What Works in Preventing Emerging Social Anxiety: Exposure, Cognitive Restructuring, or a Combination?

Brechtje de Mooij; Minne Fekkes; Anne C. Miers; Alithe L. van den Akker; Ron H. J. Scholte; Geertjan Overbeek

doi:10.1007/s10826-023-02536-w

What Works in Preventing Emerging Social Anxiety: Exposure, Cognitive Restructuring, or a Combination?

de Mooij, Brechtje; Fekkes, Minne; Miers, Anne C.; van den Akker, Alithe L.; Scholte, Ron H. J.; Overbeek, Geertjan 2023-02-01 00:00:00 Programs that aim to reduce symptoms of social anxiety in children generally include multiple components, such as exposure and cognitive restructuring. It is unknown if separate components yield positive intervention effects in children or whether a combination of components is required. We investigated the effectiveness of exposure, cognitive restructuring, and a combination of both components in reducing social anxiety symptoms and anxiety-related social-emotional outcomes in an indicated-prevention setting. To this end, we conducted a cluster-randomized microtrial using a sample of 191 children aged 8 to 13 years (M = 10.48, SD = 1.10). Children with elevated social anxiety symptoms participated in one of three group interventions, each lasting four weeks, and completed a questionnaire on four measurement occasions. Latent change models demonstrated that the intervention with either exposure or cognitive restructuring reduced social anxiety symptoms and anxiety-related outcomes. The analyses showed that both of these intervention components were effective, with more favorable effects for exposure. Combining exposure and cognitive restructuring techniques did not yield greater beneﬁt than either component alone. Future research should investigate whether speciﬁc components may be more effective for particular subgroups (e.g., based on sex or level of behavioral inhibition) in more detail. ● ● ● ● Keywords Social anxiety Exposure Cognitive restructuring Microtrial Intervention components Highlights Exposure had a positive effect on social anxiety, distress, avoidant behavior, positive thoughts, perceived social threat, internalizing behavior, social skills, and self-perceived competence in children with emerging social anxiety. Cognitive restructuring had a positive effect on social anxiety, distress, avoidant behavior, positive thoughts, perceived social threat, internalizing behavior, self-efﬁcacy, and self-perceived competence in children with emerging social anxiety. An intervention combining exposure and cognitive restructuring was less effective in preventing social anxiety and related outcomes than either component alone. Stacking multiple intervention components may not necessarily yield greater prevention beneﬁts. Findings reveal the possible beneﬁts of short-term intervention modules. Supplementary information The online version contains supplementary material available at https://doi.org/10.1007/s10826- 023-02536-w. * Anne C. Miers Institute of Psychology, Developmental and Educational acmiers@fsw.leidenuniv.nl Psychology Unit, Leiden University, 2333AK Leiden, The Netherlands Research Institute of Child Development and Education, University of Amsterdam, 1018WS Amsterdam, The Netherlands Behavioural Science Institute, Radboud University Nijmegen, 6500HE Nijmegen, The Netherlands Child Health, TNO, 2316ZL Leiden, The Netherlands 1234567890();,: 1234567890();,: Journal of Child and Family Studies Social anxiety disorder (SAD) is among the top three most Two core components of interventions aimed at preventing prevalent disorders in Western societies (Kessler et al., 2005); or treating (social) anxiety are exposure and cognitive an estimated seven to 13 percent of individuals experience restructuring (e.g., Higa-McMillan et al., 2016). Exposure SAD at some point during their life (Furmark, 2002). Social aims to reduce affective and behavioral symptoms of anxiety anxiety is characterized by a fear of negative evaluation and by entering and remaining in a situation that provokes fear distress in and potential avoidance of social situations. Even (Rodebaugh et al., 2004). By exposing the individual to fear- though the average age of onset for social anxiety disorder is provoking stimuli, they learn new adaptive responses to thirteen, prodromal symptoms of social anxiety can already be fearful situations (e.g., engagement instead of avoidance). present in childhood (Miers et al., 2013). The prevalence of Exposure thus reduces the association between anxiety- social anxiety disorder in adolescents ranges from three to nine provoking situations and their feared negative consequences percent(Rantaetal., 2015). Social anxiety disorder is rela- and helps children overcome their avoidance of social situa- tively stable over time, and individuals suffering from this tions. Exposure might also teach anxious children to control disorder are generally reluctant to seek help (Baer & Garland, and reduce visible signs of arousal, which can help them 2005). Social anxiety is conceptualized as existing on a con- experience successful social interactions. In turn, this may tinuum from normal, healthy levels of arousal to levels of decrease their negative peer experiences, such as isolation and arousal that cause distress and inhibit normal functioning bullying victimization (Rapee & Spence, 2004). Additionally, (Rapee & Spence, 2004). Socially anxious children and ado- by creating positive experiences, exposure might increase an lescents often experience excessive physiological arousal in anxious child’s perceived social competence (Donders & social situations, particularly in public performance situations Verschueren, 2004). (American Psychiatric Association, 2013; Rapee & Spence, Cognitive restructuring focuses on the cognitive processes 2004). In addition, maladaptive, automatic cognitions may that emerge in (anticipation of) or following (i.e., rumination) inhibit the correct processing of social information (i.e., inter- situations that provoke anxiety to identify and challenge preting others’ social behavior as a negative evaluation) and automatic, negative, and self-defeating thoughts and to may trigger anxious and avoidant behavior (Miers et al., 2011). implement more positive, helpful thoughts (McLellan et al., Many intervention programs for youth, both preventive and 2015). Cognitive restructuring teaches children to change curative, are currently available to reduce social anxiety in negative cognitive appraisals, reduce self-criticism, and children and adolescents. In particular, group interventions in modify interpretations of social stimuli to reduce anxiety in the clinical context have shown positive effects on speciﬁc social situations (Rodenbaugh et al., 2004). For example, social anxiety symptoms such as social distress, behavioral socially anxious children generally anticipate adverse perfor- avoidance, enhanced social skills, and social interaction, and on mance outcomes, overestimate the visibility of their nerves, secondary outcomes such as general anxiety and depressive and negatively evaluate their behavior and their performance symptoms (Scaini et al., 2016;Kleyetal., 2012). However, (Miers et al., 2009). Some socially anxious children even social anxiety interventions combine multiple components, so undermine their adequate social competence through their what component drives program effects is unknown. To ﬁll this negative self-perceptions (Miers et al., 2009; Miers et al., gap, this study presents a microtrial study (Howe et al., 2010) 2011). By tackling maladaptive cognitions using cognitive investigating which intervention components (i.e., gradual restructuring, children learn to more accurately perceive and exposure, cognitive restructuring, or a combination) effectively thus anticipate social situations, which should reduce their reduce social anxiety symptoms and secondary outcomes that anxiety (Taylor et al., 1997). may be negatively inﬂuenced by children’s anxiety in children The treatment of socially anxious children is challenging with elevated social anxiety symptoms in a prevention context. due to its various interrelated etiological determinants (Ranta The peer context plays an important role in children’s et al., 2015). Nevertheless, a recent meta-analysis showed that development of social skills (e.g., Smith & Hart, 2002). cognitive-behavioral therapy interventions have signiﬁcant Therefore, it is crucial to direct preventive intervention effects (Cohen’s d= 0.71) on children’s and adolescents’ efforts at school-age children (Alves et al., 2022). Imple- social anxiety symptoms (Scaini et al., 2016). However, the menting interventions in children’s day-to-day social con- programs included in this study combined cognitive techni- text may protect them from developing clinical-level social ques, exposure, and social skills training in multicomponent anxiety that might interfere with their healthy social programs, making it difﬁcult to infer the effectiveness of development (Baer & Garland, 2005). Research also sug- individual intervention components. Information about the gests that social anxiety is more difﬁcult to treat in ado- effects of separate intervention components is crucial because lescence (e.g., Crawley et al., 2008). Therefore, to it provides insight into which components are necessary for contribute to the prevention of social anxiety, we focused improvement, thereby maximizing intervention effects. on evaluating preventive intervention component effects in Our goal of identifying effective intervention program children aged eight to thirteen with emerging social anxiety. components to prevent childhood-based social anxiety is Journal of Child and Family Studies informed by previous research on anxious individuals. A interventions is expedient as these might be more cost- review of ﬁve meta-analyses concluded that both exposure effective, and the burden on clinicians and families might be and cognitive restructuring reduced social anxiety symp- lower. Second, the microtrial approach can elucidate which toms in adults and that a combination of cognitive components are effective and thus provide knowledge to restructuring and exposure did not seem superior to expo- develop more speciﬁc, targeted interventions (Leijten et al., sure alone (Rodebaugh et al., 2004). However, cognitive 2015). This approach is in line with the call for explanatory awareness may be less developed in children (i.e., pre- research into mechanisms of change, as opposed to tradi- adolescents), and, therefore, more cognitive-oriented tional RCTs into intervention effects (Nakamura et al., 2009). approaches may yield less effect. Also, some studies sug- The sample for the present microtrial consisted of eight- gest that a cognitive approach may be less effective for to thirteen-year-old children with elevated symptoms of children and adolescents with social anxiety than other social anxiety who participated in a brief four-week pre- affective disorders (e.g., Crawley et al., 2008). ventive group intervention. We aimed to answer two A meta-analysis by Scaini et al. (2016)showed the research questions: Are brief group interventions using effectiveness of cognitive-behavioral interventions for chil- exposure, cognitive restructuring, or combining both com- dren and adolescents with a clinical diagnosis of social ponents effective in reducing social anxiety symptoms and anxiety, but this study did not speciﬁcally compare the effects related outcomes?, and Is there a difference in effectiveness of exposure and cognitive restructuring. Another meta- between the brief group interventions? analysis provided more insight by showing that cognitive- In line with the aim of microtrials to suppress speciﬁc behavioral therapy-based interventions and exposure-based risk mechanisms or enhance protective mechanisms (Howe interventions had similar effects in children with anxiety and et al., 2010) we include several outcome measures divided avoidance problems (d= 1.19 and 1.05, respectively; Higa- into primary and secondary outcomes. Both primary and McMillan et al., 2016). Furthermore, a large RCT into anxiety secondary outcomes included risk and protective mechan- interventions (i.e., the CAMS trial) found similar results, isms. Our primary outcomes were directly related to the indicating that the introduction of cognitive restructuring and diagnostic criteria for social anxiety disorder and prominent exposure was associated with signiﬁcant declines in anxiety social anxiety cognitive models (American Psychiatric symptom severity and that exposure seemed to be most Association, 2013; Clark & Wells, 1995) and consisted of effective in children compared to adolescents (Peris et al., social anxiety symptoms, distress, avoidant behavior, 2015). A multiple single-case study by Nakamura et al. approach behavior, positive thoughts, and perceived social (2009) also concluded that exposure might be a key element threat. Previous research has related social anxiety in youth in interventions for anxiety-disordered children. to low self-esteem and fewer friendships (Fordham & Ste- The ﬁndings from these studies suggest that exposure and venson-Hinde, 1999), impaired social skills (Miers et al., cognitive-behavioral exercises might be independently effec- 2009), loneliness, and depression (Rapee & Spence, 2004). tive in improving children’s anxiety-related problems. How- Such negative outcomes may impede successful social ever, these studies mostly assessed intervention effects in interactions, which in turn may increase risk for social children with clinical anxiety levels not speciﬁcto social anxiety through heightened fear of negative evaluation anxiety. Also, Peris et al. (2015) analyzed data from an (Fredrick & Luebbe, 2022). In contrast, a more positive intervention that included more intervention components than evaluation of social skills, self-efﬁcacy, and competence, only exposure and cognitive restructuring, and, consequently, and less loneliness and depression may beneﬁt children’s the independent effect of exposure and cognitive restructuring positive social experiences and lower their fear of negative remains unclear. Furthermore, whether these intervention evaluation. In the long term, this may be associated with a components are equally effective in a prevention context is higher quality of life, therefore acting as a protective unknown. Thus, empirical research into the separate effec- mechanism (Alves et al., 2022). Thus, in line with previous tiveness of components in childhood social anxiety interven- microtrial studies we assessed changes in social anxiety tions is absent, especially in an indicated-prevention context. symptoms as well as secondary outcome measures related to We applied a microtrial approach to identify whether social anxiety more broadly (de Jong et al., 2021): inter- exposure, cognitive restructuring, or a combination of both nalizing behavior, self-efﬁcacy, social skills, and self- effectively reduced social anxiety in children. A microtrial is perceived competence. These secondary outcomes may be a brief, focused randomized experiment to assess whether an impaired in children with social anxiety and might improve isolated intervention component brings about signiﬁcant by proxy of reduced social anxiety symptoms. change (Howe et al., 2010). Using this approach has two We expected social anxiety symptoms and related sec- speciﬁc advantages. First, it can elucidate which intervention ondary outcomes to reduce in all three types of preventive components are not effective and can thus help to develop intervention. We speciﬁcally focussed on eight- to thirteen- leaner, more efﬁcient interventions. The availability of leaner year-olds because this is the age group approaching the Journal of Child and Family Studies Fig. 1 Participant ﬂow onset period for clinical diagnosis of social anxiety (Rapee Seven schools agreed to participate in the exposure con- & Spence, 2004). We did not formulate hypotheses about dition, ﬁve in the cognitive restructuring condition, and the expected difference in the effectiveness of exposure four in the condition combining both components (here- versus cognitive restructuring due to a lack of relevant after labeled the combination