pine, 2002), and are associated with school absence
and teachers’ opinions of the need for treatment have a and refusal, controlled studies of school-based treatment
major impact on referral decisions (Angold et al., 1998; for anxiety disorders are especially important (Rones &
Costello & Janiszewski, 1990; Hoberman, 1992; Tarico, Hoagwood, 2000).
Low, Trupin, & Forsyth-Stephens, 1989; Wu et al., 1999; Considering the growing evidence supporting child
Zahner & Daskalakis, 1997). Therefore, it is likely that mental health treatments tested in university research set-
educating teachers and parents about the symptoms of tings (Weisz et al., 1995; Weisz, Weiss, & Donenberg,
social anxiety disorder and its associated impairment will 1992), as well as concern over access to services and poor
enhance recognition of this disorder in youth. outcomes experienced by youth with mental disorders, the
Finally, treatment implemented within schools al- Surgeon General has called for increased development and
lows for real-world interventions. It provides opportuni- proliferation of evidence-based interventions into com-
ties for practicing skills in realistic contexts and with di- munity settings (Hoagwood, Burns, Kiser, Ringeisen, &
verse individuals (e.g., teachers, staff, and peers), thereby Schoenwald, 2001; U.S. Public Health Service, 2000).
increasing the likelihood of generalization to the natural We cannot assume, however, that treatments validated in
environment (Evans, 1999; Evans, Langberg, & Williams, research settings will demonstrate the same efficacy in
2003). School-based intervention is likely to be beneficial other environments. Rather, it is important to consider the
for treating social anxiety disorder since: (1) school is the context in which the service will be delivered (Adelman
setting where socially anxious adolescents incur the great- & Taylor, 1998; Hoagwood et al., 2001). An important
est disadvantage (Hofmann et al., 1999) and (2) it allows direction for school-based mental health, therefore, is to
for real-life exposures to the most commonly avoided determine the transportability and efficacy of evidence-
situations (e.g., answering questions in class, speaking based programs in school settings (Graczyk, Domitrovich,
with office personnel, and initiating conversations with & Zins, 2003), including how to adapt these treatments
unfamiliar peers). Lastly, peers and teachers with whom to facilitate their use in school settings without impact-
socially anxious students routinely associate can also be ing their efficacy (Hoagwood et al., 2001; Schoenwald &
enlisted to support students’ progress. This type of ap- Hoagwood, 2001).
proach reduces the division between the treatment set- To determine if providing treatment for social anxiety
ting and natural environment, and may enhance the effec- disorder in schools was feasible and potentially ef-
tiveness of school interventions compared to clinic-based ficacious, Masia and colleagues (Masia et al., 2001)
treatments (Evans et al., 2003). conducted an initial feasibility study of school-based be-
Based on the many potential advantages to provid- havioral intervention for adolescents with social anxi-
ing services in schools, there has been a proliferation of ety disorder. The intervention, Skills for Academic and
school-based programs (Adelman & Taylor, 1998). De- Social Success (SASS; Masia et al., 1999), was devel-
spite this expansion of mental health services, the majority oped with the goal of adapting clinic-based procedures
of these initiatives have not been subjected to system- to be practical for delivery in high schools. Based on the
710 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

documentation of social skills deficits in socially anx- social anxiety self-rating instruments and teacher nomi-
ious youth (Beidel et al., 1999; Spence, Donovan, & nations was conducted to identify students likely to have
Brechman-Toussaint, 1999) and the demonstrated efficacy social anxiety disorder. Of the 1,521 eligible students,
of the SET-C protocol (Beidel et al., 2000), the SASS pro- 1,358 (89.3%), completed the Social Phobia and Anxi-
gram was primarily derived from SET-C, with modifica- ety Inventory for Children (SPAI-C; Beidel, Turner, &
tions for an adolescent population (e.g., developmentally Morris, 1995), the Social Anxiety Scale for Adolescents
appropriate social skills, addition of training in realistic (SAS-A; LaGreca, 1998), and the social subscale of the
thinking) and the school environment (e.g., briefer ses- Multidimensional Anxiety Scale for Children (MASC;
sions and incorporation of teachers). The 14-session pilot March, Parker, Sullivan, Stallings, & Conners, 1997) dur-
SASS program consisted of one psychoeducational ses- ing a school guidance period. In addition, the first author
sion, one session of realistic thinking, five sessions of conducted teacher workshops on the symptoms and im-
social skills training, five sessions of exposure, and one pairment associated with social anxiety, and she asked
session of relapse prevention as well as two unstructured teachers to nominate up to five students in their class-
social activities (e.g., pizza parties). Teachers were also rooms who appeared quiet, shy, and nervous. Students
asked to conduct practice exercises with group members who scored in the top 15% on self-rating instruments
(e.g., calling on them in class, etc.). Six high school stu- or were nominated by teachers were selected for further
dents participated in this small open trial of the SASS screening (475/1521, 31.2%).
intervention. Overall, all participants showed marked or
moderate improvements. Most important, the program
Step Two of Recruitment: Telephone Screening
was well-received by students, parents, and teachers, and
appeared ecologically valid (Masia et al., 2001). The pilot
The parents of the 475 “positive” screens were tele-
study supported the feasibility of this approach.
phoned for a brief interview. Parents who indicated so-
Following the pilot study, additional components
cial anxiety associated with impairment in functioning
were added to the SASS intervention to more fully take
(171/475, 36%) were invited to participate in a diagnostic
advantage of the school context and enhance generaliza-
evaluation with their child in home. Eighty adolescents
tion of clinical gains. First, the social activities seemed to
and their parents (80/171, 47%) agreed to participate.
be particularly powerful, and thus, two additional events
were added. To increase social interactions for the socially
anxious students and create more realistic situations, the Final Recruitment Step: Diagnostic Interview
social events were “typical teenage outings” in the com-
munity and outgoing school peers were invited to attend. The interview session began by explaining the in-
Second, a more formal teacher component was developed terview procedures, describing the research study, and
to facilitate teacher involvement in identifying students’ obtaining informed consent from both the parent and the
specific difficulties and assisting in classroom exposures. adolescent. Parents and adolescents were then interviewed
Lastly, due to experiences with parental obstacles to treat- separately, by the same evaluator, using the Anxiety Dis-
ment progress, two parent sessions focusing on psychoed- orders Interview Schedule for DSM-IV: Parent and Child
ucation and management of child anxiety were developed Versions (ADIS-PC; Silverman & Albano, 1996). Stu-
to encourage parental contributions to clinical gains. The dents were considered appropriate for the study if they
modified program is described in more detail below. The received a DSM-IV diagnosis of social anxiety disorder
current investigation represents an initial examination of with significant impairment as defined by an ADIS-PC
the efficacy of the revised SASS program. Clinician Severity Rating of four or higher (at least mod-
erate severity) on the 8-point severity scale. Students were
excluded from the study if they: 1) were currently receiv-
METHOD ing psychological or pharmacological treatment for social
phobia; 2) warranted a diagnosis of substance use disorder,
Recruitment oppositional defiant disorder, conduct disorder, or major
depression that was of greater severity than social phobia;
Step One of Recruitment: School Screening 3) were experiencing psychotic symptoms or current sui-
cidal or homicidal thoughts; or 4) had a current major life
Participants were drawn from a population of 1,521 event requiring immediate attention (e.g., a parent dying).
adolescents in grades 9 through 11 from two parochial Among those interviewed (n = 80), 42 adolescents
high schools in New York City. A screening using three (52.5%) met study criteria. Of the 38 (47.5%) who did not:
School-Based Intervention for Social Anxiety 711

Table I. Participant Characteristics

SASS intervention Wait-list control Total

(n = 18) (n = 17) (n = 35)

Gender (n, % female) 14 (77.8) 12 (70.6) 26 (74.3)

