Adolescent SAD - Treatment and Outcomes

Question 1

Ginsburg et al (2011)

Answer 1

Outcomes from generic CBT less good for CYP with SAD compared to other ADs, with SAD significantly less likely to lose diagnosis (perhaps from exposure being more daunting)

Question 2

Evans et al (2021)

Answer 2

Systematic review and meta-analysis investigated recovery rates following generic CBT for youth with primary SAD versus other ADs (6 RCTs overall), showing pattern of lower SAD recovery rates (although most studies not sufficiently powered to detect cross-diagnosis outcome differences)

Question 3

Older Treatment (SAD-Specific) - Cognitive Behavioural Group Therapy (Albano et al., 1995)

Answer 3

Psychoeducation and skills training, then EXP, with significantly greater reductions in SA symptoms compared to no treatment posttreatment, but still symptoms at 1yr follow-up to the point of no significant differences (Hayward et al., 2000)

Question 4

Cognitive Therapy in Adults (Mayo-Wilson et al., 2014)

Answer 4

Developed to target cognitive processes in Clark and Wells (1995), and when compared to other active treatments, such as group CBT, EXP-therapy, and pharmacological treatments, as well as control, significantly better outcomes

Question 5

Disorder-Specific CBT - Spence et al (2017)

Answer 5

Aimed to adapt broad-based CBT to target maintenance factors in cognitive models, showing poor outcomes, with no differences between groups (Internet-delivered generic CBT; SAD-specific CBT; waitlist) beyond outperforming waitlist, and majority of pps in both active arms still meeting diagnostic criteria for SAD posttreatment

In the very least, replicated findings of poor outcomes for SAD (Evans et al., 2021) in Internet-delivered CBT

Question 6

Disorder-Specific CBT - Rapee et al (2023)

Answer 6

Compared generic CBT against modified SA treatment that incorporates cognitive model components to target, N=200, with treatment not differing significantly on remission of SAD at posttreatment nor follow-up, overall showing little evidence for modified interventions

Question 7

Ingul et al (2014)

Answer 7

RCT with SA adolescents in which individual therapy based on model compared to C.A.T Project (Kendall et al., 2002) and attention placebo

Large effect of individual therapy found on posttreatment, and surprising no effect of Group C.A.T Project (supporting Evans et al., 2021 but perhaps it was group format) on self-report measure of symptoms, with benefits maintained at follow-up - despite having highest baseline SA measures, lowest in post and follow-up

However, not wholly consistent with CT e.g., first three sessions psychoeducation and fear hierarchy, but individualised intervention based on model not wholly introduced until session 4 (compared to session 1 in CT)

Question 8

CT in Adolescent SAD Content

Answer 8

Focuses on (1) experiential exercises to demonstrate adverse effect of self-focused attention and safety behaviours; (2) feedback to correct negative self-images (such as video); (3) attention training to promote external self-focus; (4) behavioural experiments to test fearful predictions in social situations while dropping safety behaviours (in line with Craske et al., 2014); (5) potential influence of parents/peer

Question 9

CT - Leigh and Clark (2016)

Answer 9

Treatment development case series assessing feasibility of CT with adolescent SAD, to 5 adolescents, all of whom severe and chronic SAD and comorbid difficulties, with 4/5 not responding to previous CBT

SA symptoms and associated anxiety/depression reduced to subclinical levels with gains maintained at 3-6mo, accompanied by improved functioning

Average change on primary outcome measure even greater than that in some studies reported in Mayo-Wilson et al (2014), and high acceptability

Question 10

CT - Creswell et al (2021) Feasibility Study

Answer 10

Compared CT with CBT-for-SAD assessing feasibility of wide deployment in CAMHS settings

12 adolescents produced significant improvements in SA symptoms, general anxiety and depression symptoms, and reductions in processes in mode, with health economic measures indicating significantly cheaper cost of CT-SAD-A, as well as high satisfaction and acceptability in patients, parents, and therapists

Promising but lack of feasibility in assessing wide deployment in current CAMHS facilities, perhaps due to influence of COVID-19

Question 11

CT Online - Leigh and Clark (2019)

Answer 11

Showed Internet-delivered CT much better than waitlist control at mid and posttreatment assessments in terms of self-reported SA symptoms, and remission at posttreatment and 6mo (90% in latter)

Question 12

CT Online - OSCA (Internet-Delivered Therapist-Assisted CT for Adolescent SAD) RCT (Leigh and Clark, 2023)

Answer 12

OSCA takes 14 weeks, where users receive core modules to work through in first 2 weeks, with up 16 additional modules focusing on particular problems individualised for each user, targeting processes in model, and weekly brief phone calls with therapist and regular encouragement via secure messaging

43 (14-18) with SAD recruited through schools either OSCA (CT-SAD-A) or waitlist for 14 weeks

OSCA outperformed waitlist on all measures and associated with large effects maintained at 6mo follow-up, increasing from 77% posttreatment to 91% remission at 6mo, comparable to face-to-face intervention which was very similar (Ingul et al., 2014), and showing changes of OSCA were mediated through changes in cognition and safety behaviours as predicted by cognitive model

Almost all pps allocated to OSCA completed, suggesting with fairly minimal adaptations, Internet-delivered CT-SAD can be delivered successfully

But future studies should have active comparator arms, and school recruitment, not clinical, so sample may not represent adolescents seen in clinical settings, although symptom severity at baseline similar to that of Creswell et al (2021) CAMHS feasibility study with SAD adolescents