condition). A total of research for this age group and anxiety type. Nevertheless, N = 1431 children completed Pretest 1 (i.e., the baseline we might expect that a combination of two evidence-based sample). In this baseline sample, children had a mean age intervention components would yield more substantial of 10.56 (SD = 1.03) years, 48.5% (n = 694) were girls effects than the separate components. and 43.8% (n = 608) reported having a Non-Western ethnicity. We invited a total of 248 children from the baseline Method sample to take part in the study (see ﬂowchart in Fig. 1). The parents of 23% (n = 57) of these children did not Participants actively consent to participation, resulting in a ﬁnal sample of 191 children: 82 children in the exposure condition, 73 Participants for this study were children with emerging children in the cognitive restructuring condition, and 36 social anxiety symptoms from the three highest grades of children in the combination condition. Due to the smaller 16 Dutch primary schools (equivalent to American grades number of schools in the combination condition, fewer four to six), predominantly located in urban areas. We children could be invited for this intervention, resulting in randomized participants into conditions at the school level. fewer children in this condition. Journal of Child and Family Studies The ﬁnal sample had a mean age of 10.48 years (SD = into one of the three conditions. Schools that solely offered 1.07, range 8.11 to 13.29 years) with somewhat more girls special education programs or with fewer than 50 children (63.4%, n = 121). Ethnicity was deﬁned as follows: 55% in the highest three grades were excluded from participa- (n = 104) of the children had a Western origin (87% Dutch) tion. We invited schools that met our criteria by invitation and 44% (n = 84) had a Non-Western origin (30% Turkish, letter. We anticipated a fair number of schools to turn down 27% Moroccan, 16% Surinamese/Antilles, 27% other). the invitation due to the high workload in primary schools, Three children did not disclose their ethnicity. Children in and therefore, we invited a total of 100 primary schools to our sample had a mean score of 54.28 on the Social Anxiety the sample. Seven schools agreed to participate. A second Scale for Adolescents (SAS-A), which is just above the recruitment wave added nine schools to the sample. These clinical cut-off (La Greca, 1999). In total, 65.8% of the schools were recruited through an advertisement in a sample scored above the clinical cut-off at Pretest 1 national magazine for school counselors. More detailed (exposure condition 59.3%, cognitive restructuring condi- information about the participating schools is provided in tion 74%, and combination condition 63.9%). Descriptive Supplementary Appendix A, Section A.3. Participants were statistics of the baseline sample, the children selected and screened for the intervention based on their Pretest 1 scores. those that were not selected for the interventions are pre- sented in Supplementary Appendix A, Tables A.1 and A.2. Procedure Design We informed parents about the study and requested passive consent before the ﬁrst measurement occasion, which We used a cluster-randomized microtrial design to evaluate served as Pretest 1 and was used to screen participants for the effects of separate intervention components to enhance the intervention. At Pretest 1, research assistants or the ﬁrst speciﬁc outcomes (Howe et al., 2010). Schools were ran- author visited children in their classrooms to explain the domized into a condition before the invitation to participate goals of the study. We did not tell children that Pretest 1 and were blind to the assigned condition. We adopted was used to identify children with emerging social anxiety cluster randomization as individual-level randomization was symptoms to avoid drawing negative attention (i.e., stig- not practically feasible, and cluster randomization ensured matization) to children selected for the intervention. The there would not be contamination across conditions completion of the questionnaires took approximately 60 min (Campbell et al., 2000). Our microtrial included three on each measurement occasion. Children without parental conditions and four time points: Pretest 1 (approximately consent stayed in the classroom and worked on individual ﬁve weeks before the start of the intervention), Pretest 2 tasks or read a book. (one week before the start of the intervention), Posttest (one Children were selected for the interventions based on week after the end of the intervention), and Follow-up their score on the Social Anxiety Scale for Adolescents (three months after Posttest). By including two pretest (SAS-A; La Greca, 1999) at Pretest 1. For every school, measurements, individual change (i.e., natural develop- children’s scores on the SAS-A were mean-centered per ment) before the intervention could be compared to the grade, and the children scoring in the highest 20% on social change from Pretest 2 to Posttest (i.e., pre-post intervention anxiety within their class distribution were considered eli- effects). Additionally, including two pretest measurements gible for the intervention. Children were selected based on allowed participants to be their own control, strengthening class means because research has shown that social anxiety the power of our study. A priori power analysis showed that in childhood and adolescence is inﬂuenced by class climate 52 participants were necessary per condition to ﬁnd a main (Gazelle, 2006) and peer comparisons (Rapee et al., 2020), effect of condition with a medium effect of 0.40, a power of and therefore, the mean class level was deemed a suitable 0.80, and an alpha of 0.05 (two-sided). This study was benchmark to select children with emerging social anxiety. performed in line with the principles of the Declaration of After selection, school personnel reviewed the eligible Helsinki. Approval was granted by the Ethics Committee of children. School personnel did not agree with the selection the University of Amsterdam (24-04-2017/No. 8033). We of seven participants—because of participation in another retrospectively registered the study [blinded for social-emotional intervention program, not speaking Dutch submission]. ﬂuently, or a clinical diagnosis of Autistic Spectrum Dis- order, for example—, and were allowed to propose other Sampling Procedures children. The SAS-A scores of the proposed children had to be higher than the class mean to participate in the From a database of all Dutch elementary schools, we intervention. selected schools that were located within the trainers’ work After the ﬁnal list of participants had been agreed upon, catchment area; these selected schools were randomized we distributed another information letter requesting active Journal of Child and Family Studies parental consent to participate in the rest of the study. There The DAAS presents children with a social situation (e.g., was no monetary incentive. Children with parental consent “Imagine you are in class and your teacher asks you to participated in the intervention, which was provided by answer a question”). Children rated (i) how distressed they eight certiﬁed trainers (75% female) with an average of ﬁve would feel when faced with the presented situation (sub- years of experience. All trainers had a degree in Social scale Distress; 1 = I feel good to 5 = I feel very tense, ﬁve Work, Pedagogics, or Psychology. The children completed items); (ii) the extent to which they try to avoid the situation the questionnaire an additional three times (see Fig. 1). (subscale Avoidance, 1 = I never do to 5 = I always do, ﬁve School personnel supervised the measurement at Pretest 2, items); (iii) the extent to which they look forward to the Posttest, and Follow-up. After the last measurement occa- situation if it were to occur in one week (subscale sion, all schools received 50 euros for their participation. Approach, 1 = I look forward to it a lot to 5 = I do not look The ﬁnal sample sizes of the three conditions were unequal forward to it at all, ﬁve items); and (iv) the extent to which due to two reasons i) the number of schools that agreed to they feel efﬁcacy to take on the situation described (sub- participate in our study across the three conditions was scale Self-Efﬁcacy, 1 = I will do very well to 5 = I will not unequal, and ii) the number of children that could be do well at all, ﬁve items). The sum of the ﬁve items com- selected for the interventions was dependent on class size, prised the total score for each subscale. The reliability was yielding a smaller number of selected children at schools satisfactory across measurement occasions (Distress: with smaller class sizes. We collected all data between α = 0.63 to 0.91; Avoidance: α = 0.65 to 0.91; Approach: September 2017 and April 2019. α = 0.72 to 0.94; Self-efﬁcacy: α = 0.67 to 0.95). Primary Outcome Measures Positive Thoughts and Perceived Social Threat Social Anxiety The Children’s Automatic Thoughts Scale – Negative/ Positive (CATS-N/P; Hogendoorn et al., 2010) was used to To assess our primary outcome measure, children ﬁlled out assess children’s negative and positive thoughts. The sub- the Dutch translation of the Social Anxiety Scale for Ado- scales Perceived social threat (10 items) and Positive lescents (SAS-A; La Greca, 1999), a 22-item scale assessing thoughts were used (10 items). Children answered items on fear of negative evaluation, social avoidance, distress in new a ﬁve-point scale (1 = never to 5 = always), and the sum of situations, and general social avoidance and distress. Items the items comprised the subscale scores. The CATS-N/P were rated on a ﬁve-point scale (1= never,5= always), and has satisfactory discriminant validity in a community sam- the sum of the 18 substantive items (four are ﬁller items) ple (Hogendoorn et al., 2010). In this study, the reliability of comprised the total score. A score of 50 or above means was good across measurement occasions (Perceived social children experience clinical levels of social anxiety (La Greca, threat: α = 0.85 to 0.96; Positive thoughts: α = 0.82 to 1999). The SAS-A has good construct validity (Inderbitzen- 0.97). Previous research has shown that clinical anxiety Nolan & Walters, 2000). In this study, reliability was satis- groups score M = 18.26 on the social threat subscale factory across measurement occasions (α= 0.77 to 0.91). Schniering and Rapee (2002) and M = 16.09 on the positive thoughts subscale (Hogendoorn et al., 2013). Distress, Avoidant, Approach Behavior, and Self-Efﬁcacy Secondary Outcome Measures To assess levels of distress and if children actively try to avoid speciﬁc social situations, we developed a ques- Internalizing Behavior tionnaire based on social situations from the Anxiety Disorders Interview Schedule for Children (ADIS-C; Sil- Children’s internalizing behavior was measured using the verman & Albano, 1996). Research previously used these subscale Internalizing problem behavior from the Dutch situations to measure distress and avoidance (e.g., Miers translation of the self-report version of the Social Skills et al., 2014). We adapted the scale by selecting ﬁve social Improvement System-Rating Scales (SSIS-RS; Gresham & situations that can provoke anxiety and are relevant to the Elliott, 2008; van den Heuvel et al., 2017). This 10-item current age group (i.e., answering a question in class, subscale is answered on a four-point scale (1 = not true to reading aloud in class, giving an oral presentation, playing 4 = very true). The items pertain to children’s experience of with unfamiliar children, and asking a classmate a ques- anxiety, loneliness, and depression, as well as physical signs tion), andbyaddingan itemtomeasure the tendency to of anxiety and depression (i.e., nausea and tiredness). The approach social situations. These adaptations resulted in sum of the items comprised the subscale score. The English the Distress, Avoidance, Approach, and Self-efﬁcacy version of the SSIS-RS has strong internal consistency, and (DAAS) scale. convergent and divergent validity (Gresham et al., 2011). In Journal of Child and Family Studies this study, reliability was satisfactory across measurement psychoeducation about social anxiety; (ii) the exercises occasions (α = 0.62 to 0.89). gradually built up to the (hypothetical) situation of giving an oral presentation in front of the class; (iii) they were Social Skills provided by trained professionals with an average of 10.6 years of experience in CBT for children (SD = 8.5, range Children’s social skills were also measured using the SSIS- 2–27 years); (iv) they were implemented as a group RS. We used the subscales Assertion (seven items), Coop- training consisting of four one-hour sessions, provided eration (seven items), Communication (six items), over a month; (v) given during school hours in groups of Responsibility (seven items), Empathy (six items), eightto10children, and(vi)includedsupportingmate- Engagement (seven items), and Self-control (six items). All rials like a workbook for participants and posters. At the items were answered on a four-point scale (1 = not true to end of each session, trainers stimulated children to prac- 4 = very true). The sum of the items across the subscales tice what they had learned outside of the intervention. comprised the outcome Social skills. In this study, relia- Table 1 and the following paragraphs provide a broad bility was good across measurement occasions (α = 0.96 overview of the intervention modules. Supplementary to 0.99). Appendix B, Tables B.1, B.2, and B.3 provide more detailed information, and the module manuals are avail- Self-Perceived Competence able upon request from the third author [blinded for submission]. Implementation was closely monitored by Children’s self-perceived competence was measured using the ﬁrst author, who scheduled calls with the trainers after the Dutch translation (Veerman et al., 1997) of the Self- completion of the intervention to check program ﬁdelity. perception Scale for Children (SPPC; Harter, 1985), which Trainers indicated all exercises were implemented as comprises 36 items. We used a shorter version, comprising described in the intervention manual. items from the conceptually most relevant subscales namely In the exposure module, children were taught that they social acceptance, behavioral conduct, and global self- could overcome anxiety by decomposing an anxiety- worth. In the original version items consist of two opposing provoking situation into small steps (i.e., habitual desensi- statements, and children indicate how true the best ﬁtting tization). The exposure module included exercises targeting statement is for them. We reformulated items and answering three situations that can be difﬁcult for socially anxious categories to simplify the items and make them more con- children: one social interaction situation, starting and join- sistent with the other measures. An example item is “Some ing a conversation, and two performance situations, asking children ﬁnd it difﬁcult to make friends”. Items were and answering a question and giving an oral presentation. answered on a four-point scale (1 = I am not like these These situations were divided into smaller steps that gra- children to 4 = I am exactly like these children), and the dually increased in difﬁculty. These steps were presented to sum of the items comprised the scale score. The SPPC had children using the metaphor of a stepladder, which dis- good internal consistency, test-retest stability, and con- assembles larger tasks or goals into small steps. Children vergent validity in a community sample (Muris et al., 2003). practiced with these situations using role-plays. Trainers In this study, reliability was good across measurement were instructed not to talk to children about their thoughts occasions (α = 0.82 to 0.86). in this module, but to solely focus on practicing with fear- evoking situations. Intervention Modules In the cognitive restructuring module, children were taught that they could overcome anxiety by changing their The intervention modules were inspired by cognitive thinking patterns. The cognitive restructuring module used behavioral training programs such as Cool Kids (Rapee the same three social situations hypothetically (e.g., “Ima- et al., 2006) and PASTA training (Sportel et al., 2013). We gine you have to answer a question in class”) to teach adapted exposure exercises and cognitive restructuring children to reﬂect on the inﬂuence their thoughts have on exercises to ﬁt the purpose of this study. We extensively their behavior. Exercises consisted of written exercises and reviewed and revised the modules with professionals with group discussions. The cognitive restructuring module ﬁve to 10 years of training experience to ensure the worked with a handout containing six steps to turn negative appropriateness for the target audience and employability of thoughts into positive, helpful thoughts. The cognitive the modules. Psychoeducation is an important component in restructuring condition did not include role-plays. Trainers improving treatment effects and therefore was included in were instructed not to talk to children about children con- each condition (de Mooij et al., 2020). fronting their fears by engaging in anxiety-provoking Several elements were the same for all three interven- situations but to solely focus on practicing with challen- tion modules: (i) they started with three exercises on ging unhelpful thoughts. Journal of Child and Family Studies Table 1 Broad session overview of the implemented intervention modules Session Exposure module Cognitive restructuring module Combination module 1 � Psychoeducation about � Psychoeducation about (social) anxiety. � Psychoeducation about (social) anxiety. (social) anxiety. � Group discussion of the Thoughts-Feelings-Behavior- � Habitual exposure: starting and joining a � Habitual exposure: model using a story character: connecting thoughts and conversation (step 1 of 3). starting and joining a feelings (giving a presentation step 1 of 4). � Explain two strategies to decrease anxiety: conversation (step 1 of 3). � Written exercise with the Thoughts-Feelings-Behavior- change thoughts (cognitive restructuring) and � Habitual exposure: asking model: giving a presentation (step 2 of 4). face the situation (exposure). and answering a question � Habitual exposure: giving a presentation (step (step 1 of 3). 