Ethnicity (n, %)
Caucasian 16 (88.9) 13 (76.5) 29 (82.9)
African American 2 (11.1) 1 (5.9) 3 (8.6)
Asian American 0 1 (5.9) 1 (2.9)
Latin American 0 1 (5.9) 1 (2.9)
Other 0 1 (5.9) 1 (2.9)
Mean age (SD) 15 (.59) 14.5 (.94) 14.8 (.81)
Grade (n, %)
9 4 (22.2) 9 (52.9) 13 (37.1)
10 13 (72.2) 7 (41.2) 20 (57.1)
11 1 (5.6) 1 (5.9) 2 (5.7)
Generalized type (n, %) 17 (94.4) 16 (94.1) 33 (94.3)
Comorbidity (n, %) 9 (50) 8 (47.1) 17 (48.6)
GAD 6 (33.3) 8 (47.1) 14 (40.0)
Dysthymia 3 (16.7) 2 (11.8) 5 (14.3)
Agoraphobia 1 (5.6) 0 1 (2.9)
Eating disorder NOS 1 (5.6) 0 1 (2.9)

32 (40%) did not receive a diagnosis of social phobia, four vironments. Seven participants (three assigned to SASS
(5%) were excluded due to current major depression, one and four to wait-list) terminated their participation early
(1.3%) was currently receiving treatment, and one (1.3%) in the study. One drop-out from the intervention group
needed immediate other assistance due to his mother’s attended only the first session, the second noncompleter
pending death. Agreement on social phobia diagnoses attended two sessions, and the third attended four. There
was determined on a random sample of 28 audiotaped were no significant differences in demographic infor-
interviews that were independently rated by a second clin- mation or initial diagnostic severity between completers
ician. Agreement occurred in 26 of the 28 (98%) cases. and noncompleters. However, adolescents with fears re-
In the first case of disagreement, the interviewer had as- stricted to public speaking were more likely to termi-
signed a diagnosis of generalized anxiety disorder. For the nate participation than those meeting criteria for the
other, the interviewer rated the subject’s social anxiety at generalized subtype (60% versus 10.8%, Fisher’s Exact
a subclinical level. Both cases were reviewed with the Test = .03)
interviewers and expert clinicians, and given a diagnosis Demographic data for adolescents who completed
of social phobia. the study are depicted in Table I. Mean age was 14.8 years
(range = 13–17 years). The majority were female (74.3%,
Enrolled Participants n = 26). Ethnicity was as follows: 82.9% Caucasian,
8.6% African American, 2.9% Asian American, 2.9%
Of the 42 adolescents admitted to the study, five Latin American, and 2.9% other. About half of the sample
(12%) were diagnosed with a “specific” subtype of social had other disorders, the most common being generalized
phobia, as their main concerns surrounded performance anxiety disorder (40%) and dysthymia (14.3%).
situations and public speaking in class. The other 37 ado-
lescents received a diagnosis of social anxiety disorder, School-Based Intervention: Skills for Social
generalized subtype, as their anxiety interfered with a and Academic Success
wide range of social and performance situations. Only
four of these students (9.5%) had ever sought treatment The process of moving efficacious treatments into
for anxiety. other settings is complex and requires adaptations
Students were randomly assigned to either the SASS (Schoenwald & Hoagwood, 2001). In transporting a
intervention (n = 21) or wait-list control condition (n = clinic-based protocol to a school setting, several consid-
21). Randomization occurred within schools (i.e., there erations guided the SASS intervention design: 1) sessions
was an intervention group and a control group in each could last no longer than a typical class period, approx-
school) to control for possible differences in school en- imately 42 min, 2) sessions could not interrupt academic
712 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

courses, 3) the school environment was to be used as a Social Events

setting for exposures in order to encourage generalization,
4) teachers would be asked to identify students’ specific The four social events provide essential opportunities
difficulties and assist in classroom exposures, 5) parents for group members to practice program skills with “real-
would learn techniques to decrease their children’s avoid- world” school peers in natural community “hang-outs.”
ance and enhance skills generalization, and 6) the program Activities may include bowling, laser tag, going to the
was to utilize outgoing school peers to facilitate social mall, playing billiards, miniature golf, or a picnic. These
interactions. events are attended by group members and peer assistants
The SASS intervention is designed for implemen- recruited from participating high schools.
tation in school settings. It consists of 12 weekly group
school sessions (approximately 40 min each), two brief Peer Assistants
individual meetings (15 min), and two group booster ses-
sions. Additionally, four weekend social events (90 min) Teachers and administrators are asked to nominate
that include prosocial peers, called “peer assistants” (de- students who are friendly and kind to be peer assistants.
scribed below) provide real-world exposures and oppor- A consent form is mailed to parents of nominated students
tunities for skills generalization. Parents attend two group to explain the role of peer assistants and to obtain signed
meetings (45 min) at school during which they receive permission to participate. The potential peer assistants are
psychoeducation regarding social anxiety and learn tech- interviewed by a member of the research team and dis-
niques to address their child’s anxiety. Teachers partic- cussed with school personnel (e.g., counselors, principal)
ipate in two psychoeducational meetings (30 min) and prior to final selection. Group leaders meet twice with
conduct classroom exposures supervised by group leaders. peer assistants prior to the intervention to discuss their
The program is designed to be flexible to accommodate responsibilities. In addition to attending the social events,
school calendars (e.g., vacations and exams), and typi- they assist with exposures and skill practice during the
cally spans about 3 months. All groups were co-led by week when necessary (e.g., introducing a group mem-
a behaviorally trained clinical psychologist and a clinical ber to a new peer in class). As peer assistants attend the
psychology graduate student. Attendance at the program same schools as program participants, their involvement
was high (90.3%). Attendance at parental sessions was facilitates peer support within the school environment.
lower, with a 69.4% participation rate.

School Group Sessions Parent Meetings

The 12 school meetings consist of one psychoeduca- Many parents have a limited understanding of the
tional session, one session on realistic thinking, four so- symptoms and impairment associated with social anxi-
cial skills training sessions (i.e., initiating conversations, ety. They may misinterpret their child’s socially anxious
maintaining conversations and establishing friendships, behavior (e.g., “my child is unfriendly”) and are often
listening and remembering, and assertiveness), five ses- frustrated by their child’s avoidance behaviors (e.g., re-
sions of exposure, and one session on relapse prevention. fusing to answer the telephone). The two parent meetings
Exposures are regularly integrated into the school envi- focus on psychoeducation about social anxiety and ways
ronment and include the assistance of school personnel to manage children’s anxiety and facilitate improvement.
or peer assistants (e.g., ordering and returning food in the
lunchroom, going to the office to ask the school secretary Teacher Meetings
questions, starting a conversation with the principal).
Teacher education and collaboration are important
Individual Meetings benefits of conducting the intervention in a school set-
ting. Teachers are often eager for information on how
Each group member meets individually with group to assist shy students. Group leaders meet with teachers
leaders at least twice during the program. These sessions for two 30-min meetings. Teachers are educated about
are designed to identify individual treatment goals and social anxiety, the goals of the SASS program, and ways
problem-solve any treatment obstacles. Given the limited to manage anxiety in the classroom. Teachers identify
amount of time available during group sessions, individual areas of social difficulty for participants, potential class-
meetings provide an opportunity to adapt the program to room exposures are discussed, and teachers provide feed-
each student’s needs. back about students’ progress. Group leaders work with
School-Based Intervention for Social Anxiety 713

teachers to develop appropriate, gradual exposures. For for each situation, but is given latitude to question re-
instance, if a group member fears bringing attention to sponses and adjust ratings accordingly. The LSAS-CA
himself, a teacher may have the student enter the class- provides a total score and six subscale scores: social anx-
room late, wait for the student to arrive before start- iety, social avoidance, performance anxiety, performance
ing the lesson, and possibly reprimand him in front of avoidance, total anxiety, and total avoidance. The LSAS-
classmates. CA has demonstrated satisfactory psychometric proper-
ties (Masia-Warner et al., 2003).
Booster Sessions Social Phobic Disorders Severity and Change Form
(SPDSCF; Liebowitz et al., 1992) is a 7-point rating of
Two monthly group booster sessions are conducted severity and change specific to social phobia symptoms.
with group members after the completion of the program. It has been used to measure treatment response in well-
Their purpose is to monitor progress since termination, designed treatment trials of adult social phobia (Heimburg
evaluate and discuss any obstacles to continued improve- et al., 1998; Liebowitz et al., 1992). Severity ranges from
ment, and highlight additional ways to practice skills and 1 (normal) to 7 (among the most severely ill patients).
establish relationships. In addition, change scores denote improvement in social
anxiety symptoms ranging from 1 (markedly improved)
to 7 (markedly worse). Ratings of 1 or 2 (markedly or
MEASURES moderately improved) define treatment responders. Rat-
ings were based on child and parent responses during the
Participants were evaluated at preintervention and clinical interview.
postintervention. Since the wait-list controls were pro- Children’s Global Assessment Scale (CGAS; Shaffer
vided with treatment following postassessment evalua- et al., 1983) a clinician rating of functioning considering
tions, only SASS group subjects participated in 9-month psychological, social, and school behavior, is scored from
follow-up assessments. Assessments included indepen- 0 to 100, with higher ratings indicating better function-
dent evaluator ratings, self-report inventories, and parent ing. Psychometric data support the use of the CGAS to
ratings. Trained independent evaluators, blind to treatment assess overall impairment (Bird, Canino, Rubio-Stipec, &
condition, conducted all clinical assessments in partici- Ribera, 1987; Shaffer et al., 1983).
pants’ homes.

Independent Evaluator Ratings Self-Report Inventories

Anxiety Disorders Interview Schedule for DSM- Social Phobia and Anxiety Inventory for Children
IV: Parent and Child Versions (ADIS-PC; Silverman & (SPAI-C; Beidel et al., 1995) consists of 26 items that as-
Albano, 1996) provides coverage for anxiety and mood sess specific somatic symptoms, cognitions, and behavior
disorders, and screens for the presence of externalizing across potentially fear-producing situations. Questions are
behavior disorders, psychosis, and eating disorders. Inter- answered on a 3-point Likert-type scale ranging from (0)
views are conducted with parents and children separately, Never to (2) Most of the time or Always. The SPAI-C has
and independent data are recorded. Based on information been reported to have adequate psychometric properties
from both interviews, the independent evaluator assigns (see Beidel et al., 1995; Beidel, Turner, & Fink, 1996;
composite diagnoses and corresponding severity ratings. Beidel, Turner, Hamlin, & Morris, 2000).
A diagnosis is assigned if a severity rating of 4 or greater Social Anxiety Scale for Adolescents (SAS-A;
on a 0–8 rating of distress/impairment is given. The ADIS LaGreca, 1998) contains 18 items focusing on social
has demonstrated sensitivity to treatment effects (Kendall anxiety and four filler items reflecting activity or social
et al., 1997). preferences. Items are rated on a 5-point Likert scale
Liebowitz Social Anxiety Scale for Children and Ado- from (1) not at all true to (5) all the time. The follow-
lescents (LSAS-CA; Masia-Warner, Klein, & Liebowitz, ing three factors have been generated: Fear of Negative
2003) assesses a range of situations that children and Evaluation (FNE), Social Avoidance and Distress-New
adolescents with social phobia may fear and/or avoid. (SAD-New), and Social Avoidance and Distress-General
Its 24 items are divided into social interaction (12 items) (SAD-General). The SAS-A has been found to be psy-
and performance (12 items) situations. The independent chometrically sound (LaGreca & Lopez, 1998) and to
evaluator asks the adolescent to provide separate ratings discriminate adolescents with and without social phobia
for anxiety and avoidance on a 0–3 Likert-type scale (Ginsburg, LaGreca, & Silverman, 1998).
714 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

Children’s Depression Inventory (CDI; Kovacs & not account for treatment group as a random variable in
Beck, 1977) is a 27-item self-report measure that assesses the planned random regression models.
the severity and presence of affective, behavioral, and cog- Preassessment comparisons of the treatment and con-
nitive symptoms of depression during the previous 2-week trol groups were conducted using chi-square and t-tests
period. The CDI demonstrates good test–retest reliability for independent samples. Dichotomous outcomes, such as
and construct validity (Craighead, Smucker, Craighead, the SPDSCF-Change (number of patients rated as moder-
& Ilardi, 1998; Kovacs, 1992), and has been found to dif- ately or markedly improved) and ADIS diagnosis (num-
ferentiate between depressed and nondepressed children ber of participants diagnosis-free following the interven-
(Carlson & Cantwell, 1979). tion), were examined using chi-square or Fisher’s Exact
Loneliness Scale (LS; Asher & Wheeler, 1985) con- Test. The Mantel–Haenszel χ 2 test was used to compare
sists of 16 items that assess feelings of loneliness (e.g., “I postintervention comorbidity rates, controlling for base-
have nobody to talk to at school) rated on a 5-point scale. line comorbidity. Effect sizes were calculated by dividing
Factor analysis generated one primary factor with high the difference in change between groups by the standard
internal consistency (Asher & Wheeler, 1985). deviation of the change score. The criteria proposed by
Cohen (1988) were used, in which 0.2 means a low effect
size, 0.5 average, and 0.8 high. Finally, since only SASS
Parent Report
intervention group subjects participated in follow-up as-
sessments, paired sample t-tests were used to examine
Social Anxiety Scale for Adolescents: Parent Version
maintenance of treatment gains from postintervention to
(SAS-AP; LaGreca, 1998) asks parents to report on their
the 9-month follow-up.
adolescent’s social anxiety on a 5-point Likert scale from
(1) not at all true to (5) all the time. The SAS-AP items
and factor structure are identical to the SAS-A.

DATA ANALYSIS Pretreatment Comparisons

Seven individuals did not complete the study, and There was no significant difference on any demo-
all refused a final evaluation upon termination. Three sets graphic variable between treatment (n = 18) and con-
of analyses were performed: 1) completer analyses that trol (n = 17) groups. In addition, groups did not differ
included the 35 adolescents who completed the study; in rate of comorbidity. No significant group differences
2) random regression models that included all available were found on any clinical measures. (See Tables I and II
data on the 42 randomized adolescents; and 3) intent-to- for demographics and preassessment values.)
treat analyses that carried forward the baseline measures
for noncompleters. All analyses used a random regres-
sion approach (Gibbons et al., 1993), which allows the Independent Evaluator Ratings
use of missing data. The major parameter of interest is
the Group × Time interaction that estimates differential Table II presents descriptive information for outcome
treatment effects. The three separate sets of analyses were measures at pre- and postintervention.
compared to assess the robustness of the findings. Since
analyses revealed identical results, only completer analy- ADIS-PC Severity
ses are presented. The others are available from the first
author. At posttreatment, severity ratings were significantly
As the intervention was provided in six separate lower in the intervention than the control group, as indi-
groups, random regression models tested whether treat- cated by a significant Group × Time interaction effect,
ment group accounted significantly for variance in out- F (1, 33) = 50.6, p < .0001.
come measures (i.e., cluster effects). If intracluster cor-
relations were present, analyses would have to adjust for SPDSCF
them by including the intervention group as a random vari-
able. This requirement is similar to the need to account A significant Group × Time effect was obtained. As
for intraindividual correlation when multiple observations shown in Table II, the treated subjects had a substantial
within individuals are analyzed (Gibbons et al., 1993). decrease in severity, in contrast to a slight increase in the
Because these analyses yielded negative results, we did wait-list group, F (1, 33) = 34.9, p < .0001.
School-Based Intervention for Social Anxiety 715

Table II. Mean (Standard Deviation) and Effect Size for Outcome Measures

Pre Post

Measure Range SASS (n = 18) Control (n = 17) SASS (n = 18) Control (n = 17) p value Effect size