1of4) � Habitual exposure: giving a presentation (step 1 of 4) 2 � Habitual exposure: asking � Group exercise to practice identifying and transforming � Group discussion of the Thoughts-Feelings- and answering a question helpful and non-helpful thoughts. Behavior-model using a story character: (step 2 of 3). � Written exercise with Thoughts-Feelings-Behavior- connecting thoughts and feelings. � Habitual exposure: model: asking and answering a question (step 2 of 3). � Written exercise with Thoughts-Feelings- starting and joining a � Written exercise with Thoughts-Feelings-Behavior- Behavior-model: giving a presentation. conversation (step 2 of 3). model: starting and joining a conversation (step 2 of 3). � Group discussion on the Thoughts-Feelings- � Habitual exposure: giving Behavior-model: connecting thoughts, a presentation (step 2 of 4) feelings, and behavior. � Habitual exposure: starting and joining a conversation (step 2 of 3). 3 � Habitual exposure: � Group discussion on the Thoughts-Feelings-Behavior- � Group exercise to practice identifying and starting and joining a model: connecting thoughts, feelings, and behavior. transforming helpful and non-helpful thoughts. conversation (step 3 of 3). � Written exercise with Thoughts-Feelings-Behavior- � Written exercise with Thoughts-Feelings- � Habitual exposure: asking model: asking and answering a question (step 3 of 3). Behavior-model: starting and joining a and answering a question � Written exercise with Thoughts-Feelings-Behavior- conversation (step 3 of 3) (step 3 of 3). model: starting and joining a conversation (step 3 of 3). � Habitual exposure: giving a presentation (step � Habitual exposure: giving 2of4) a presentation (step 3 of 4) 4 � Habitual exposure: giving � Introduction of the session. � Introduction of the session. a presentation (step 4 of 4) � Group game to recap transforming non-helpful � Written exercise with Thoughts-Feelings- � Review of all sessions. thoughts to helpful thoughts. Behavior-model: giving a presentation (step � Closure of the module � Written exercise with Thoughts-Feelings-Behavior- 3 of 4). with a certiﬁcate. model: giving a presentation (step 4 of 4). � Habitual exposure: giving a presentation (step � Review of all sessions. 3of4) � Closure of the module with a certiﬁcate. � Review of all sessions. � Closure of module with a certiﬁcate. In the combination module, children were taught that Statistical Analyses they could overcome anxiety by decomposing an anxiety- provoking situation into small steps and by identifying We analyzed the data using latent change models (LCMs) in negative thoughts and replacing them with positive, helpful Mplus version 7.31 (Muthén & Muthén, 1998–2015). thoughts. The combination module combined exposure and LCMs have a larger power to detect effects and are robust to cognitive restructuring in all sessions. This module com- non-normality compared to analyses of variance (Kline, bined role-play exercises with written exercises and group 2011; Schmidt et al., 2014). All analyses were intention-to- discussions. As this module had to ﬁt exposure exercises treat, and models were ﬁt using full information maximum and cognitive restructuring exercises into four sessions, likelihood (e.g., Raykov, 2005) to make optimal use of participants worked with only two social situations: starting available information. We assessed non-independence of and joining a conversation and giving an oral presentation. observations due to nesting of participants in schools using The exercises aimed at cognitive restructuring preceded the linear mixed models in SPSS (Version 28), with school exposure exercises in every session and were similar in speciﬁed at level two. Intraclass correlations for nine out- structure to the exercises in the cognitive restructuring come variables ranged from 0.014 to 0.126 (i.e., 1.4–12.6% module. The exposure exercises were mostly the same as in variance explained at the school level) and were non-sig- the exposure module, with one key difference: the instruc- niﬁcant, meaning there is not a random effect of school- tions before the exposure exercises reminded children to level variation on participant-level scores. Thus, the Pretest think about the positive thoughts they had previously 1 means did not vary by school (Garson, 2020). There was a formulated. signiﬁcant random effect of school-level (ICC = 0.261, Journal of Child and Family Studies p = 0.03) for distress, so we accounted for non- condition (CM-condition in this section; 22.2%; independence by correcting the standard errors of the esti- χ [2,N = 188] = 65.67, p < 0.001). Further analyses of mates for the non-independence of the data (type = Pretest 1 scores revealed that non-Western children reported complex command) in further analyses (Muthén & Muthén, signiﬁcantly more social anxiety (SAS-A) compared to 1998–2015). Western children (F[1186] = 7.00, p < 0.01), therefore we To assess if the three conditions yielded signiﬁcant controlled for ethnicity in further analyses. Children in the changes in the 10 outcome variables, we evaluated LCMs CR-condition reported less distress (DAAS; using a multigroup approach, basing our models on Schmidt F[2187] = 13.56, p < 0.001) and more approach behavior et al. (2014). A base model with Pretest 2 as the intercept (DAAS; F[2187] = 9.01, p < 0.001) at Pretest 1 compared allowed us to assess changes in children’s self-reported to children in both the EXP-condition and the CM- behavior from Pretest 1 to Pretest 2 (hereafter labeled the condition. The conditions did not differ in children’s age pre-intervention period), and from Pretest 2 to post-test (F[2189] = 1.71, p = 0.15) or sex (χ [2,N = 191] = 6.18, (hereafter labeled the intervention period). An equivalent p = 0.05), nor were there Pretest 1 differences on the other model with Posttest as the intercept allowed us to assess the outcome variables. Analyses of variance showed there was changes from Posttest to Follow-up (hereafter labeled the not a systematic inﬂuence of age or sex on our ﬁndings, so follow-up period). Supplementary Appendix C, Fig. C.1 we did not control for age or sex in further analyses. illustrates the model. Model ﬁt was considered good when An inspection of bivariate correlations indicated that all the chi-square statistic was non-signiﬁcant, the root mean variables signiﬁcantly correlated in the predicted direction square error of approximation (RMSEA) value was lower at all time points. Overall, correlations between outcome than 0.08, and the comparative ﬁt index (CFI) value was variables were in the expected direction: social anxiety higher than 0.95 (Hu & Bentler, 1999). disorder related variables (social anxiety, distress, avoidant To assess within- and between-condition differences, the behavior, and negative thoughts) and internalizing behavior parameters representing change between time points were showed positive inter-correlations, and negative correlations constrained to equality within conditions (e.g., pre- with the positively formulated outcomes (positive thoughts, intervention period change and intervention period change approach behavior, self-efﬁcacy, social skills, and self- in the EX-condition) and between conditions (e.g., inter- perceived competence). The latter variables showed positive vention period change in the EX-condition and CR-condi- inter-correlations. There was a weak correlation between tion). We then compared the constrained model’s chi-square children’s age and internalizing behavior at Pretest 1 and statistic to the base model’s chi-square statistic. A sig- self-efﬁcacy at Follow-up. There was a weak correlation niﬁcant chi-square difference meant that the parameters between children’s sex and social anxiety, distress, constrained in the model were statistically different. Mplus approach behavior, positive thoughts, negative thoughts, syntax for the LCMs is available in Supplementary and self-efﬁcacy at Pretest 2, and avoidant behavior and Appendix C. approach behavior at Posttest. There was a weak correlation between children’s ethnicity and social anxiety, distress and approach behavior at Pretest 1, distress, approach behavior, Results and self-efﬁcacy at Pretest 2, distress, avoidant behavior, approach behavior, and self-efﬁcacy at Posttest, and distress Compared to the children that were not selected to partici- and approach behavior at Follow-up. None of these corre- pate in the intervention based on Pretest 1, there were more lations exceeded the 0.40 threshold. Supplementary girls in the ﬁnal sample (χ [1, N = 1420] = 18.51, Appendix D, Tables D.1 and D.2 present the correlation p < 0.001). There were no differences in age and ethnicity matrices. between selected and not-selected children (see Supple- mentary Appendix A, Table A.1). All children that parti- Intervention Component Effects cipated in the interventions completed all four intervention sessions. Table 2 presents demographics and the raw means We assessed the effectiveness of the individual intervention and standard deviations of all outcome variables at every components using unconstrained multigroup latent change measurement occasion for all three conditions. models (LCMs), and the ﬁt indices were adequate for all Before our main analyses, we assessed if there were outcomes: chi-squares were non-signiﬁcant, RMSEA values between-condition differences in children’s age, sex, and were lower than 0.08, and CFI values were higher than 0.95 ethnicity. The cognitive restructuring condition (CR-con- (see Supplementary Appendix D, Table E.1 for the full ﬁt dition in this section) contained signiﬁcantly more non- statistics). Table 2 presents parameter estimates for all Western children (79.5%) than the exposure condition models. Bold parameters indicate a signiﬁcant difference (EXP-condition in this section; 22%) and the combination between the change during the intervention period and the Journal of Child and Family Studies Table 2 Means (M) and standard deviations (SD) for the primary and secondary outcomes (N = 191) Exposure (n = 82) Cognitive restructuring (n = 73) Combination (n = 36) Age at Pretest 10.32 (0.95) 10.64 (1.12) 10.53 (1.18) 1(M[SD]) Sex: Girls 44 (53.7) 53 (72.6) 24 (66.7) (n [%]) Ethnicity: 18 (22.0) 58 (82.9) 8 (22.2) Non-Western (n [%]) Pretest 1 Pretest 2 Posttest Follow-up Pretest 1 Pretest 2 Posttest Follow-up Pretest 1 Pretest 2 Posttest Follow-up M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) Primary outcomes Social anxiety 53.22 (9.73) 52.00 (13.04) 45.92 (13.59) 42.60 (12.29) 55.96 (11.10) 49.79 (13.27) 40.80 (15.52) 39.84 (15.66) 53.29 (11.23) 51.70 (12.96) 50.34 (15.62) 45.31 (14.52) Above clinical 48 (59.3) 40 (53.3) 30 (40.0) 15 (22.1) 54 (74.0) 30 (52.6) 16 (28.6) 12 (26.1) 23 (63.9) 19 (57.6) 17 (53.1) 11 (39.3) cut-off (>50.0; n[%]) Distress 14.77 (3.37) 15.17 (4.38) 13.34 (4.70) 12.28 (4.12) 12.12 (3.77) 12.07 (4.60) 9.54 (4.30) 9.83 (4.37) 15.26 (3.84) 15.23 (4.52) 13.15 (5.50) 12.48 (5.54) Avoidant 10.72 (3.92) 11.15 (4.59) 9.99 (3.85) 8.74 (3.65) 10.04 (3.47) 9.25 (3.69) 7.82 (3.35) 8.20 (3.37) 10.81 (4.50) 11.70 (4.94) 10.89 (3.93) 9.95 (4.54) behavior Approach 8.86 (3.68) 9.03 (4.18) 9.65 (3.42) 10.19 (3.90) 11.00 (3.98) 11.07 (3.57) 12.92 (3.71) 12.83 (4.06) 8.11 (3.90) 7.33 (4.20) 8.98 (4.38) 9.31 (5.19) behavior Positive 21.40 (6.84) 22.22 (8.83) 24.74 (8.06) 24.72 (8.80) 23.12 (9.07) 24.27 (8.62) 27.14 (8.20) 26.43 (9.93) 22.90 (7.75) 21.77 (9.48) 23.19 (8.29) 24.11 (8.33) thoughts Perceived 21.84 (7.42) 20.70 (7.33) 19.16 (7.44) 17.10 (6.06) 22.31 (8.96) 21.22 (8.72) 18.42 (8.13) 18.27 (8.27) 20.95 (8.45) 20.65 (8.68) 20.90 (9.35) 18.00 (7.80) social threat Secondary outcomes Internalizing 21.76 (6.45) 21.45 (6.72) 20.13 (7.01) 18.85 (6.99) 21.06 (6.52) 20.53 (7.92) 18.51 (6.09) 17.52 (6.55) 21.99 (6.82) 22.36 (7.20) 19.38 (6.50) 20.89 (8.00) behavior Self-efﬁcacy 11.11 (3.05) 10.89 (3.70) 12.19 (3.66) 12.48 (3.52) 12.19 (3.66) 12.41 (3.57) 13.94 (3.71) 13.65 (4.06) 11.14 (3.66) 10.14 (3.95) 12.19 (3.94) 12.96 (3.56) Social skills 136.27 (20.94) 141.25 (17.11) 145.06 (19.33) 148.06 (19.05) 137.35 (22.26) 141.39 (22.41) 143.83 (23.79) 145.62 (28.17) 133.47 (19.19) 136.13 (18.02) 133.12 (21.46) 137.38 (18.83) Self-perceived 54.03 (8.81) 55.50 (8.57) 57.41 (8.61) 58.97 (8.31) 53.75 (9.89) 55.81 (10.01) 58.49 (9.45) 57.77 (9.72) 54.34 (8.78) 55.30 (9.37) 56.60 (8.67) 58.06 (7.46) competence Journal of Child and Family Studies pre-intervention period. Supplementary Appendix E, Table intervention period, it was signiﬁcantly larger than the non- E.2 presents the complete ﬁt indices for the constrained signiﬁcant change during the pre-intervention period models and chi-square differences. (Δχ = 4.89, p < 0.01). Children in the EXP-condition signiﬁcantly improved on Children’s self-perceived competence signiﬁcantly all outcome measures during the intervention period. These improved further during the follow-up period. This improvements were signiﬁcantly larger than the non- improvement was signiﬁcantly larger than children’s signiﬁcant changes during the pre-intervention period for improvement in self-perceived competence during the 2 2 social anxiety (Δχ = 17.25, p < 0.001), distress intervention period (Δχ = 7.45, p < 0.01). Children did not 2 2 (Δχ = 8.84, p < 0.01), approach behavior (Δχ = 5.97, show signiﬁcant further improvement on any other outcome p < 0.05), positive thoughts (Δχ = 15.21, p < 0.001), per- measures during the follow-up period, but intervention ceived social threat (Δχ = 11.48, p < 0.001), internalizing effects were sustained at follow-up. behavior (Δχ = 6.25, p < 0.05) and self-perceived compe- Children in the CM-condition signiﬁcantly improved in tence (Δχ = 8.39, p < 0.01). Improvements during the distress, approach behavior, internalizing behavior, and self- intervention period on children’s avoidant behavior and efﬁcacy during the intervention period. However, only self-efﬁcacy were not signiﬁcantly larger than during the children’s improvement in distress and internalizing