Clinician ratings
ADIS-PC Severity 0–8 5.4 (1.1) 5.4 (1.3) 3.1 (1.1) 5.8 (1.6) <.0001 2.4
SPDSCF 1–7 4.3 (.84) 4.4 (1.0) 2.9 (.94) 4.9 (1.1) <.0001 2.0
LSAS-CA Total 0–144 55.4 (25.0) 52.0 (25.0) 33.9 (12.7) 46.4 (23.5) .03 .77
Social anxiety 0–36 15.9 (7.6) 16.7 (9.3) 11.4 (4.2) 16.1 (8.4) ns .66
Perform anxiety 0–36 13.7 (6.2) 11.6 (4.8) 8.0 (3.3) 9.5 (5.8) .053 .68
Total anxiety 0–72 29.6 (12.6) 29.1 (13.0) 19.4 (6.9) 25.6 (12.8) .056 .67
Social avoid 0–36 14.7 (8.3) 14.4 (8.8) 8.8 (3.5) 13.9 (8.2) .04 .72
Perform avoid 0–36 11.2 (6.5) 9.2 (5.3) 5.6 (3.2) 6.9 (5.0) ns .52
Total avoidance 0–72 25.8 (12.9) 22.9 (13.0) 14.6 (6.2) 20.8 (11.7) .03 .75
CGAS 0–100 52.7 (8.9) 55.2 (10.8) 73.1 (10.1) 51.5 (14.2) <.0001 2.3
SPAI-C 0–52 24.4 (7.4) 24.4 (10.3) 16.3 (6.3) 21.5 (10.6) .052 .68
FNE 0–40 24.3 (6.4) 25.7 (8.9) 20.7 (4.9) 23.1 (10.0) ns .17
SAD-New 0–30 20.7 (4.5) 19.3 (6.4) 17.6 (3.2) 18.9 (6.7) .03 .79
SAD-General 0–20 10.4 (2.4) 11.4 (4.3) 8.4 (2.4) 10.1 (4.0) ns .21
CDI 0–54 12.4 (6.6) 11.9 (6.5) 8.1 (5.0) 8.9 (5.6) ns .24
LS 0–80 39.2 (11.9) 41.0 (12.8) 32.4 (8.6) 35.8 (12.5) ns .20
Parent ratings
SAS-A Parent
FNE 0–40 24.6 (7.5) 26.4 (6.1) 21.5 (3.6) 25.2 (5.8) ns .35
SAD-New 0–30 21.1 (4.3) 21.5 (3.9) 17.4 (3.1) 20.4 (3.2) .02 .82
SAD-General 0–20 10.1 (3.5) 11.8 (3.2) 9.4 (2.6) 11.5 (3.1) ns .16

Note. ADIS-PC: Anxiety Disorders Interview Schedule for DSM-IV: Parent and Child Version, Severity Rating; SPDSCF: Social Phobic
Disorders Severity and Change Form, Severity Rating; LSAS-CA: Liebowitz Social Anxiety Scale for Children and Adolescents; CGAS:
Children’s Global Assessment Scale; SPAI-C: Social Phobia and Anxiety Inventory for Children; SAS-A: Social Anxiety Scale for Ado-
lescents; FNE: Fear of Negative Evaluation, subscale of both SAS-A and SAS-A Parent; SAD-New: Social Avoidance and Distress-New,
subscale of both SAS-A and SAS-A Parent; SAD-General: Social Avoidance and Distress-General, subscale of both SAS-A and SAS-A
Parent; CDI: Children’s Depression Inventory; LS: Loneliness Scale; SAS-AP: Social Anxiety Scale for Adolescents, Parent Version; ns =
not significant.

LSAS-CA Self-Report Inventories

Differences were examined for the LSAS-CA to- SPAI-C

tal score and subscales. Of the seven scores, signif-
icant Group × Time effects were obtained for the SASS participants, compared to wait-list partici-
following: Total score, F (1, 33) = 5.1, p = .03, To- pants, reported fewer social phobia symptoms from pre- to
tal Avoidance, F (1, 33) = 4.9, p = .03, and Social postassessment, a difference that approached significance,
Avoidance, F (1, 33) = 4.6, p = .04. Group × Time ef- F (1, 33) = 4.1, p = .052.
fects approached significance for Performance Anxiety,
F (1, 33) = 4.0, p = .053 and Total Anxiety, F (1, 33) =
3.9, p = .056. No treatment effect was found for Social SAS-A
Anxiety or Performance Avoidance.
Of the three SAS-A subscales, a Group × Time
CGAS effect was found only for social anxiety in new situa-
tions (SAD-New), F (1, 33) = 5.4, p = .03. The SASS
The treated group, relative to the wait-list con- group reported a significantly greater reduction of so-
trols, showed a significant improvement in overall func- cial anxiety with new peers or in new situations
tioning, as indicated by a significant Group × Time compared to the wait-list control group. No signif-
interaction effect, F (1, 33) = 44.5, p < .0001. icant differences between groups were observed for
716 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

Fear of Negative Evaluation (FNE) or SAD-General postassessment. Among the SASS group, 12 of 18 stu-
subscales. dents (67%) no longer met criteria, compared with 1
of 17 students (6%) in the wait-list group, χ 2 = 13.84,
p < .001. In addition, responder status was defined a pri-
ori as ratings of moderate or marked improvement on
the Social Phobic Disorders Severity and Change Form
No significant treatment effect was found for self-
(SPDSCF). Only 2 of 17 (11.8%) wait-list group partici-
reported ratings of depression.
pants were classified as responders, compared to 17 of 18
LS (94.4%) SASS participants, χ 2 = 24.08, p < .001. These
results were robust to sensitivity analyses, even under the
No significant treatment effect was found for self- conservative condition wherein study dropouts from the
rated loneliness. treatment group were assumed to be nonresponders and
those from the wait-list were assumed to be responders
Parent Report (χ 2 = 4.84, p < .03 and χ 2 = 13.48, p < .001, respec-
Nine-Month Follow-Up
Findings from parent reports on the SAS-A were
similar to those of adolescents. Parents reported signif- Sixteen (88.9%) of the 18 adolescents in the SASS
icantly less social anxiety in new situations (SAD-New) group completed the 9-month follow-up. The two ado-
for the SASS group compared to controls, F (1, 32) = 5.8, lescents who did not participate in the follow-up evalu-
p = .02. No significant differences were found for FNE ation were responders at postintervention, and indicated
or SAD-General subscales. that their refusal was due to time constraints. As shown
in Table III, overall results suggest that the interven-
Comorbidity tion group maintained clinical gains 9 months following
the completion of treatment. One additional intervention
Of the 35 study completers, 17 had a comorbid diag- group participant no longer met criteria for social anxiety
nosis at baseline (n = 9 for SASS intervention and n = 8 disorder at follow-up.
for control group) and 18 did not (n = 9 for SASS in-
tervention and n = 9 for control group). No interven- DISCUSSION
tion group participant had developed a new comorbid
diagnosis at postassessment, whereas two (22.2%) wait- The present study is the first to report on the efficacy
listed participants did. Among the nine intervention group and transportability of an intervention in high schools
participants who had baseline comorbidity, only one re- for students with social anxiety disorder. Overall, this in-
tained the comorbid diagnosis after treatment, compared vestigation suggested that an empirically-based, school
to five of the eight wait-listed adolescents. Controlling for intervention consisting of social skills training, exposure,
baseline comorbidity, intervention reduced the occurrence and realistic thinking is feasible and resulted in signif-
of comorbid diagnoses (χMantel−Haenszel = 6.73, df = 1, icant improvement in the functioning of teenagers with
p < .01). social anxiety disorder. More specifically, the SASS in-
tervention was superior to a waiting list in reducing social
Effect Sizes anxiety and avoidance and enhancing social functioning,
as noted by independent evaluator, parent, and adolescent
Effect sizes for all outcome measures are presented ratings. The outcome was not only statistically significant,
in Table II. Of the 19, 6 were low (i.e., LS, CDI, FNE, and but was also clinically significant. Sixty-seven percent
SAD-General parent and adolescent reports), and the rest of the SASS group, compared with 6% in the wait-list
were in the moderate to large range. group, no longer met diagnostic criteria for social phobia
at postassessment. Only 2 of 17 (11.8%) wait-list par-
Clinical Significance ticipants were classified as responders, compared to 17
of the 18 (94.4%) SASS participants. These positive ef-
The clinical significance of treatment effects was es- fects were maintained even when study dropouts from
timated by the percentage of adolescents in each group treatment were assumed to be nonresponders, and those
who no longer met DSM-IV criteria for social phobia at from the wait-list to be responders.
School-Based Intervention for Social Anxiety 717

Table III. Descriptive Data (Means and Standard Deviations) for SASS Group at
9-Month Follow-Up

Measure Post (n = 16) (n = 16) t P

ADIS-PC severity 3.1 (1.1) 2.4 (1.3) −2.4 .03

SPDSCF 2.9 (.96) 2.6 (1.0) −1.3 ns
LSAS-CA total score 33.2 (13.1) 22.6 (13.8) −4.0 .001
Social anxiety 11.3 (4.2) 6.9 (3.7) −4.6 <.0001
Performance anxiety 7.6 (3.3) 6.2 (4.7) −1.3 ns
Total anxiety 18.9 (7.0) 12.4 (6.6) −4.6 <.0001
Social avoidance 8.9 (3.6) 5.6 (4.5) −3.6 .003
Performance avoidance 5.3 (3.2) 4.6 (4.8) −0.73 ns
Total avoidance 14.3 (6.4) 10.2 (7.8) −2.8 .01
CGAS 74.0 (10.2) 72.2 (8.1) −1.3 ns
SPAI-C 15.9 (6.4) 12.5 (9.1) −2.6 .02
FNE 20.3 (4.4) 16.5 (5.6) −2.8 .01
SAD-New 17.3 (2.5) 15.3 (3.4) −3.0 .01
SAD-General 8.3 (2.2) 6.9 (2.4) −2.6 .02
CDI 6.7 (3.2) 6.8 (5.4) 0.1 ns
LS 30.6 (7.1) 33.8 (16.2) 0.8 ns
SAS-A Parent
FNE 21.4 (3.7) 17.9 (4.9) −2.7 .02
SAD-New 17.5 (3.1) 16.1 (3.5) −1.4 ns
SAD-General 9.2 (2.8) 8.2 (2.6) −1.1 ns

Note. ADIS-PC: Anxiety Disorders Interview Schedule for DSM-IV: Parent and Child
Version, Severity Rating; SPDSCF: Social Phobic Disorders Severity and Change
Form, Severity Rating; LSAS-CA: Liebowitz Social Anxiety Scale for Children and
Adolescents; CGAS: Children’s Global Assessment Scale; SPAI-C: Social Phobia
and Anxiety Inventory for Children; SAS-A: Social Anxiety Scale for Adolescents;
FNE: Fear of Negative Evaluation, subscale of both SAS-A and SAS-A Parent;
SAD-New: Social Avoidance and Distress-New, subscale of both SAS-A and SAS-A
Parent; SAD-General: Social Avoidance and Distress-General, subscale of both SAS-A
and SAS-A Parent; CDI: Children’s Depression Inventory; LS: Loneliness Scale;
SAS-AP: Social Anxiety Scale for Adolescents, Parent Version; NS = no significant
difference between post and follow-up means.

Since wait-list controls did not complete follow- tinue participation than teenagers with generalized social
up assessments due to ethical concerns of withholding phobia. Informal conversations with the study dropouts
treatment, the long-term effects of the SASS program suggested that they felt the treatment was not appropriate
are not certain. However, follow-up evaluations of treated for them or that they no longer required clinical interven-
participants suggest that treatment gains are maintained tion. The SASS program emphasizes social interaction
9 months following intervention with indications of ac- and interpersonal skills via five social skills training ses-
crued improvement. Of the nine participants treated in the sions and four social events with peers. Since SASS ses-
first year of the study, seven voluntarily served as peer as- sions occur during school hours and group members miss
sistants for subsequent treatment groups. Based on anec- academic class time, another approach is likely necessary
dotal observations by therapists and naı̈ve participants, for adolescents with circumscribed performance anxiety.
the formerly treated peer assistants were indistinguishable Most importantly, this study demonstrates the vi-
from the “outgoing peers” nominated to be peer assistants ability of transporting effective laboratory-based inter-
by teachers. In addition, teachers, parents, and partici- ventions into school settings. Efforts to bring efficacious
pants requested that we continue the program at their treatments to community settings is a major priority for
school. the U.S. Surgeon General and the National Institute of
Adolescents with circumscribed social phobia (i.e., Mental Health (Hoagwood & Olin, 2002; U.S. Public
main concerns surrounded performance situations and Health Service, 2000) due to the high prevalence of psy-
public speaking in class) were more likely to discon- chopathology in children and adolescents coupled with
718 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

concern over low service utilization and poor outcomes typical peers to facilitate behavior change via providing
experienced by youth with mental disorders. Social anx- support and encouragement in the natural environment
iety disorder is chronic and debilitating yet often goes (e.g., introducing group members to others at school, ac-
unrecognized or untreated. Only four of the 42 students companying group members to school clubs, etc). Peer
with social anxiety disorder in the study had ever received assistants suggested the social events based on their “usual
mental health treatment. Based on our experience, work- hangouts” in the community and activities they believed
ing in the schools provides a rich opportunity to edu- would encourage interaction. In addition, group members
cate and raise awareness of school personnel, teachers, were able to offer each other support on an ongoing ba-
and parents in recognizing social anxiety, and facilitates sis since they had regular contact during the week (e.g.,
access to efficacious intervention for impaired teenagers one group member met another in the cafeteria and en-
who otherwise would likely not seek or receive treat- couraged him to order his own food). Another advantage
ment. In addition, school-based treatment is particularly was the ability to practice new skills and conduct expo-
beneficial for accomplishing early-after-onset identifica- sures in rich real-world settings and with diverse individ-
tion and intervention (Adelman & Taylor, 1999), which uals (e.g., asking a group member to mess up her hair
can potentially prevent the chronicity and secondary and make-up and then walk through the school hallways,
problems associated with this disorder (e.g., depression, practicing conversations with school peers, teachers, sec-
substance use). retaries, and lunchroom staff). Collaboration with teachers
Overall, the benefits of this school-based intervention also supported treatment goals. Teachers suggested which
are comparable to those reported in studies of clinic-based classroom behaviors to target (e.g., answering questions),
treatments for referred children with social anxiety disor- prompted students to practice relevant skills, and assisted
der (Beidel et al., 2000; Spence et al., 2000). Due to time with classroom exposures (e.g., called on group members
constraints in school, the SASS sessions are substantially during class discussion). When teachers observed the pos-
shorter than clinic-based treatments (40 min versus 90– itive effects of their efforts, they became even more mo-
120 min, respectively), and only four SASS social events tivated to participate. Finally, being present in the school
are provided, compared to 12 in the SET-C program. Al- allowed treatment providers to observe group members’
though it is impossible to determine from this study, some behaviors in diverse locations (e.g., lunchroom, gym class,
possibilities for these findings are: (1) shorter treatments walking in the hallways), and provide specific feedback
are equally effective in producing change, (2) nonreferred on various situations.
community adolescents with social anxiety disorder re- Although the school setting offered many advan-
quire less intensive treatment than those who seek out tages, there were also many challenges. First, school per-
professional help for their anxiety, or (3) conducting in- sonnel and parents were initially wary of researchers, and
tervention for social anxiety disorder in school settings is reluctant to allow students to participate. Collaborating
particularly powerful. It would be informative to examine with a community nonprofit organization that was famil-
the timing of clinical improvement, the effects of various iar to the schools helped in addressing such concerns,
“doses” of treatment, and differences between referred as did fostering a reciprocal partnership by donating our
and community samples of adolescents with social anxi- time and resources to school activities such as career day,
ety disorder. faculty workshops, honor societies, and parent meetings.
Moreover, future studies should examine if clinical In addition, parents who had participated in the program
interventions for social anxiety disorder are more effec- in its initial year served as parent advisors in following
tive when delivered in schools than in clinics. Conducting years to educate other parents about social anxiety and the
treatment in school may foster more clinically significant benefits of the program. Parents and students also seemed
gains since this context provides a uniquely productive reassured by being informed that services were provided
opportunity to address relevant contextual variables (e.g., by trained professionals from the New York University
peers, teachers, and parents), thereby providing a real- School of Medicine with expertise in social anxiety dis-
world treatment approach and facilitating generalization order. Parents appeared to view this as a “special” oppor-
(see Evans, 1999; Evans et al., 2003). For example, al- tunity and a better quality of service than the standard
though peer generalization exercises are used in the SET- mental health options available to them. This impression
C program, the “outgoing peers” may not live in the same is consistent with Adelman, Barker, and Nelson (1993)
community as the treated children, they do not see each and Evans, Altenderfer, Mirarchi, and Achre (1996) who
other outside of the clinic sessions, and the social events found that parent and adolescent concerns about treat-
may take place outside of their immediate community. ment quality were an obstacle to the use of school-based
Partnering with schools provided the opportunity to train services. Lastly, research program activities were held at
School-Based Intervention for Social Anxiety 719