beha- pre-intervention period (Δχ = 3.08, p > 0.05 and vior was signiﬁcantly larger than the change during the pre- 2 2 2 Δχ = 2.09, p > 0.05, respectively). Children’s improvement intervention period (Δχ = 6.04, p < 0.05, and Δχ = 4.55, in social skills was signiﬁcant during both the pre- p < 0.05, respectively). Children’s improvements in intervention period and the intervention period, however, approach behavior, and self-efﬁcacy during the intervention the improvement during the intervention period was sig- period were not signiﬁcantly larger than the non-signiﬁcant 2 2 niﬁcantly larger (Δχ = 14.23, p < 0.001). changes during the pre-intervention period (Δχ = 1.25, Children reported an additional signiﬁcant improvement p > 0.05, and Δχ = 1.58, p > 0.05, respectively). Children in social anxiety, distress, and avoidant behavior during the in the CM-condition did not signiﬁcantly improve in social follow-up period. However, children’s improvement in anxiety, avoidant behavior, positive thoughts, perceived social anxiety and distress during the follow-up period was social threat, social skills, or self-perceived competence. signiﬁcantly smaller than during the intervention period Children did not show signiﬁcant further improvement on 2 2 (Δχ = 33.91, p < 0.001, and Δχ = 27.56, p < 0.001, any of the outcome measures, but the intervention effects respectively). The improvement in avoidant behavior during were sustained at follow-up. the follow-up period was signiﬁcantly larger than the improvement during the intervention period (Δχ = 19.43, Differences in Effectiveness between the p < 0.001). Children did not show signiﬁcant further Intervention Conditions improvement on any other outcome measures, but inter- vention effects were sustained at follow-up. To assess whether there were between-condition (i.e., EXP-, Children in the CR-condition signiﬁcantly improved on CR-, and CM-condition) differences concerning the chan- all outcome measures during the intervention period except ges during the intervention period and the follow-up period, for social skills. The improvements for social anxiety we compared a model that constrained these periods to 2 2 (Δχ = 37.01, p < 0.001), distress (Δχ = 16.75, p < 0.001), equality across the conditions with a model that estimated approach behavior (Δχ = 15.30, p < 0.001), positive these changes for each condition separately. In Table 3, thoughts (Δχ = 11.31, p < 0.001), perceived social threat subscripts indicate signiﬁcant differences between the con- 2 2 (Δχ = 9.37, p < 0.01), internalizing behavior (Δχ = 9.57, ditions. Supplementary Appendix E, Table E.3 presents the p < 0.01), self-efﬁcacy (Δχ = 13.47, p < 0.001), and self- ﬁt indices for the constrained models and chi-square dif- perceived competence (Δχ = 9.17, p < 0.01) during the ference tests. intervention period were signiﬁcantly larger than the non- During the intervention period, children’s signiﬁcant signiﬁcant changes on these outcomes during the pre- improvements in social anxiety and perceived social threat intervention period. Children in the CR-condition also sig- were similar in the EXP-condition and the CR-condition, niﬁcantly improved on social anxiety during the pre- but children’s signiﬁcant improvement in social anxiety was intervention period, however, improvement during the signiﬁcantly larger in the CR-condition than in the CM- 2 2 intervention period was signiﬁcantly larger (Δχ = 37.01, condition (Δχ = 5.30, p < 0.05). Also, children’s signiﬁcant p < 0.01). Children’s improvement in avoidant behavior improvement on perceived social threat was signiﬁcantly during the intervention period was signiﬁcantly larger than larger in the EXP-condition and the CR-condition than in children’s signiﬁcant worsening during the pre-intervention the CM-condition (Δχ = 4.76, p < 0.05). Children’s sig- period (Δχ = 19.27, p < 0.001). Although children’s niﬁcant improvement on social skills during the intervention improvement in social skills was not signiﬁcant during the period was signiﬁcantly larger in the EXP-condition than Journal of Child and Family Studies Table 3 Model parameters for the unconstrained latent change models controlling for ethnicity across conditions Exposure Cognitive restructuring Combination intercept Δ Δ Δ intercept Δ Δ Δ intercept Δ Δ Δ 2-1 3-2 4-3 2-1 3-2 4-3 2-1 3-2 4-3 µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) Primary outcomes *** *** *** ** *** *** Social 51.49 (1.64) −0.39 (1.30) −6.71 (1.37) −2.79* (1.17) 50.03 (1.72) −5.90 (1.71) −8.88 (1.63) −2.13 (1.76) 51.25 (2.44) −1.98 (2.26) −1.07 (2.88) −3.05 (1.57) b a anxiety *** *** *** *** *** * Distress 15.02 (0.57) 0.27 (0.46) −2.01 (0.51) −0.98* (0.43) 11.90 (0.61) −0.31 (0.58) −2.44 (0.53) 0.09 (0.55) 15.35 (0.83) −0.04 (0.64) −2.01 (0.80) −0.09 (0.54) *** * ** *** * ** *** Avoidant 11.04 (0.58) 0.27 (0.45) −1.16 (0.47) −1.30 (0.37) 9.13 (0.48) −0.98 (0.40) −1.35 (0.46) 0.35 (0.40) 11.93 (0.91) 1.14 (0.66) 0.73 (0.75) −0.61 (0.77) a a b behavior *** ** *** *** *** * Approach 8.74 (0.53) 0.08 (0.40) 0.96 (0.36) 0.56 (0.38) 11.27 (0.46) 0.36 (0.85) 1.82 (0.49) −0.12 (0.36) 6.89 (0.74) −0.79 (0.51) 1.59 (0.63) 0.22 (0.52) behavior *** ** *** ** *** Positive 21.67 (1.12) 0.75 (1.02) 2.72 (0.91) 0.40 (0.87) 23.94 (1.12) 1.15 (1.01) 3.13 (1.06) −0.66 (0.91) 22.08 (1.79) −0.10 (0.88) 0.29 (1.05) 0.51 (1.35) thoughts *** *** * *** Perceived 20.08 (0.95) −1.06 (0.77) −2.18* (0.91) −1.22 (0.84) 21.17 (1.10) −1.17 (0.95) −2.54 (1.01) −0.83 (0.98) 20.51 (1.65) 0.24 (0.88) 0.80 (1.12) −2.26 (1.63) a b ab social threat Secondary outcomes *** * *** * *** ** Internalizing 21.09 (0.86) −0.51 (0.66) −1.45 (0.72) −1.09 (0.84) 20.72 (1.06) −0.44 (0.91) −2.33 (0.99) −1.39 (0.86) 22.75 (1.32) −0.18 (1.08) −2.76 (0.94) 2.73 (1.49) a b ab behavior *** ** *** ** *** ** Self-efﬁcacy 10.75 (0.46) −0.54 (0.38) 1.16 (0.40) 0.73 (0.40) 12.55 (0.46) 0.34 (0.40) 1.54 (0.46) −1.30 (0.40) 9.77 (0.70) −1.05 (0.62) 1.89 (0.58) 0.35 (0.40) *** * ** *** *** Social skills 140.36 (2.24) 4.01 (1.76) 4.95 (1.54) 1.60 (2.31) 140.02 (2.83) 3.49 (2.50) 2.43 (1.21) 2.43 (2.32) 135.30 (3.43) 2.86 (1.78) −2.81 (3.26) 2.53 (3.42) a b a *** *** *** * * *** Self- 55.08 (1.07) 0.51 (0.84) 2.93 (0.85) 0.34 (0.87) 55.79 (1.26) 1.90 (1.99) 2.38 (2.28) 9.52 (4.18) 54.51 (1.72) 1.54 (1.23) 1.23 (1.75) 2.19 (1.75) a a b percieved competence * ** *** Intercept = pretest 1; Δ = pre-intervention period; Δ = intervention period; Δ = Follow-up period. Asterixis indicate a signiﬁcant within-group change ( p < 0.05, p < 0.01, p < 0.001). 2-1 3-2 4-3 Latent means in bold indicate that there was a signiﬁcant (p < 0.05) within-group difference between the intervention period and the pre-intervention period. Latent means in the same row that share subscripts indicate that there was a signiﬁcant (p < 0.05) difference between conditions Journal of Child and Family Studies children’s non-signiﬁcant change in the CM-condition cognitions and positive thoughts. Between Pretest 1 and (Δχ = 4.44, p < 0.05), but not signiﬁcantly larger than follow-up participants’ social threat cognitions reduced by children’s non-signiﬁcant change in the CR-condition an average of 3.88, which is broadly in line with a 5-point (Δχ = 1.32, p > 0.05). There were no signiﬁcant between- change following a full CBT intervention (Rapee et al., condition differences during the intervention period on any 2022) for youth with social anxiety disorder; positive of the other outcome measures. thoughts increased by an average of 2.61, comparable to During the follow-up period, children’s signiﬁcant previously reported change in anxious youth following improvement in avoidant behavior was signiﬁcantly larger treatment of 3.29 (Hogendoorn et al., 2013). in the EXP-condition than children’s non-signiﬁcant change in the CR-condition (Δχ = 9.08, p < 0.01), but not sig- niﬁcantly larger than children’s non-signiﬁcant change in Discussion the CM-condition (Δχ = 0.63, p > 0.05). Children’s non- signiﬁcant worsening of internalizing behavior during the This microtrial aimed to identify whether brief preventive follow-up period in the CM-condition was signiﬁcantly group interventions using exposure, cognitive restructuring, different from children’s non-signiﬁcant improvement on or both effectively reduced social anxiety in children with internalizing behavior in the EXP-condition and CR- emerging symptoms. We assessed changes in symptoms of 2 2 condition (Δχ = 4.63, p < 0.05, and Δχ = 5.32, p < 0.05, social anxiety and social-emotional outcomes that might respectively). Children’s signiﬁcant improvement in self- change by proxy of the reduction in social anxiety symp- perceived competence was signiﬁcantly larger in the CR- toms. Our ﬁndings show that exposure and cognitive condition than in the EXP-condition (Δχ = 4.42, p < 0.05), restructuring effectively improved social anxiety and related but not signiﬁcantly larger than in the CM-condition outcomes as single intervention components. Exposure (Δχ = 0.31, p > 0.05). There were no signiﬁcant between- improved children’s symptoms of social anxiety and all condition differences for any other outcome measures dur- related outcomes measured, except for self-efﬁcacy. Cog- ing the follow-up period. nitive restructuring also improved children’s symptoms of social anxiety and related outcomes, except for social skills. Clinical Relevance After intervention with exposure or cognitive restructuring, 69 and 78%, respectively, of the children scoring in the To give an indication of the clinical relevance of the clinical range of social anxiety at Pretest 1 returned to changes in the intervention conditions, we analyzed the “normal” levels of anxiety at Follow-up; this is in line with number of children scoring above the clinical cut-off on the previous studies (Kendall & Peterman, 2015). Overall, our SAS-A in the different conditions. Analyses showed that in ﬁndings demonstrate that exposure and cognitive restruc- the exposure condition, 59.3% (n = 48) of the participants turing are similarly effective in reducing social anxiety and scored above the clinical cut-off at Pretest 1, versus 40.0% related outcomes in children with emerging symptoms, (n = 30) at Posttest (χ [74] = 11.90, p < 0.001) and 22.1% which is in line with ﬁndings from previous research (e.g., (n = 15) at Follow-up (χ [67] = 7.062, p < 0.01). In other Peris et al., 2015; Rodebaugh et al., 2004). words, 69% of the participants that scored in the clinical Previous research has found that reductions in anxious range of social anxiety at Pretest 1 improved to “normal” self-talk are associated with reduced anxiety symptoms levels (i.e., below the clinical cut-off) of social anxiety at (Kendall & Treadwell, 2007). In line with that study, we Follow-up. In the cognitive restructuring condition, 74.0% found that cognitive restructuring positively affected chil- (n = 54) of the participants scored above the clinical cut-off dren’s cognition. Children reported more positive thoughts at Pretest 1, versus 28.6% (n = 16) at Posttest (χ and perceived less social threat after the intervention. This [56] = 4.82, p < 0.05) and 26.1% (n = 12) at Follow-up (χ was also found for exposure—noteworthy given that only [46] = 3.18, p = 0.07). Thus, 78% of the participants in this cognitive restructuring paid explicit attention to children’s condition improved to the non-clinical range of social cognition. Exposure might elicit self-administered cognitive anxiety from Pretest 1 to Follow-up. In the combination restructuring (Rodebaugh et al., 2004), and the exposure condition, 63.9% (n = 23) of the participants scored above exercises might have served as expectancy violation exer- the clinical cut-off at Pretest 1, versus 53.1% (n = 17) at cises by disconﬁrming children’s expectation of negative Posttest (χ [32] = 0.40, p = 0.53) and 39.1% (n = 11) at evaluation (Craske et al., 2014). In this way, exposure may Follow-up (χ [28] = 1.10, p = 0.29). Hence, 47% of the cause children to adjust their unhelpful thoughts without participants in this condition improved to the non-clinical explicitly focusing on the negative cognitions. This ﬁnding range of social anxiety from Pretest 1 to Follow-up. implies a possibility of improving children’s cognition In addition, the interventions showed clinically relevant within a four-week exposure-based intervention. If expo- change in the following outcome measures: social threat sure is effective in improving children’s self-perceptions — Journal of Child and Family Studies as our ﬁndings suggest— this relatively easy-to-execute avoidant behavior needs time to ‘internalize’, as positive component could be used to prevent the development of effects of the intervention only emerged in the follow-up maladaptive thoughts in at-risk children. This is important period. It may be that children’s avoidance of anxiety- given that research has shown that negative self-perceptions provoking situations only reduces after a reduction in mediate the longitudinal relationship between shyness and anxiety symptoms and distress in these situations has been social anxiety (Blöte et al., 2019). established. An alternative explanation may be that, in line The structure of the exposure and cognitive restructuring with the gradual nature of the exposure component, children intervention modules may explain their similar effect on continued to work towards engaging in anxiety-provoking many outcomes. As well as teaching children to adjust their situations, thereby reducing their avoidant behavior (e.g., unhelpful thoughts, the cognitive restructuring intervention Peris et al., 2015). might also prompt imaginal exposure by instructing chil- An important ﬁnding of this microtrial is that an inter- dren to visualize hypothetical social situations. This vention combining exposure and cognitive restructuring mechanism was previously found in research with adults was less effective in preventing social anxiety than either with post-traumatic stress disorder: visualizing a situation component alone. Although this ﬁnding should be inter- yielded a signiﬁcant change in anxiety levels (Bryant et al., preted with caution due to the small sample size of the 2003). The possibility that exposure exercises prompt combination condition, it is in line with previous research children to engage in self-administered cognitive restruc- (e.g., Rodebaugh et al., 2004). Stacking multiple interven- turing may suggest that it is impossible to rule out non- tion components may thus not necessarily yield greater targeted components in separate component interventions; intervention beneﬁts. In fact, our ﬁndings suggest that there might be some cognitive restructuring in an exposure- compared to a combined intervention, cognitive restructur- only intervention and vice versa. ing was superior in reducing children’s social anxiety, that However, the exposure and cognitive restructuring both exposure and cognitive restructuring outperformed the components had a differential effect on several outcomes. combined intervention in reducing children’s perceived Unlike exposure, cognitive restructuring did not improve social threat, and that exposure outperformed the combined children’s social skills, which might be due to the focus on intervention in increasing children’s social skills. Possibly, cognition. While exposure is focused more “outward” each component may need to be administered in a certain towards behavior, cognitive restructuring is focused more minimum dosage and a combination of exposure and cog- “inward” towards the child’s inner world, which may make nitive restructuring might only be effective when the a difference in improving social skills. Children may spe- separate components are implemented in the right dosage. ciﬁcally need to enact social situations that provoke anxiety The combination intervention included fewer exposure and practice improving their social skills (e.g., Miers et al., exercises and cognitive restructuring exercises than the 2011)—which was the case in the exposure intervention but time-equal separate interventions, which may explain the not the cognitive restructuring condition. We also found that apparent absence of effects for the combined intervention. exposure did not improve children’s