familiar locations and accommodated families’ schedules Limitations

(e.g., parent meetings occurred at school, assessments
were conducted at their homes, social events were held The following study limitations should be noted.
in their community). First, participants were recruited from parochial schools
There were also pragmatic challenges such as space in an urban New York area, and were largely Caucasian.
and scheduling. Conducting groups after school is diffi- Second, due to ethical concerns, the wait-list group was
cult due to extracurricular school programs, transporta- provided with treatment following postassessment eval-
tion schedules, and students’ desire to leave school at uations, and thus, there is no comparison group for the
the end of the day. Therefore, groups were held during follow-up assessments. Third, there is no end-point infor-
school hours, which limited sessions to 40 min and re- mation on dropouts.
quired use of rooms during peak times. The program’s Furthermore, one might view the lack of teacher rat-
schedule was also affected by school trips, exams, va- ings as a limitation. However, in our initial feasibility
cations, and, at times, teacher reluctance to release stu- trial (Masia et al., 2001), the burden placed on teachers
dents from class. Flexibility is an essential component in by completing measures for multiple students outweighed
managing the implementation of a school program. To the benefit of the information gained because: (1) there are
address these issues, meetings were scheduled around the no established anxiety measures for teachers, and (2) high
availability of rooms and the session meeting time was school students have multiple instructors with whom they
rotated weekly to decrease interference with academic have minimal daily contact. In addition, we did not in-
classes. clude observational measures such as school observations
Another obstacle was students’ fear or reluctance to or behavioral assessment tests (e.g., role-plays of conver-
participate in the intervention. Some families expressed sations). Such measures are difficult in school settings due
apprehension regarding classmates knowing about stu- to a lack of confederates (e.g., individuals with available
dents’ participation. We addressed this in a few ways: time to participate in simulated interactions), and schools’
(1) the program was named Skills for Social and Aca- sensitivity to privacy that prohibits the use of video cam-
demic Success to prevent it from sounding too “therapy- eras in school. Future studies of school-based intervention
oriented,” or revealing the nature of the program; (2) con- for social anxiety should include self- and parent-report
fidentiality was clearly explained to families, including measures of social skills.
that school personnel would be aware of the purpose of In addition, in examining Table II, it may seem as
the program and of which students were participating, but if substantial treatment effects were only demonstrated
would not be informed about specific assessment infor- by clinician-rated rather than on self- or parent-report
mation or treatment progress. The role of teachers and measures. However, a closer examination reveals that it
peer assistants in the program was also thoroughly clari- is most likely the type of measure, rather than the rater,
fied; (3) we informed second-year participants that we had that accounts for apparent differences in effect sizes. First,
been in their school the previous year, but they had not the measures that indicated the largest effects (ADIS-PC
been aware of our presence; and (4) since students rou- Severity, SPDSCF, and CGAS), each consist of one over-
tinely received guidance passes during homeroom, this all global rating which takes into account multiple sources
approach was utilized to inform students of the time and of clinical information (e.g., behavioral observations, par-
location of intervention sessions while maintaining their ent and child reports). The remaining instruments obtain
anonymity. discrete ratings that assess different situations, and these
A final challenge was the burdensome recruitment ratings are then summed to obtain various scores. Al-
and assessment process. Because this was a research study, though the LSAS-CA is a clinician-rated measure, its
we employed large-scale recruitment strategies and a com- format is consistent with that of the parent- and self-
prehensive evaluation of participants. For further integra- report social phobia instruments (SPAI-C and SAS-A),
tion into schools, the assessment of group members should and it demonstrated treatment effects similar to those in-
be shortened and more focused. In addition, to success- struments. Another indication of the validity of reported
fully disseminate treatment for social anxiety disorder in treatment changes is the consistency in parent and ado-
schools, barriers to referral and treatment participation lescent reports indicating improvement around unfamiliar
will need to be identified to enable the development of peers and in new situations (SAD-New), but not in more
more efficient screening and recruitment methods. A study general anxiety (SAD-General) or in worry about nega-
to examine the barriers to identification of social anxi- tive evaluation (FNE). One would expect the SAD-New
ety disorder, and to referral and treatment participation is to show the most rapid change since these behaviors are
currently underway. the main focus of the SASS program, and for changes
720 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

on the SAD-General and FNE to follow. The follow-up Adelman, H. S., & Taylor, L. (1998). Reframing mental health in schools
evaluation 9 months later indicated further improvement and expanding school reform. Educational Psychologist, 33, 135–
on the SAD-General and FNE subscales. In addition, the Adelman, H. S., & Taylor, L. (1999). Mental health in schools and
other adolescent rating scales (CDI and LS) are measures system restructuring. Clinical Psychology Review, 19, 137–163.
of depression and loneliness, not social anxiety. Albano, A. M. (1995). Treatment of social anxiety in adolescents. Cog-
nitive and Behavioral Practice, 2, 271–298.
Finally, this investigation demonstrates the absolute Albano, A. M., Marten, P. A., Holt, C. S., Heimberg, R. G., &
efficacy of the SASS intervention. That is, positive results Barlow, D. H. (1995). Cognitive-behavioral group treatment for
demonstrate that the SASS intervention is superior to no social phobia in adolescents: A preliminary study. The Journal of
Nervous and Mental Disease, 183, 649–656.
intervention, but do not provide information about relative Anglin, T. M. (2003). Mental health in schools: Programs of the Fed-
efficacy, namely whether effects are due to specific treat- eral Government. In M. D. Weist, S. W. Evans, & N. A. Lever
ment ingredients or general therapeutic factors (e.g., at- (Eds.), Handbook of school mental health: Advancing practice and
research (pp. 89–105). New York: Kluwer Academic/Plenum.
tention, client or therapist expectations) (Wampold, 2001). Angold, A., Messer, S. C., Stangl, D., Farmer, E. M., Costello, E. J.,
A study comparing the SASS program to a therapy that & Burns, B. (1998). Perceived parental burden and service use for
controls for nonspecific treatment effects is underway. child and adolescent psychiatric disorders. American Journal of
Public Health, 88, 75–80.
Demonstrating the superiority of the SASS intervention Asher, S. R., & Wheeler, V. A. (1985). Children’s loneliness: A compar-
to an attention control condition would justify training ison of rejected and neglected peer status. Journal of Consulting
school psychologists and guidance counselors to deliver and Clinical Psychology, 53, 500–505.
Beidel, D. C., Turner, S. M., & Fink, C. M. (1996). Assessment of
the program in schools. Future work should explore the childhood social phobia: Construct, convergent, and discriminative
type and amount of training necessary for school coun- validity of the Social Phobia and Anxiety Inventory for Children
selors to deliver the intervention, as well as issues involved (SPAI-C). Psychological Assessment, 3, 73–79.
Beidel, D. C., Turner, S. M., Hamlin, K., & Morris, T. L. (2000). The So-
in the dissemination and sustainability of the program in cial Phobia and Anxiety Inventory for Children (SPAI-C): External
schools (Schoenwald & Hoagwood, 2001). and discriminative validity. Behavior Therapy, 31, 75–87.
Beidel, D. C., Turner, S. M., & Morris, T. L. (1995). A new inventory
to assess childhood social anxiety and phobia: The Social Phobia
Conclusion and Anxiety Inventory for Children. Psychological Assessment, 7,
The present study provides support for the trans- Beidel, D. C., Turner, S. M., & Morris, T. L. (1998). Social effective-
ness therapy for children: A treatment manual. Charleston, Medical
portability and potential efficacy of conducting school- University of South Carolina.
based intervention for social anxiety disorder in adoles- Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology
cents. Treated students were significantly less impaired of childhood social phobia. Journal of the American Academy of
Child and Adolescent Psychiatry, 38, 643–650.
following treatment and maintained their improvement Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treatment
9 months later. Intervening schools is a promising treat- of childhood social phobia. Journal of Consulting and Clinical
ment approach that provides opportunities largely unavail- Psychology, 68, 1072–1080.
Bird, H. R., Canino, G., Rubio-Stipec, M., & Ribera, J. (1987). Further
able to clinicians in other contexts, such as incorporating measures of the psychometric properties of the Children’s Global
support from peers, teachers, and parents in a natural set- Assessment Scale. Archives of General Psychiatry, 44, 821–824.
ting. In addition, partnering with schools may prevent Burns, B. J., Costello, E. J., Angold, A., Tweed, D. L., Stangl, D. K.,
Farmer, E. M. Z., et al. (1995). Children’s mental health service use
long-term impairment by improving the recognition of across service sectors. Health Affairs, 14, 147–159.
social anxiety disorder and facilitating access to treatment. Burns, B. J., & Hoagwood, K. (2002). Community-based treatment for
youth: Evidence-based interventions for severe emotional and be-
havioral disorders. New York: Oxford University Press.
ACKNOWLEDGMENTS Carlson, G. A., & Cantwell, D. P. (1979). A survey of depressive
symptoms in a child and adolescent psychiatric population. Jour-
nal of the American Academy of Child Psychiatry, 18, 587–
This research was supported by the Anxiety Disor- 599.
ders Association of America and the Lowenstein Foun- Catron, T., Harris, V. S., & Weiss, B. (1998). Posttreatment results af-
dation. The authors thank Dr. Deborah Beidel for her ter 2 years of services in the Vanderbilt School-Based Counseling
project. In M. H. Epstein, K. Kutash, & A. Duchnowski (Eds.),
consultation on this study, and Ben Adams, Joseph Capo- Outcomes for children and youth with emotional and behavioral
bianco, Nisha Patel, Eric Storch, and Jonathan Tobkes for disorders and their families: Programs and evaluation best prac-
their assistance in conducting the study. tices (pp. 653–656). Austin, TX: PRO-ED.
Catron, T., & Weiss, B. (1994). The Vanderbilt School-Based Counseling
Program: An interagency, primary-care model of mental health
services. Journal of Emotional and Behavioral Disorders, 2, 247–
Cohen, J. (1988). Statistical power analysis for the behavioral sciences
Adelman, H. S., Barker, L. A., & Nelson, P. (1993). A study of a school- (2nd ed.). Hillsdale, NJ: Erlbaum.
based clinic: Who uses it and who doesn’t? Journal of Clinical Cohen, P., Kasen, S., Brook, J. S., & Struening, E. L. (1991). Diagnostic
Child Psychology, 22, 52–59. predictors of treatment patterns in a cohort of adolescents. Journal
School-Based Intervention for Social Anxiety 721

of the American Academy of Child and Adolescent Psychiatry, 30, Hofmann, S. C., Albano, A. M., Heimberg, R. G., Tracey, S.,
989–993. Chorpita, B. F., & Barlow, D. H. (1999). Subtypes of social phobia
Costello, E. J., & Angold, A. (1995). Epidemiology. In J. S. March (Ed.), in adolescents. Depression and Anxiety, 9, 15–18.
Anxiety disorders in children and adolescents (pp. 109–124). New HoganBruen, K., Clauss-Ehlers, C., Nelson, D., & Faenza, M. M. (2003).
York: Guilford. Effective advocacy for school-based mental health programs. In
Costello, E. J., & Janiszewski, S. (1990). Who gets treated? Factors M. D. Weist, S. W. Evans, & N. A. Lever (Eds.), Handbook of
associated with referral in children with psychiatric disorders. Acta school mental health: Advancing practice and research (pp. 45–
Psychiatrica Scandinavica, 81, 523–529. 59). New York: Kluwer Academic/Plenum.
Craighead, W. E., Smucker, M. R., Craighead, L. W., & Ilardi, S. S. Kashdan, T. B., & Herbert, J. D. (2001). Social anxiety disorder in
(1998). Factor analysis of the Children’s Depression Inventory in a childhood and adolescence: Current status and future directions.
community sample. Psychological Assessment, 10, 156–165. Clinical Child and Family Psychology Review, 4, 37–61.
Essau, C. A., Conradt, J., & Petermann, F. (1999). Frequency and comor- Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M.,
bidity of social phobia and social fears in adolescents. Behaviour Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy
Research and Therapy, 37, 831–843. for youths with anxiety disorders: A second randomized clinical
Evans, S. W. (1999). Mental health services in schools: Utilization, trial. Journal of Consulting and Clinical Psychology, 65, 366–380.
effectiveness, and consent. Clinical Psychology Review, 19, 165– Klein, R. G., & Pine, D. S. (2002). Anxiety disorders. In M. Rutter
178. & E. Taylor (Eds.), Child and adolescent psychiatry: Modern ap-
Evans, S. W., Altenderfer, L., Mirarchi, S., & Achre, C. (1996). Exam- proaches (pp. 486–509). London: Blackwell Science.
ining the cost-effectiveness of schools as a service delivery site for Kovacs, M. (1992). The Children’s Depression Inventory Manual.
outpatient treatment. In S. Little (Chair), Implementing behavior Toronto, Ontario, Canada: Multi-Health Systems.
interventions in the classroom. Symposium conducted at the An- Kovacs, M., & Beck, A. T. (1977). An empirical–clinical approach to-
nual Meeting of the Association for the Advancement of Behavioral ward a definition of childhood depression. In J. G. Schulterbrandt &
Therapy, New York. A. Raskin (Eds.), Depression in childhood: Diagnosis, treatment,
Evans, S. W., Langberg, J., & Williams, J. (2003). Achieving gener- and conceptual models (pp. 1–25). New York: Raven.
alization in school-based mental health. In M. D. Weist, S. W. LaGreca, A. M. (1998). Social anxiety scales for children and adoles-
Evans, & N. A. Lever (Eds.), Handbook of school mental health: cents: Manual and instructions for the SASC, SASC-R, SAS-A, and
Advancing practice and research (pp. 335–348). New York: Kluwer parent versions of the scales. Unpublished manuscript available
Academic/Plenum. from the author. University of Miami, Coral Gables, FL.
Farmer, E. M. Z., Stangl, D. K., Burns, B. J., Costello, E. J., & Angold, LaGreca, A. M., & Lopez, N. (1998). Social anxiety among adolescents:
A. (1999). Use, persistence, and intensity: Patterns of care for chil- Linkages with peer relations and friendships. Journal of Abnormal
dren’s mental health across one year. Community Mental Health Child Psychology, 26, 83–94.
Journal, 35, 31–46. Laitinen-Krispijn, S., van der Ende, J., Wierdsma, A. I., & Verhulst,
Gibbons, R. D., Hedeker, D., Elkin, I., Waternaux, C., Kraemer, H. C., F. C. (1999). Predicting adolescent mental health service use in a
Greenhouse, J. B., et al. (1993). Some conceptual and statistical prospective record-linkage study. Journal of the American Academy
issues in analysis of longitudinal psychiatric data. Archives of Gen- of Child and Adolescent Psychiatry, 38, 1073–1080.
eral Psychiatry, 50, 739–750. Leaf, P. J., Alegria, M., Cohen, P., Goodman, S. H., Horowitz, S. M.,
Ginsburg, G. S., LaGreca, A. M., & Silverman, W. K. (1998). Social Hoven, C. W., et al. (1996). Mental health service use in the commu-
anxiety in children with anxiety disorders: Relation with social and nity and schools: Results from the four-community MECA study.
emotional functioning. Journal of Abnormal Child Psychology, 26, Journal of the American Academy of Child and Adolescent Psychi-
175–185. atry, 35, 889–897.
Graczyk, P. A., Domitrovich, C. E., & Zins, J. E. (2003). Facilitat- Leff, S. S., Power, T. J., Manz, P. H., Costigan, T. E., & Nabors, L. A.
ing the implementation of evidence-based prevention and mental (2001). School-based aggression prevention programs for young
health promotion efforts in schools. In M. D. Weist, S. W. Evans, children: Current status and implications for violence prevention.
& N. A. Lever (Eds.), Handbook of school mental health: Ad- School Psychology Review, 30, 344–362.
vancing practice and research (pp. 301–318). New York: Kluwer Liebowitz, M. R., Gorman, J. M., Fryer, A. J., & Klein, D. F. (1985).
Academic/Plenum. Social phobia: Review of a neglected anxiety disorder. Archives of
Hayward, C., Varady, S., Albano, A. M., Thienemann, M., Henderson, General Psychiatry, 42, 729–736.
L., & Schatzberg, A. F. (2000). Cognitive-behavioral group ther- Liebowitz, M. R., Scheiner, F., Campeas, R., Hollander, E., Hatterer,
apy for social phobia in female adolescents: Results from a pilot J., Fyer, A., et al. (1992). Phenelzine vs. atenolol in social phobia:
study. Journal of the American Academy of Child and Adolescent A placebo-controlled comparison. Archives of General Psychiatry,
Psychiatry, 39, 721–726. 49, 290–300.
Heimburg, R. G., Liebowitz, M. R., Hope, D. A., Scheiner, F. R., March, J. S., Parker, J. D. A., Sullivan, K., Stallings, P., & Conners, C. K.
Holt, C. S., Welkowitz, L. A., et al. (1998). Cognitive behav- (1997). The Multidimensional Anxiety Scale for Children (MASC):
ioral group therapy vs. phenelzine therapy for social phobia: Factor structure, reliability, and validity. Journal of the American
12-week outcome. Archives of General Psychiatry, 55, 1133– Academy of Child and Adolescent Psychiatry, 36, 554–565.
1141. Masia, C., Beidel, D. C., Albano, A. M., Rapee, R. M., Turner, S. M.,
Hoagwood, K., Burns, B. J., Kiser, L., Ringeisen, H., & Schoenwald, Morris, T. L., et al. (1999). Skills for Academic and Social Success.
S. K. (2001). Evidence-based practice in child and adolescent men- Available from Carrie Masia-Warner, PhD, New York University
tal health services. Psychiatric Services, 52, 1179–1189. School of Medicine, Child Study Center, 215 Lexington Avenue,
Hoagwood, K., & Erwin, H. (1997). Effectiveness of school-based men- 13th floor, New York 10016.
tal health services for children: A 10-year research review. Journal Masia, C. L., Klein, R. G., Storch, E., & Corda, B. (2001). School-based
of Child and Family Studies, 6, 435–451. behavioral treatment for social anxiety disorder in adolescents:
Hoagwood, K., & Olin, S. S. (2002). The NIMH blueprint for change Results of a pilot study. Journal of the American Academy of Child
report: Research priorities in child and adolescent mental health. and Adolescent Psychiatry, 40, 780–786.
Journal of the American Academy of Child and Adolescent Psychi- Masia-Warner, C., Klein, R. G., & Liebowitz, M. R. (2003). The
atry, 41, 760–767. Liebowitz Social Anxiety Scale for Children and Adolescents
Hoberman, H. (1992). Ethnic minority status and adolescent mental (LSAS-CA). Available from Carrie Masia-Warner, PhD, NYU
health services utilization. Journal of Mental Health Administra- Child Study Center, 215 Lexington Avenue, 13th floor, New York
tion, 19, 246–267. 10016.
722 Masia-Warner, Klein, Dent, Fisher, Alvir, Albano, and Guardino