self-efﬁcacy, whereas We cannot rule out that a higher dose of the combination of cognitive restructuring did. In addition, cognitive restruc- exposure and cognitive restructuring would have an addi- turing was more effective in increasing children’s positive tive positive effect on social anxiety symptoms; four ses- thoughts, and this increase in positive thinking may be sions might be too few to implement both exposure and instrumental to the improvement in self-efﬁcacy (i.e., chil- cognitive restructuring sufﬁciently. By the same token, the dren’s prediction of how well they will perform certain lack of effects in the combined intervention may be ascribed tasks). Also, children’s belief in their ability to restructure to the fact that children practiced with fewer social situa- unhelpful thoughts and thereby control their emotions in tions (i.e., two instead of three) in this intervention. Alter- anxious situations may increase their self-efﬁcacy (e.g., natively, exposure and cognitive restructuring may be more Goldin et al., 2012). potent in the absence of other intervention components The positive effects of both exposure and cognitive (Peris et al., 2015). restructuring were sustained until the three-month follow-up Interpretation of our ﬁndings must take into account that on all outcomes for which an intervention effect was found. all interventions developed for this study included psy- Exposure continued to have an effect on social anxiety, choeducation about anxiety. Previous research (de Mooij distress, and avoidance of social situations up to three et al., 2020) has shown this is an important component in months after the intervention ended, and cognitive restruc- enhancing intervention effects. Therefore, we cannot rule turing continued to have an effect on self-perceived com- out that this common element is responsible for our lack of petence up to three months after the intervention ended. In differences between the intervention conditions. Future contrast to these sustained effects during the follow-up research may consider a factorial design to assess treatment period, our ﬁndings suggest that the effect of exposure on order effects (Leijten et al., 2015). Journal of Child and Family Studies Our study is not without limitations. First, one may view 2017). Future research might also evaluate the effectiveness the group setting of the brief interventions as a form of of other components frequently included in social anxiety exposure in itself. Although the exposure condition expli- interventions, such as problem-solving. Assessing the citly targeted social exposure through speaking in front of a effects of a parent component in social anxiety interventions group, differences with the cognitive restructuring condition might also prove insightful, as research has shown parenting may be somewhat less optimal. However, research has to be an etiological factor that may predict social anxiety shown that group CBT (which included both exposure and (Spence & Rapee, 2016). cognitive restructuring) had similar effects to individual It was beyond the scope of this study to assess subgroup CBT (Silverman et al., 2008); thus, we do not expect the variability in the effectiveness of intervention components. group context to have confounded our ﬁndings. Second, we In line with research suggesting that social anxiety is more assessed all outcomes with self-report measures. Although prevalent in women (Asher et al., 2017), slightly more girls this is common in anxiety research, including parent reports, than boys from the baseline sample reported elevated levels teacher reports and observations could provide a more of social anxiety and were selected for our interventions. comprehensive assessment of the children’s social anxiety Future research could assess what works for whom in social (Silverman & Ollendick, 2005). Third, there was an uneven anxiety interventions. Research has also shown that social distribution of participants across the conditions. Third, anxiety symptoms may differ based on ethnicity (e.g., fear implementation forms were not completed for all training of embarrassing oneself versus the other person), which groups, The workload of primary school teachers is high in may mean intervention components aimed at social anxiety the Netherlands, and as a result, many schools were reluc- are also differentially effective based on participants’ ethnic tant to participate in a study with multiple measurement backgrounds (Hofmann et al., 2010). A child’s level of occasions. Only a few schools randomized into the com- behavioral inhibition before the training (e.g., Clauss & bination condition agreed to participate, and thus only a Blackford, 2012) or the use of safety behaviors such as small number of children participated in the combined avoiding eye contact (e.g., Blakey & Abramowitz, 2016) condition. We could not include a no-treatment control may also inﬂuence intervention effectiveness. Social anxi- group for similar reasons, which limits our ability to con- ety is also often comorbid with other anxiety disorders and clude the effects of the brief interventions compared to no depression (Spence & Rapee, 2016). Future research might treatment. However, due to the use of two pretest mea- collect data on comorbid disorders to assess how this surements, we could compare pre-post intervention effects impacts intervention component effects. Insight into what to children’s natural development before the intervention’s works for whom regarding indicated prevention interven- implementation, which provides stronger conclusions tions could be valuable to better tailor interventions to a regarding intervention effects. Including a follow-up mea- child’s individual needs. surement allowed us to assess the sustainability of inter- These limitations notwithstanding, we were the ﬁrst to vention effects, and including multiple outcome measures assess components of social anxiety interventions sepa- related to social anxiety provided a detailed picture of the rately, and our ﬁndings provide valuable information about effectiveness of the interventions. Fourth, it should be taken separate and combined effects of exposure and cognitive into account that the study may be underpowered to detect restructuring. Our ﬁndings have several practical implica- small to medium effects for the number of outcome mea- tions, the most important being that a relatively brief, four- sures, hence it is important that our ﬁndings are replicated in week intervention could protect children from developing future studies. Finally, our ﬁndings should be interpreted in elevated levels of social anxiety and associated negative light of its mild to moderately symptomatic community consequences. Because we found the stand-alone exposure sample. It may be that the differences between the separate and cognitive restructuring approaches to be effective, we intervention components are more pronounced in a clinical conclude that practitioners can safely focus on exposure or sample of socially anxious children. cognitive restructuring alone if there is little time for a Future research using a microtrial approach might multicomponent intervention. include multiple informants and observational data to assess Our study provides preliminary evidence that exposure the moderating effects of common factors such as working might be the most valuable component regarding the breadth alliance and client and/or therapist motivation, a more of intervention effects, although cognitive restructuring evenly distributed sample, and a no-treatment control group. yielded positive effects too. From a prevention perspective, An observational measure, such as a role-play task, may be the effectiveness of short-term intervention modules is included as a real-world assessment of changes in children’s advantageous because they are easy to implement. The social behavior in school. Possibly, this could provide modules were highly structured, so future implementation by researchers with more insight into the generalization of the teachers or school-based clinicians might be feasible. More- effects of the intervention components (e.g., Le & Beidel, over, the regular school curriculum could integrate Journal of Child and Family Studies intervention module exercises, which could make addressing Bryant, R. A., Moulds, M. L., Guthrie, R. M., Dang, S. T., & Nixon, R. D. V. (2003). Imaginal exposure alone and imaginal exposure elevated social anxiety in children more cost-effective, and with cognitive restructuring in treatment of posttraumatic stress less burdensome for both children and parents as it could disorder. Journal of Consulting and Clinical Psychology, 71(4), reduce the need to visit clinical childcare facilities. 706–712. https://doi.org/10.1037/0022-006X.71.4.706. Campbell, M. K., Mollison, J., Steen, N., Grimshaw, J. M., & Eccles, M. (2000). Analysis of cluster randomized trials in primary care: Acknowledgements This study was funded by ZonMw “Effectief a practical approach. Family Practice, 17(2), 192–196. https:// werken in de Jeugdsector”, project number 729300011. doi.org/10.1093/fampra/17.2.192. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. Compliance with Ethical Standards In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment, and treatment (pp. 69–93). Guilford Press. Conﬂict of Interest The authors declare no competing interests. Clauss, J. A., & Blackford, J. U. (2012). Behavioral inhibition and risk for developing social anxiety disorder: a meta-analytic study. Consent to Participate Written informed consent was obtained from Journal of the American Academy of Child & Adolescent Psy- the parents or legal guardians of participants. chiatry, 51(10), 1066–1075. https://doi.org/10.1016/j.jaac.2012. 08.002. Ethics Approval This study was performed in line with the principles Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. of the Declaration of Helsinki. Approval was granted by the Ethics (2014). Maximizing exposure therapy: an inhibitory learning Committee of the University of Amsterdam (24-04-2017/No. 8033). approach. Behaviour Research and Therapy, 58,10–23. https:// doi.org/10.1016/j.brat.2014.04.006. Publisher’s note Springer Nature remains neutral with regard to Crawley, S. A., Beidas, R. S., Benjamin, C. 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Publisher: Springer Journals
Copyright: Copyright © The Author(s) 2023
ISSN: 1062-1024
eISSN: 1573-2843
DOI: 10.1007/s10826-023-02536-w
Publisher site: See Article on Publisher Site

Abstract

Programs that aim to reduce symptoms of social anxiety in children generally include multiple components, such as exposure and cognitive restructuring. It is unknown if separate components yield positive intervention effects in children or whether a combination of components is required. We investigated the effectiveness of exposure, cognitive restructuring, and a combination of both components in reducing social anxiety symptoms and anxiety-related social-emotional outcomes in an indicated-prevention setting. To this end, we conducted a cluster-randomized microtrial using a sample of 191 children aged 8 to 13 years (M = 10.48, SD = 1.10). Children with elevated social anxiety symptoms participated in one of three group interventions, each lasting four weeks, and completed a questionnaire on four measurement occasions. Latent change models demonstrated that the intervention with either exposure or cognitive restructuring reduced social anxiety symptoms and anxiety-related outcomes. The analyses showed that both of these intervention components were effective, with more favorable effects for exposure. Combining exposure and cognitive restructuring techniques did not yield greater beneﬁt than either component alone. Future research should investigate whether speciﬁc components may be more effective for particular subgroups (e.g., based on sex or level of behavioral inhibition) in more detail. ● ● ● ● Keywords Social anxiety Exposure Cognitive restructuring Microtrial Intervention components Highlights Exposure had a positive effect on social anxiety, distress, avoidant behavior, positive thoughts, perceived social threat, internalizing behavior, social skills, and self-perceived competence in children with emerging social anxiety. Cognitive restructuring had a positive effect on social anxiety, distress, avoidant behavior, positive thoughts, perceived social threat, internalizing behavior, self-efﬁcacy, and self-perceived competence in children with emerging social anxiety. An intervention combining exposure and cognitive restructuring was less effective in preventing social anxiety and related outcomes than either component alone. Stacking multiple intervention components may not necessarily yield greater prevention beneﬁts. Findings reveal the possible beneﬁts of short-term intervention modules. Supplementary information The online version contains supplementary material available at https://doi.org/10.1007/s10826- 023-02536-w. * Anne C. Miers Institute of Psychology, Developmental and Educational acmiers@fsw.leidenuniv.nl Psychology Unit, Leiden University, 2333AK Leiden, The Netherlands Research Institute of Child Development and Education, University of Amsterdam, 1018WS Amsterdam, The Netherlands Behavioural Science Institute, Radboud University Nijmegen, 6500HE Nijmegen, The Netherlands Child Health, TNO, 2316ZL Leiden, The Netherlands 1234567890();,: 1234567890();,: Journal of Child and Family Studies Social anxiety disorder (SAD) is among the top three most Two core components of interventions aimed at preventing prevalent disorders in Western societies (Kessler et al., 2005); or treating (social) anxiety are exposure and cognitive an estimated seven to 13 percent of individuals experience restructuring (e.g., Higa-McMillan et al., 2016). Exposure SAD at some point during their life (Furmark, 2002). Social aims to reduce affective and behavioral symptoms of anxiety anxiety is characterized by a fear of negative evaluation and by entering and remaining in a situation that provokes fear distress in and potential avoidance of social situations. Even (Rodebaugh et al., 2004). By exposing the individual to fear- though the average age of onset for social anxiety disorder is provoking stimuli, they learn new adaptive responses to thirteen, prodromal symptoms of social anxiety can already be fearful situations (e.g., engagement instead of avoidance). present in childhood (Miers et al., 2013). The prevalence of Exposure thus reduces the association between anxiety- social anxiety disorder in adolescents ranges from three to nine provoking situations and their feared negative consequences percent(Rantaetal., 2015). Social anxiety disorder is rela- and helps children overcome their avoidance of social situa- tively stable over time, and individuals suffering from this tions. Exposure might also teach anxious children to control disorder are generally reluctant to seek help (Baer & Garland, and reduce visible signs of arousal, which can help them 2005). Social anxiety is conceptualized as existing on a con- experience successful social interactions. In turn, this may tinuum from normal, healthy levels of arousal to levels of decrease their negative peer experiences, such as isolation and arousal that cause distress and inhibit normal functioning bullying victimization (Rapee & Spence, 2004). Additionally, (Rapee & Spence, 2004). Socially anxious children and ado- by creating positive experiences, exposure might increase an lescents often experience excessive physiological arousal in anxious child’s perceived social competence (Donders & social situations, particularly in public performance situations Verschueren, 2004). (American Psychiatric Association, 2013; Rapee & Spence, Cognitive restructuring focuses on the cognitive processes 2004). In addition, maladaptive, automatic cognitions may that emerge in (anticipation of) or following (i.e., rumination) inhibit the correct processing of social information (i.e., inter- situations that provoke anxiety to identify and challenge preting others’ social behavior as a negative evaluation) and automatic, negative, and self-defeating thoughts and to may trigger anxious and avoidant behavior (Miers et al., 