Masia-Warner, C., Storch, E. A., Pincus, D. B., Klein, R. G., Heimberg, Turner, S. M., Beidel, D. C., Dancu, C. V., & Keys, D. J. (1986).
R. G., & Liebowitz, M. R. (2003). The Liebowitz Social Anxiety Psychopathology of social phobia and comparison to avoidant
Scale for Children and Adolescents: An initial psychometric inves- personality disorder. Journal of Abnormal Psychology, 95, 389–
tigation. Journal of the American Academy of Child and Adolescent 394.
Psychiatry, 4, 1076–1084. U.S. Department of Health and Human Services. (1999). Mental Health:
Pandey, P., Han, S., Fisher, P. H., Ferrante, D., Selinger, A., Cho, L.Y- A report of the Surgeon General. Rockville, MD: U.S. Depart-
J., et al. (2003). Barriers to referral of socially anxious students: ment of Health and Human Services, Substance Abuse and Men-
Teacher perspectives of why they go unnoticed. Poster presented at tal Health Services Administration, Center for Mental Health Ser-
the 37th Annual Convention of the Association for the Advance- vices, National Institutes of Health and National Institute of Mental
ment of Behavior Therapy, Boston, MA. Health.
Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The U.S. Public Health Service. (2000). Report on the Surgeon Gen-
risk for early-adulthood anxiety and depressive disorders in adoles- eral’s conference on children’s mental health: A national ac-
cents with anxiety and depressive disorders. Archives of General tion agenda. Washington, DC: Department of Health and Human
Psychiatry, 55, 56–64. Services.
Power, T. J., Manz, P. H., & Leff, S. S. (2003). Training for effective Verhulst, F. C., & van der Ende, J. (1997). Factors associated with
practice in the schools. In M. D. Weist, S. W. Evans, & N. A. Lever child mental health service use in the community. Journal of the
(Eds.), Handbook of school mental health: Advancing practice and American Academy of Child and Adolescent Psychiatry, 36, 901–
research (pp. 257–273). New York: Kluwer Academic/Plenum. 909.
Rones, M., & Hoagwood, K. (2000). School-based mental health ser- Verhulst, F. C., van der Ende, J., Ferdinand, R. F., & Kasius, M. C.
vices: A research review. Clinical Child and Family Psychology (1997). The prevalence of DSM-III-R diagnoses in a national sam-
Review, 3, 223–240. ple of Dutch adolescents. Archives of General Psychiatry, 54, 329–
Schneier, F. R., Johnson, J., Hornig, C. D., Liebowitz, M. R., & 336.
Weissman, M. M. (1992). Social phobia: Comorbidity and mor- Wampold, B. E. (2001). The great psychotherapy debate. Mahwah, NJ:
bidity in an epidemiologic sample. Archives of General Psychiatry, Erlbaum.
49, 282–288. Weist, M. D. (1997). Expanded school mental health services: A national
Schoenwald, S., & Hoagwood, K. (2001). Effectiveness, transportability, movement in progress. In T. H. Ollendick & R. J. Prinz (Eds.),
and dissemination of interventions: What matters when? Psychi- Advances in clinical child psychology (Vol. 19, pp. 319–352). New
atric Services, 52, 1190–1197. York: Plenum.
Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., Weist, M. D. (1999). Challenges and opportunities in expanded school
et al. (1983). A Children’s Global Assessment Scale. Archives of mental health. Clinical Psychology Review, 19, 131–135.
General Psychiatry, 40, 1228–1231. Weisz, J. R., Donenberg, G. R., Han, S. S., & Weiss, B. (1995). Bridg-
Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview ing the gap between laboratory and clinic in child and adolescent
Schedule for DSM-IV-Child and Parent Versions. San Antonio, TX: psychotherapy. Journal of Consulting and Clinical Psychology, 63,
Graywind, A Division of the Psychological Corporation. 688–701.
Spence, S. H. (1995). Social skills training: Enhancing social compe- Weisz, J. R., Weiss, B., & Donenberg, G. R. (1992). The lab versus the
tence with children and adolescents. Windsor, UK: NFER-Nelson. clinic: Effects of child and adolescent psychotherapy. American
Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (1999). Social Psychologist, 47, 1578–1585.
skills, social outcomes, and cognitive features of childhood social Wittchen, H.-U., Stein, M. B., & Kessler, R. C. (1999). Social fears and
phobia. Journal of Abnormal Psychology, 108, 211–221. social phobia in a community sample of adolescents and young
Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (2000). The adults: Prevalence, risk factors, and comorbidity. Psychological
treatment of childhood social phobia: The effectiveness of a social Medicine, 29, 309–323.
skills training-based, cognitive-behavioral intervention, with and Wu, P., Hoven, C. W., Bird, H. R., Moore, R. E., Cohen, P. C., Alegria,
without parental involvement. Journal of Child Psychology and M., et al. (1999). Depressive and disruptive disorders and mental
Psychiatry, 41, 713–726. health service utilization in children and adolescents. Journal of
Staghezza-Jaramillo, B., Bird, H. R., Gould, M. S., & Canino, G. (1995). the American Academy of Child and Adolescent Psychiatry, 38,
Mental health service utilization among Puerto Rican children ages 1081–1090.
4 through 16. Journal of Child and Family Studies, 4, 399–418. Zahner, G. E. P., & Daskalakis, M. S. (1997). Factors associated with
Tarico, V. S., Low, B. P., Trupin, E., & Forsyth-Stephens, A. (1989). mental health, general health, and school-based service use for
Children’s mental health services: A parent perspective. Community child psychopathology. American Journal of Public Health, 87,
Mental Health Journal, 25, 313–326. 1440–1448.