2011). implement more positive, helpful thoughts (McLellan et al., Many intervention programs for youth, both preventive and 2015). Cognitive restructuring teaches children to change curative, are currently available to reduce social anxiety in negative cognitive appraisals, reduce self-criticism, and children and adolescents. In particular, group interventions in modify interpretations of social stimuli to reduce anxiety in the clinical context have shown positive effects on speciﬁc social situations (Rodenbaugh et al., 2004). For example, social anxiety symptoms such as social distress, behavioral socially anxious children generally anticipate adverse perfor- avoidance, enhanced social skills, and social interaction, and on mance outcomes, overestimate the visibility of their nerves, secondary outcomes such as general anxiety and depressive and negatively evaluate their behavior and their performance symptoms (Scaini et al., 2016;Kleyetal., 2012). However, (Miers et al., 2009). Some socially anxious children even social anxiety interventions combine multiple components, so undermine their adequate social competence through their what component drives program effects is unknown. To ﬁll this negative self-perceptions (Miers et al., 2009; Miers et al., gap, this study presents a microtrial study (Howe et al., 2010) 2011). By tackling maladaptive cognitions using cognitive investigating which intervention components (i.e., gradual restructuring, children learn to more accurately perceive and exposure, cognitive restructuring, or a combination) effectively thus anticipate social situations, which should reduce their reduce social anxiety symptoms and secondary outcomes that anxiety (Taylor et al., 1997). may be negatively inﬂuenced by children’s anxiety in children The treatment of socially anxious children is challenging with elevated social anxiety symptoms in a prevention context. due to its various interrelated etiological determinants (Ranta The peer context plays an important role in children’s et al., 2015). Nevertheless, a recent meta-analysis showed that development of social skills (e.g., Smith & Hart, 2002). cognitive-behavioral therapy interventions have signiﬁcant Therefore, it is crucial to direct preventive intervention effects (Cohen’s d= 0.71) on children’s and adolescents’ efforts at school-age children (Alves et al., 2022). Imple- social anxiety symptoms (Scaini et al., 2016). However, the menting interventions in children’s day-to-day social con- programs included in this study combined cognitive techni- text may protect them from developing clinical-level social ques, exposure, and social skills training in multicomponent anxiety that might interfere with their healthy social programs, making it difﬁcult to infer the effectiveness of development (Baer & Garland, 2005). Research also sug- individual intervention components. Information about the gests that social anxiety is more difﬁcult to treat in ado- effects of separate intervention components is crucial because lescence (e.g., Crawley et al., 2008). Therefore, to it provides insight into which components are necessary for contribute to the prevention of social anxiety, we focused improvement, thereby maximizing intervention effects. on evaluating preventive intervention component effects in Our goal of identifying effective intervention program children aged eight to thirteen with emerging social anxiety. components to prevent childhood-based social anxiety is Journal of Child and Family Studies informed by previous research on anxious individuals. A interventions is expedient as these might be more cost- review of ﬁve meta-analyses concluded that both exposure effective, and the burden on clinicians and families might be and cognitive restructuring reduced social anxiety symp- lower. Second, the microtrial approach can elucidate which toms in adults and that a combination of cognitive components are effective and thus provide knowledge to restructuring and exposure did not seem superior to expo- develop more speciﬁc, targeted interventions (Leijten et al., sure alone (Rodebaugh et al., 2004). However, cognitive 2015). This approach is in line with the call for explanatory awareness may be less developed in children (i.e., pre- research into mechanisms of change, as opposed to tradi- adolescents), and, therefore, more cognitive-oriented tional RCTs into intervention effects (Nakamura et al., 2009). approaches may yield less effect. Also, some studies sug- The sample for the present microtrial consisted of eight- gest that a cognitive approach may be less effective for to thirteen-year-old children with elevated symptoms of children and adolescents with social anxiety than other social anxiety who participated in a brief four-week pre- affective disorders (e.g., Crawley et al., 2008). ventive group intervention. We aimed to answer two A meta-analysis by Scaini et al. (2016)showed the research questions: Are brief group interventions using effectiveness of cognitive-behavioral interventions for chil- exposure, cognitive restructuring, or combining both com- dren and adolescents with a clinical diagnosis of social ponents effective in reducing social anxiety symptoms and anxiety, but this study did not speciﬁcally compare the effects related outcomes?, and Is there a difference in effectiveness of exposure and cognitive restructuring. Another meta- between the brief group interventions? analysis provided more insight by showing that cognitive- In line with the aim of microtrials to suppress speciﬁc behavioral therapy-based interventions and exposure-based risk mechanisms or enhance protective mechanisms (Howe interventions had similar effects in children with anxiety and et al., 2010) we include several outcome measures divided avoidance problems (d= 1.19 and 1.05, respectively; Higa- into primary and secondary outcomes. Both primary and McMillan et al., 2016). Furthermore, a large RCT into anxiety secondary outcomes included risk and protective mechan- interventions (i.e., the CAMS trial) found similar results, isms. Our primary outcomes were directly related to the indicating that the introduction of cognitive restructuring and diagnostic criteria for social anxiety disorder and prominent exposure was associated with signiﬁcant declines in anxiety social anxiety cognitive models (American Psychiatric symptom severity and that exposure seemed to be most Association, 2013; Clark & Wells, 1995) and consisted of effective in children compared to adolescents (Peris et al., social anxiety symptoms, distress, avoidant behavior, 2015). A multiple single-case study by Nakamura et al. approach behavior, positive thoughts, and perceived social (2009) also concluded that exposure might be a key element threat. Previous research has related social anxiety in youth in interventions for anxiety-disordered children. to low self-esteem and fewer friendships (Fordham & Ste- The ﬁndings from these studies suggest that exposure and venson-Hinde, 1999), impaired social skills (Miers et al., cognitive-behavioral exercises might be independently effec- 2009), loneliness, and depression (Rapee & Spence, 2004). tive in improving children’s anxiety-related problems. How- Such negative outcomes may impede successful social ever, these studies mostly assessed intervention effects in interactions, which in turn may increase risk for social children with clinical anxiety levels not speciﬁcto social anxiety through heightened fear of negative evaluation anxiety. Also, Peris et al. (2015) analyzed data from an (Fredrick & Luebbe, 2022). In contrast, a more positive intervention that included more intervention components than evaluation of social skills, self-efﬁcacy, and competence, only exposure and cognitive restructuring, and, consequently, and less loneliness and depression may beneﬁt children’s the independent effect of exposure and cognitive restructuring positive social experiences and lower their fear of negative remains unclear. Furthermore, whether these intervention evaluation. In the long term, this may be associated with a components are equally effective in a prevention context is higher quality of life, therefore acting as a protective unknown. Thus, empirical research into the separate effec- mechanism (Alves et al., 2022). Thus, in line with previous tiveness of components in childhood social anxiety interven- microtrial studies we assessed changes in social anxiety tions is absent, especially in an indicated-prevention context. symptoms as well as secondary outcome measures related to We applied a microtrial approach to identify whether social anxiety more broadly (de Jong et al., 2021): inter- exposure, cognitive restructuring, or a combination of both nalizing behavior, self-efﬁcacy, social skills, and self- effectively reduced social anxiety in children. A microtrial is perceived competence. These secondary outcomes may be a brief, focused randomized experiment to assess whether an impaired in children with social anxiety and might improve isolated intervention component brings about signiﬁcant by proxy of reduced social anxiety symptoms. change (Howe et al., 2010). Using this approach has two We expected social anxiety symptoms and related sec- speciﬁc advantages. First, it can elucidate which intervention ondary outcomes to reduce in all three types of preventive components are not effective and can thus help to develop intervention. We speciﬁcally focussed on eight- to thirteen- leaner, more efﬁcient interventions. The availability of leaner year-olds because this is the age group approaching the Journal of Child and Family Studies Fig. 1 Participant ﬂow onset period for clinical diagnosis of social anxiety (Rapee Seven schools agreed to participate in the exposure con- & Spence, 2004). We did not formulate hypotheses about dition, ﬁve in the cognitive restructuring condition, and the expected difference in the effectiveness of exposure four in the condition combining both components (here- versus cognitive restructuring due to a lack of relevant after labeled the combination condition). A total of research for this age group and anxiety type. Nevertheless, N = 1431 children completed Pretest 1 (i.e., the baseline we might expect that a combination of two evidence-based sample). In this baseline sample, children had a mean age intervention components would yield more substantial of 10.56 (SD = 1.03) years, 48.5% (n = 694) were girls effects than the separate components. and 43.8% (n = 608) reported having a Non-Western ethnicity. We invited a total of 248 children from the baseline Method sample to take part in the study (see ﬂowchart in Fig. 1). The parents of 23% (n = 57) of these children did not Participants actively consent to participation, resulting in a ﬁnal sample of 191 children: 82 children in the exposure condition, 73 Participants for this study were children with emerging children in the cognitive restructuring condition, and 36 social anxiety symptoms from the three highest grades of children in the combination condition. Due to the smaller 16 Dutch primary schools (equivalent to American grades number of schools in the combination condition, fewer four to six), predominantly located in urban areas. We children could be invited for this intervention, resulting in randomized participants into conditions at the school level. fewer children in this condition. Journal of Child and Family Studies The ﬁnal sample had a mean age of 10.48 years (SD = into one of the three conditions. Schools that solely offered 1.07, range 8.11 to 13.29 years) with somewhat more girls special education programs or with fewer than 50 children (63.4%, n = 121). Ethnicity was deﬁned as follows: 55% in the highest three grades were excluded from participa- (n = 104) of the children had a Western origin (87% Dutch) tion. We invited schools that met our criteria by invitation and 44% (n = 84) had a Non-Western origin (30% Turkish, letter. We anticipated a fair number of schools to turn down 27% Moroccan, 16% Surinamese/Antilles, 27% other). the invitation due to the high workload in primary schools, Three children did not disclose their ethnicity. Children in and therefore, we invited a total of 100 primary schools to our sample had a mean score of 54.28 on the Social Anxiety the sample. Seven schools agreed to participate. A second Scale for Adolescents (SAS-A), which is just above the recruitment wave added nine schools to the sample. These clinical cut-off (La Greca, 1999). In total, 65.8% of the schools were recruited through an advertisement in a sample scored above the clinical cut-off at Pretest 1 national magazine for school counselors. More detailed (exposure condition 59.3%, cognitive restructuring condi- information about the participating schools is provided in tion 74%, and combination condition 63.9%). Descriptive Supplementary Appendix A, Section A.3. Participants were statistics of the baseline sample, the children selected and screened for the intervention based on their Pretest 1 scores. those that were not selected for the interventions are pre- sented in Supplementary Appendix A, Tables A.1 and A.2. Procedure Design We informed parents about the study and requested passive consent before the ﬁrst measurement occasion, which We used a cluster-randomized microtrial design to evaluate served as Pretest 1 and was used to screen participants for the effects of separate intervention components to enhance the intervention. At Pretest 1, research assistants or the ﬁrst speciﬁc outcomes (Howe et al., 2010). Schools were ran- author visited children in their classrooms to explain the domized into a condition before the invitation to participate goals of the study. We did not tell children that Pretest 1 and were blind to the assigned condition. We adopted was used to identify children with emerging social anxiety cluster randomization as individual-level randomization was symptoms to avoid drawing negative attention (i.e., stig- not practically feasible, and cluster randomization ensured matization) to children selected for the intervention. The there would not be contamination across conditions completion of the questionnaires took approximately 60 min (Campbell et al., 2000). Our microtrial included three on each measurement occasion. Children without parental conditions and four time points: Pretest 1 (approximately consent stayed in the classroom and worked on individual ﬁve weeks before the start of the intervention), Pretest 2 tasks or read a book. (one week before the start of the intervention), Posttest (one Children were selected for the interventions based on week after the end of the intervention), and Follow-up their score on the Social Anxiety Scale for Adolescents (three months after Posttest). By including two pretest (SAS-A; La Greca, 1999) at Pretest 1. For every school, measurements, individual change (i.e., natural develop- children’s scores on the SAS-A were mean-centered per ment) before the intervention could be compared to the grade, and the children scoring in the highest 20% on social change from Pretest 2 to Posttest (i.e., pre-post intervention anxiety within their class distribution were considered eli- effects). Additionally, including two pretest measurements gible for the intervention. Children were selected based on allowed participants to be their own control, strengthening class means because research has shown that social anxiety the power of our study. A priori power analysis showed that in childhood and adolescence is inﬂuenced by class climate 52 participants were necessary per condition to ﬁnd a main (Gazelle, 2006) and peer comparisons (Rapee et al., 2020), effect of condition with a medium effect of 0.40, a power of and therefore, the mean class level was deemed a suitable 0.80, and an alpha of 0.05 (two-sided). This study was benchmark to select children with emerging social anxiety. performed in line with the principles of the Declaration of After selection, school personnel reviewed the eligible Helsinki. Approval was granted by the Ethics Committee of children. School personnel did not agree with the selection the University of Amsterdam (24-04-2017/No. 8033). We of seven participants—because of participation in another retrospectively registered the study [blinded for social-emotional intervention program, not speaking Dutch submission]. ﬂuently, or a clinical diagnosis of Autistic Spectrum Dis- order, for example—, and were allowed to propose other Sampling Procedures children. The SAS-A scores of the proposed children had to be higher than the class mean to participate in the From a database of all Dutch elementary schools, we intervention. selected schools that were located within the trainers’ work After the ﬁnal list of participants had been agreed upon, catchment area; these selected schools were randomized we distributed another information letter requesting active Journal of Child and Family Studies parental consent to participate in the rest of the study. There The DAAS presents children with a social situation (e.g., was no monetary incentive. Children with parental consent “Imagine you are in class and your teacher asks you to participated in the intervention, which was provided by answer a question”). Children rated (i) how distressed they eight certiﬁed trainers (75% female) with an average of ﬁve would feel when faced with the presented situation (sub- years of experience. All trainers had a degree in Social scale Distress; 1 = I feel good to 5 = I feel very tense, ﬁve Work, Pedagogics, or Psychology. The children completed items); (ii) the extent to which they try to avoid the situation the questionnaire an additional three times (see Fig. 1). (subscale Avoidance, 1 = I never do to 5 = I always do, ﬁve School personnel supervised the measurement at Pretest 2, items); (iii) the extent to which they look forward to the Posttest, and Follow-up. After the last measurement occa- situation if it were to occur in one week (subscale sion, all schools received 50 euros for their participation. Approach, 1 = I look forward to it a lot to 5 = I do not look The ﬁnal sample sizes of the three conditions were unequal forward to it at all, ﬁve items); and (iv) the extent to which due to two reasons i) the number of schools that agreed to they feel efﬁcacy to take on the situation described (sub- participate in our study across the three conditions was scale Self-Efﬁcacy, 1 = I will do very well to 5 = I will not unequal, and ii) the number of children that could be do well at all, ﬁve items). The sum of the ﬁve items com- selected for the interventions was dependent on class size, prised the total score for each subscale. The reliability was yielding a smaller number of selected children at schools satisfactory across measurement occasions (Distress: with smaller class sizes. We collected all data between α = 0.63 to 0.91; Avoidance: α = 0.65 to 0.91; Approach: September 2017 and April 2019. α = 0.72 to 0.94; Self-efﬁcacy: α = 0.67 to 0.95). Primary Outcome Measures Positive Thoughts and Perceived Social Threat Social Anxiety The Children’s Automatic Thoughts Scale – Negative/ Positive (CATS-N/P; Hogendoorn et al., 2010) was used to To assess our primary outcome measure, children ﬁlled out assess children’s negative and positive thoughts. The sub- the Dutch translation of the Social Anxiety Scale for Ado- scales Perceived social threat (10 items) and Positive lescents (SAS-A; La Greca, 1999), a 22-item scale assessing thoughts were used (10 items). Children answered items on fear of negative evaluation, social avoidance, distress in new a ﬁve-point scale (1 = never to 5 = always), and the sum of situations, and general social avoidance and distress. Items the items comprised the subscale scores. The CATS-N/P were rated on a ﬁve-point scale (1= never,5= always), and has satisfactory discriminant validity in a community sam- the sum of the 18 substantive items (four are ﬁller items) ple (Hogendoorn et al., 2010). In this study, the reliability of comprised the total score. A score of 50 or above means was good across measurement occasions (Perceived social children experience clinical levels of social anxiety (La Greca, threat: α = 0.85 to 0.96; Positive thoughts: α = 0.82 to 1999). The SAS-A has good construct validity (Inderbitzen- 0.97). Previous research has shown that clinical anxiety Nolan & Walters, 2000). In this study, reliability was satis- groups score M = 18.26 on the social threat subscale factory across measurement occasions (α= 0.77 to 0.91). Schniering and Rapee (2002) and M = 16.09 on the positive thoughts subscale (Hogendoorn et al., 2013). Distress, Avoidant, Approach Behavior, and Self-Efﬁcacy Secondary Outcome Measures To assess levels of distress and if children actively try to avoid speciﬁc social situations, we developed a ques- Internalizing Behavior tionnaire based on social situations from the Anxiety Disorders Interview Schedule for Children (ADIS-C; Sil- Children’s internalizing behavior was measured using the verman & Albano, 1996). Research previously used these subscale Internalizing problem behavior from the Dutch situations to measure distress and avoidance (e.g., Miers translation of the self-report version of the Social Skills et al., 2014). We adapted the scale by selecting ﬁve social Improvement System-Rating Scales (SSIS-RS; Gresham & situations that can provoke anxiety and are relevant to the Elliott, 2008; van den Heuvel et al., 2017). This 10-item current age group (i.e., answering a question in class, subscale is answered on a four-point scale (1 = not true to reading aloud in class, giving an oral presentation, playing 4 = very true). The items pertain to children’s experience of with unfamiliar children, and asking a classmate a ques- anxiety, loneliness, and depression, as well as physical signs tion), andbyaddingan itemtomeasure the tendency to of anxiety and depression (i.e., nausea and tiredness). The approach social situations. These adaptations resulted in sum of the items comprised the subscale score. The English the Distress, Avoidance, Approach, and Self-efﬁcacy version of the SSIS-RS has strong internal consistency, and (DAAS) scale. convergent and divergent validity (Gresham et al., 2011). In Journal of Child and Family Studies this study, reliability was satisfactory across measurement psychoeducation about social anxiety; (ii) the exercises occasions (α = 0.62 to 0.89). gradually built up to the (hypothetical) situation of giving an oral presentation in front of the class; (iii) they were Social Skills provided by trained professionals with an average of 10.6 years of experience in CBT for children (SD = 8.5, range Children’s social skills were also measured using the SSIS- 2–27 years); (iv) they were implemented as a group RS. We used the subscales Assertion (seven items), Coop- training consisting of four one-hour sessions, provided eration (seven items), Communication (six items), over a month; (v) given during school hours in groups of Responsibility (seven items), Empathy (six items), eightto10children, and(vi)includedsupportingmate- Engagement (seven items), and Self-control (six items). All rials like a workbook for participants and posters. At the items were answered on a four-point scale (1 = not true to end of each session, trainers stimulated children to prac- 4 = very true). The sum of the items across the subscales tice what they had learned outside of the intervention. comprised the outcome Social skills. In this study, relia- Table 1 and the following paragraphs provide a broad bility was good across measurement occasions (α = 0.96 overview of the intervention modules. Supplementary to 0.99). Appendix B, Tables B.1, B.2, and B.3 provide more detailed information, and the module manuals are avail- Self-Perceived Competence able upon request from the third author [blinded for submission]. Implementation was closely monitored by Children’s self-perceived competence was measured using the ﬁrst author, who scheduled calls with the trainers after the Dutch translation (Veerman et al., 1997) of the Self- completion of the intervention to check program ﬁdelity. perception Scale for Children (SPPC; Harter, 1985), which Trainers indicated all exercises were implemented as comprises 36 items. We used a shorter version, comprising described in the intervention manual. items from the conceptually most relevant subscales namely In the exposure module, children were taught that they social acceptance, behavioral conduct, and global self- could overcome anxiety by decomposing an anxiety- worth. In the original version items consist of two opposing provoking situation into small steps (i.e., habitual desensi- statements, and children indicate how true the best ﬁtting tization). The exposure module included exercises targeting statement is for them. We reformulated items and answering three situations that can be difﬁcult for socially anxious categories to simplify the items and make them more con- children: one social interaction situation, starting and join- sistent with the other measures. An example item is “Some ing a conversation, and two performance situations, asking children ﬁnd it difﬁcult to make friends”. Items were and answering a question and giving an oral presentation. answered on a four-point scale (1 = I am not like these These situations were divided into smaller steps that gra- children to 4 = I am exactly like these children), and the dually increased in difﬁculty. These steps were presented to sum of the items comprised the scale score. The SPPC had children using the metaphor of a stepladder, which dis- good internal consistency, test-retest stability, and con- assembles larger tasks or goals into small steps. Children vergent validity in a community sample (Muris et al., 2003). practiced with these situations using role-plays. Trainers In this study, reliability was good across measurement were instructed not to talk to children about their thoughts occasions (α = 0.82 to 0.86). in this module, but to solely focus on practicing with fear- evoking situations. Intervention Modules In the cognitive restructuring module, children were taught that they could overcome anxiety by changing their The intervention modules were inspired by cognitive thinking patterns. The cognitive restructuring module used behavioral training programs such as Cool Kids (Rapee the same three social situations hypothetically (e.g., “Ima- et al., 2006) and PASTA training (Sportel et al., 2013). We gine you have to answer a question in class”) to teach adapted exposure exercises and cognitive restructuring children to reﬂect on the inﬂuence their thoughts have on exercises to ﬁt the purpose of this study. We extensively their behavior. Exercises consisted of written exercises and reviewed and revised the modules with professionals with group discussions. The cognitive restructuring module ﬁve to 10 years of training experience to ensure the worked with a handout containing six steps to turn negative appropriateness for the target audience and employability of thoughts into positive, helpful thoughts. The cognitive the modules. Psychoeducation is an important component in restructuring condition did not include role-plays. Trainers improving treatment effects and therefore was included in were instructed not to talk to children about children con- each condition (de Mooij et al., 2020). fronting their fears by engaging in anxiety-provoking Several elements were the same for all three interven- situations but to solely focus on practicing with challen- tion modules: (i) they started with three exercises on ging unhelpful thoughts. Journal of Child and Family Studies Table 1 Broad session overview of the implemented intervention modules Session Exposure module Cognitive restructuring module Combination module 1 � Psychoeducation about � Psychoeducation about (social) anxiety. � Psychoeducation about (social) anxiety. (social) anxiety. � Group discussion of the Thoughts-Feelings-Behavior- � Habitual exposure: starting and joining a � Habitual exposure: model using a story character: connecting thoughts and conversation (step 1 of 3). starting and joining a feelings (giving a presentation step 1 of 4). � Explain two strategies to decrease anxiety: conversation (step 1 of 3). � Written exercise with the Thoughts-Feelings-Behavior- change thoughts (cognitive restructuring) and � Habitual exposure: asking model: giving a presentation (step 2 of 4). face the situation (exposure). and answering a question � Habitual exposure: giving a presentation (step (step 1 of 3). 1of4) � Habitual exposure: giving a presentation (step 1 of 4) 2 � Habitual exposure: asking � Group exercise to practice identifying and transforming � Group discussion of the Thoughts-Feelings- and answering a question helpful and non-helpful thoughts. Behavior-model using a story character: (step 2 of 3). � Written exercise with Thoughts-Feelings-Behavior- connecting thoughts and feelings. � Habitual exposure: model: asking and answering a question (step 2 of 3). � Written exercise with Thoughts-Feelings- starting and joining a � Written exercise with Thoughts-Feelings-Behavior- Behavior-model: giving a presentation. conversation (step 2 of 3). model: starting and joining a conversation (step 2 of 3). � Group discussion on the Thoughts-Feelings- � Habitual exposure: giving Behavior-model: connecting thoughts, a presentation (step 2 of 4) feelings, and behavior. � Habitual exposure: starting and joining a conversation (step 2 of 3). 3 � Habitual exposure: � Group discussion on the Thoughts-Feelings-Behavior- � Group exercise to practice identifying and starting and joining a model: connecting thoughts, feelings, and behavior. transforming helpful and non-helpful thoughts. conversation (step 3 of 3). � Written exercise with Thoughts-Feelings-Behavior- � Written exercise with Thoughts-Feelings- � Habitual exposure: asking model: asking and answering a question (step 3 of 3). Behavior-model: starting and joining a and answering a question � Written exercise with Thoughts-Feelings-Behavior- conversation (step 3 of 3) (step 3 of 3). model: starting and joining a conversation (step 3 of 3). � Habitual exposure: giving a presentation (step � Habitual exposure: giving 2of4) a presentation (step 3 of 4) 4 � Habitual exposure: giving � Introduction of the session. � Introduction of the session. a presentation (step 4 of 4) � Group game to recap transforming non-helpful � Written exercise with Thoughts-Feelings- � Review of all sessions. thoughts to helpful thoughts. Behavior-model: giving a presentation (step � Closure of the module � Written exercise with Thoughts-Feelings-Behavior- 3 of 4). with a certiﬁcate. model: giving a presentation (step 4 of 4). � Habitual exposure: giving a presentation (step � Review of all sessions. 3of4) � Closure of the module with a certiﬁcate. � Review of all sessions. � Closure of module with a certiﬁcate. In the combination module, children were taught that Statistical Analyses they could overcome anxiety by decomposing an anxiety- provoking situation into small steps and by identifying We analyzed the data using latent change models (LCMs) in negative thoughts and replacing them with positive, helpful Mplus version 7.31 (Muthén & Muthén, 1998–2015). thoughts. The combination module combined exposure and LCMs have a larger power to detect effects and are robust to cognitive restructuring in all sessions. This module com- non-normality compared to analyses of variance (Kline, bined role-play exercises with written exercises and group 2011; Schmidt et al., 2014). All analyses were intention-to- discussions. As this module had to ﬁt exposure exercises treat, and models were ﬁt using full information maximum and cognitive restructuring exercises into four sessions, likelihood (e.g., Raykov, 2005) to make optimal use of participants worked with only two social situations: starting available information. We assessed non-independence of and joining a conversation and giving an oral presentation. observations due to nesting of participants in schools using The exercises aimed at cognitive restructuring preceded the linear mixed models in SPSS (Version 28), with school exposure exercises in every session and were similar in speciﬁed at level two. Intraclass correlations for nine out- structure to the exercises in the cognitive restructuring come variables ranged from 0.014 to 0.126 (i.e., 1.4–12.6% module. The exposure exercises were mostly the same as in variance explained at the school level) and were non-sig- the exposure module, with one key difference: the instruc- niﬁcant, meaning there is not a random effect of school- tions before the exposure exercises reminded children to level variation on participant-level scores. Thus, the Pretest think about the positive thoughts they had previously 1 means did not vary by school (Garson, 2020). There was a formulated. signiﬁcant random effect of school-level (ICC = 0.261, Journal of Child and Family Studies p = 0.03) for distress, so we accounted for non- condition (CM-condition in this section; 22.2%; independence by correcting the standard errors of the esti- χ [2,N = 188] = 65.67, p < 0.001). Further analyses of mates for the non-independence of the data (type = Pretest 1 scores revealed that non-Western children reported complex command) in further analyses (Muthén & Muthén, signiﬁcantly more social anxiety (SAS-A) compared to 1998–2015). Western children (F[1186] = 7.00, p < 0.01), therefore we To assess if the three conditions yielded signiﬁcant controlled for ethnicity in further analyses. Children in the changes in the 10 outcome variables, we evaluated LCMs CR-condition reported less distress (DAAS; using a multigroup approach, basing our models on Schmidt F[2187] = 13.56, p < 0.001) and more approach behavior et al. (2014). A base model with Pretest 2 as the intercept (DAAS; F[2187] = 9.01, p < 0.001) at Pretest 1 compared allowed us to assess changes in children’s self-reported to children in both the EXP-condition and the CM- behavior from Pretest 1 to Pretest 2 (hereafter labeled the condition. The conditions did not differ in children’s age pre-intervention period), and from Pretest 2 to post-test (F[2189] = 1.71, p = 0.15) or sex (χ [2,N = 191] = 6.18, (hereafter labeled the intervention period). An equivalent p = 0.05), nor were there Pretest 1 differences on the other model with Posttest as the intercept allowed us to assess the outcome variables. Analyses of variance showed there was changes from Posttest to Follow-up (hereafter labeled the not a systematic inﬂuence of age or sex on our ﬁndings, so follow-up period). Supplementary Appendix C, Fig. C.1 we did not control for age or sex in further analyses. illustrates the model. Model ﬁt was considered good when An inspection of bivariate correlations indicated that all the chi-square statistic was non-signiﬁcant, the root mean variables signiﬁcantly correlated in the predicted direction square error of approximation (RMSEA) value was lower at all time points. Overall, correlations between outcome than 0.08, and the comparative ﬁt index (CFI) value was variables were in the expected direction: social anxiety higher than 0.95 (Hu & Bentler, 1999). disorder related variables (social anxiety, distress, avoidant To assess within- and between-condition differences, the behavior, and negative thoughts) and internalizing behavior parameters representing change between time points were showed positive inter-correlations, and negative correlations constrained to equality within conditions (e.g., pre- with the positively formulated outcomes (positive thoughts, intervention period change and intervention period change approach behavior, self-efﬁcacy, social skills, and self- in the EX-condition) and between conditions (e.g., inter- perceived competence). The latter variables showed positive vention period change in the EX-condition and CR-condi- inter-correlations. There was a weak correlation between tion). We then compared the constrained model’s chi-square children’s age and internalizing behavior at Pretest 1 and statistic to the base model’s chi-square statistic. A sig- self-efﬁcacy at Follow-up. There was a weak correlation niﬁcant chi-square difference meant that the parameters between children’s sex and social anxiety, distress, constrained in the model were statistically different. Mplus approach behavior, positive thoughts, negative thoughts, syntax for the LCMs is available in Supplementary and self-efﬁcacy at Pretest 2, and avoidant behavior and Appendix C. approach behavior at Posttest. There was a weak correlation between children’s ethnicity and social anxiety, distress and approach behavior at Pretest 1, distress, approach behavior, Results and self-efﬁcacy at Pretest 2, distress, avoidant behavior, approach behavior, and self-efﬁcacy at Posttest, and distress Compared to the children that were not selected to partici- and approach behavior at Follow-up. None of these corre- pate in the intervention based on Pretest 1, there were more lations exceeded the 0.40 threshold. Supplementary girls in the ﬁnal sample (χ [1, N = 1420] = 18.51, Appendix D, Tables D.1 and D.2 present the correlation p < 0.001). There were no differences in age and ethnicity matrices. between selected and not-selected children (see Supple- mentary Appendix A, Table A.1). All children that parti- Intervention Component Effects cipated in the interventions completed all four intervention sessions. Table 2 presents demographics and the raw means We assessed the effectiveness of the individual intervention and standard deviations of all outcome variables at every components using unconstrained multigroup latent change measurement occasion for all three conditions. models (LCMs), and the ﬁt indices were adequate for all Before our main analyses, we assessed if there were outcomes: chi-squares were non-signiﬁcant, RMSEA values between-condition differences in children’s age, sex, and were lower than 0.08, and CFI values were higher than 0.95 ethnicity. The cognitive restructuring condition (CR-con- (see Supplementary Appendix D, Table E.1 for the full ﬁt dition in this section) contained signiﬁcantly more non- statistics). Table 2 presents parameter estimates for all Western children (79.5%) than the exposure condition models. Bold parameters indicate a signiﬁcant difference (EXP-condition in this section; 22%) and the combination between the change during the intervention period and the Journal of Child and Family Studies Table 2 Means (M) and standard deviations (SD) for the primary and secondary outcomes (N = 191) Exposure (n = 82) Cognitive restructuring (n = 73) Combination (n = 36) Age at Pretest 10.32 (0.95) 10.64 (1.12) 10.53 (1.18) 1(M[SD]) Sex: Girls 44 (53.7) 53 (72.6) 24 (66.7) (n [%]) Ethnicity: 18 (22.0) 58 (82.9) 8 (22.2) Non-Western (n [%]) Pretest 1 Pretest 2 Posttest Follow-up Pretest 1 Pretest 2 Posttest Follow-up Pretest 1 Pretest 2 Posttest Follow-up M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) Primary outcomes Social anxiety 53.22 (9.73) 52.00 (13.04) 45.92 (13.59) 42.60 (12.29) 55.96 (11.10) 49.79 (13.27) 40.80 (15.52) 39.84 (15.66) 53.29 (11.23) 51.70 (12.96) 50.34 (15.62) 45.31 (14.52) Above clinical 48 (59.3) 40 (53.3) 30 (40.0) 15 (22.1) 54 (74.0) 30 (52.6) 16 (28.6) 12 (26.1) 23 (63.9) 19 (57.6) 17 (53.1) 11 (39.3) cut-off (>50.0; n[%]) Distress 14.77 (3.37) 15.17 (4.38) 13.34 (4.70) 12.28 (4.12) 12.12 (3.77) 12.07 (4.60) 9.54 (4.30) 9.83 (4.37) 15.26 (3.84) 15.23 (4.52) 13.15 (5.50) 12.48 (5.54) Avoidant 10.72 (3.92) 11.15 (4.59) 9.99 (3.85) 8.74 (3.65) 10.04 (3.47) 9.25 (3.69) 7.82 (3.35) 8.20 (3.37) 10.81 (4.50) 11.70 (4.94) 10.89 (3.93) 9.95 (4.54) behavior Approach 8.86 (3.68) 9.03 (4.18) 9.65 (3.42) 10.19 (3.90) 11.00 (3.98) 11.07 (3.57) 12.92 (3.71) 12.83 (4.06) 8.11 (3.90) 7.33 (4.20) 8.98 (4.38) 9.31 (5.19) behavior Positive 21.40 (6.84) 22.22 (8.83) 24.74 (8.06) 24.72 (8.80) 23.12 (9.07) 24.27 (8.62) 27.14 (8.20) 26.43 (9.93) 22.90 (7.75) 21.77 (9.48) 23.19 (8.29) 24.11 (8.33) thoughts Perceived 21.84 (7.42) 20.70 (7.33) 19.16 (7.44) 17.10 (6.06) 22.31 (8.96) 21.22 (8.72) 18.42 (8.13) 18.27 (8.27) 20.95 (8.45) 20.65 (8.68) 20.90 (9.35) 18.00 (7.80) social threat Secondary outcomes Internalizing 21.76 (6.45) 21.45 (6.72) 20.13 (7.01) 18.85 (6.99) 21.06 (6.52) 20.53 (7.92) 18.51 (6.09) 17.52 (6.55) 21.99 (6.82) 22.36 (7.20) 19.38 (6.50) 20.89 (8.00) behavior Self-efﬁcacy 11.11 (3.05) 10.89 (3.70) 12.19 (3.66) 12.48 (3.52) 12.19 (3.66) 12.41 (3.57) 13.94 (3.71) 13.65 (4.06) 11.14 (3.66) 10.14 (3.95) 12.19 (3.94) 12.96 (3.56) Social skills 136.27 (20.94) 141.25 (17.11) 145.06 (19.33) 148.06 (19.05) 137.35 (22.26) 141.39 (22.41) 143.83 (23.79) 145.62 (28.17) 133.47 (19.19) 136.13 (18.02) 133.12 (21.46) 137.38 (18.83) Self-perceived 54.03 (8.81) 55.50 (8.57) 57.41 (8.61) 58.97 (8.31) 53.75 (9.89) 55.81 (10.01) 58.49 (9.45) 57.77 (9.72) 54.34 (8.78) 55.30 (9.37) 56.60 (8.67) 58.06 (7.46) competence Journal of Child and Family Studies pre-intervention period. Supplementary Appendix E, Table intervention period, it was signiﬁcantly larger than the non- E.2 presents the complete ﬁt indices for the constrained signiﬁcant change during the pre-intervention period models and chi-square differences. (Δχ = 4.89, p < 0.01). Children in the EXP-condition signiﬁcantly improved on Children’s self-perceived competence signiﬁcantly all outcome measures during the intervention period. These improved further during the follow-up period. This improvements were signiﬁcantly larger than the non- improvement was signiﬁcantly larger than children’s signiﬁcant changes during the pre-intervention period for improvement in self-perceived competence during the 2 2 social anxiety (Δχ = 17.25, p < 0.001), distress intervention period (Δχ = 7.45, p < 0.01). Children did not 2 2 (Δχ = 8.84, p < 0.01), approach behavior (Δχ = 5.97, show signiﬁcant further improvement on any other outcome p < 0.05), positive thoughts (Δχ = 15.21, p < 0.001), per- measures during the follow-up period, but intervention ceived social threat (Δχ = 11.48, p < 0.001), internalizing effects were sustained at follow-up. behavior (Δχ = 6.25, p < 0.05) and self-perceived compe- Children in the CM-condition signiﬁcantly improved in tence (Δχ = 8.39, p < 0.01). Improvements during the distress, approach behavior, internalizing behavior, and self- intervention period on children’s avoidant behavior and efﬁcacy during the intervention period. However, only self-efﬁcacy were not signiﬁcantly larger than during the children’s improvement in distress and internalizing beha- pre-intervention period (Δχ = 3.08, p > 0.05 and vior was signiﬁcantly larger than the change during the pre- 2 2 2 Δχ = 2.09, p > 0.05, respectively). Children’s improvement intervention period (Δχ = 6.04, p < 0.05, and Δχ = 4.55, in social skills was signiﬁcant during both the pre- p < 0.05, respectively). Children’s improvements in intervention period and the intervention period, however, approach behavior, and self-efﬁcacy during the intervention the improvement during the intervention period was sig- period were not signiﬁcantly larger than the non-signiﬁcant 2 2 niﬁcantly larger (Δχ = 14.23, p < 0.001). changes during the pre-intervention period (Δχ = 1.25, Children reported an additional signiﬁcant improvement p > 0.05, and Δχ = 1.58, p > 0.05, respectively). Children in social anxiety, distress, and avoidant behavior during the in the CM-condition did not signiﬁcantly improve in social follow-up period. However, children’s improvement in anxiety, avoidant behavior, positive thoughts, perceived social anxiety and distress during the follow-up period was social threat, social skills, or self-perceived competence. signiﬁcantly smaller than during the intervention period Children did not show signiﬁcant further improvement on 2 2 (Δχ = 33.91, p < 0.001, and Δχ = 27.56, p < 0.001, any of the outcome measures, but the intervention effects respectively). The improvement in avoidant behavior during were sustained at follow-up. the follow-up period was signiﬁcantly larger than the improvement during the intervention period (Δχ = 19.43, Differences in Effectiveness between the p < 0.001). Children did not show signiﬁcant further Intervention Conditions improvement on any other outcome measures, but inter- vention effects were sustained at follow-up. To assess whether there were between-condition (i.e., EXP-, Children in the CR-condition signiﬁcantly improved on CR-, and CM-condition) differences concerning the chan- all outcome measures during the intervention period except ges during the intervention period and the follow-up period, for social skills. The improvements for social anxiety we compared a model that constrained these periods to 2 2 (Δχ = 37.01, p < 0.001), distress (Δχ = 16.75, p < 0.001), equality across the conditions with a model that estimated approach behavior (Δχ = 15.30, p < 0.001), positive these changes for each condition separately. In Table 3, thoughts (Δχ = 11.31, p < 0.001), perceived social threat subscripts indicate signiﬁcant differences between the con- 2 2 (Δχ = 9.37, p < 0.01), internalizing behavior (Δχ = 9.57, ditions. Supplementary Appendix E, Table E.3 presents the p < 0.01), self-efﬁcacy (Δχ = 13.47, p < 0.001), and self- ﬁt indices for the constrained models and chi-square dif- perceived competence (Δχ = 9.17, p < 0.01) during the ference tests. intervention period were signiﬁcantly larger than the non- During the intervention period, children’s signiﬁcant signiﬁcant changes on these outcomes during the pre- improvements in social anxiety and perceived social threat intervention period. Children in the CR-condition also sig- were similar in the EXP-condition and the CR-condition, niﬁcantly improved on social anxiety during the pre- but children’s signiﬁcant improvement in social anxiety was intervention period, however, improvement during the signiﬁcantly larger in the CR-condition than in the CM- 2 2 intervention period was signiﬁcantly larger (Δχ = 37.01, condition (Δχ = 5.30, p < 0.05). Also, children’s signiﬁcant p < 0.01). Children’s improvement in avoidant behavior improvement on perceived social threat was signiﬁcantly during the intervention period was signiﬁcantly larger than larger in the EXP-condition and the CR-condition than in children’s signiﬁcant worsening during the pre-intervention the CM-condition (Δχ = 4.76, p < 0.05). Children’s sig- period (Δχ = 19.27, p < 0.001). Although children’s niﬁcant improvement on social skills during the intervention improvement in social skills was not signiﬁcant during the period was signiﬁcantly larger in the EXP-condition than Journal of Child and Family Studies Table 3 Model parameters for the unconstrained latent change models controlling for ethnicity across conditions Exposure Cognitive restructuring Combination intercept Δ Δ Δ intercept Δ Δ Δ intercept Δ Δ Δ 2-1 3-2 4-3 2-1 3-2 4-3 2-1 3-2 4-3 µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) µ (SE) Primary outcomes *** *** *** ** *** *** Social 51.49 (1.64) −0.39 (1.30) −6.71 (1.37) −2.79* (1.17) 50.03 (1.72) −5.90 (1.71) −8.88 (1.63) −2.13 (1.76) 51.25 (2.44) −1.98 (2.26) −1.07 (2.88) −3.05 (1.57) b a anxiety *** *** *** *** *** * Distress 15.02 (0.57) 0.27 (0.46) −2.01 (0.51) −0.98* (0.43) 11.90 (0.61) −0.31 (0.58) −2.44 (0.53) 0.09 (0.55) 15.35 (0.83) −0.04 (0.64) −2.01 (0.80) −0.09 (0.54) *** * ** *** * ** *** Avoidant 11.04 (0.58) 0.27 (0.45) −1.16 (0.47) −1.30 (0.37) 9.13 (0.48) −0.98 (0.40) −1.35 (0.46) 0.35 (0.40) 11.93 (0.91) 1.14 (0.66) 0.73 (0.75) −0.61 (0.77) a a b behavior *** ** *** *** *** * Approach 8.74 (0.53) 0.08 (0.40) 0.96 (0.36) 0.56 (0.38) 11.27 (0.46) 0.36 (0.85) 1.82 (0.49) −0.12 (0.36) 6.89 (0.74) −0.79 (0.51) 1.59 (0.63) 0.22 (0.52) behavior *** ** *** ** *** Positive 21.67 (1.12) 0.75 (1.02) 2.72 (0.91) 0.40 (0.87) 23.94 (1.12) 1.15 (1.01) 3.13 (1.06) −0.66 (0.91) 22.08 (1.79) −0.10 (0.88) 0.29 (1.05) 0.51 (1.35) thoughts *** *** * *** Perceived 20.08 (0.95) −1.06 (0.77) −2.18* (0.91) −1.22 (0.84) 21.17 (1.10) −1.17 (0.95) −2.54 (1.01) −0.83 (0.98) 20.51 (1.65) 0.24 (0.88) 0.80 (1.12) −2.26 (1.63) a b ab social threat Secondary outcomes *** * *** * *** ** Internalizing 21.09 (0.86) −0.51 (0.66) −1.45 (0.72) −1.09 (0.84) 20.72 (1.06) −0.44 (0.91) −2.33 (0.99) −1.39 (0.86) 22.75 (1.32) −0.18 (1.08) −2.76 (0.94) 2.73 (1.49) a b ab behavior *** ** *** ** *** ** Self-efﬁcacy 10.75 (0.46) −0.54 (0.38) 1.16 (0.40) 0.73 (0.40) 12.55 (0.46) 0.34 (0.40) 1.54 (0.46) −1.30 (0.40) 9.77 (0.70) −1.05 (0.62) 1.89 (0.58) 0.35 (0.40) *** * ** *** *** Social skills 140.36 (2.24) 4.01 (1.76) 4.95 (1.54) 1.60 (2.31) 140.02 (2.83) 3.49 (2.50) 2.43 (1.21) 2.43 (2.32) 135.30 (3.43) 2.86 (1.78) −2.81 (3.26) 2.53 (3.42) a b a *** *** *** * * *** Self- 55.08 (1.07) 0.51 (0.84) 2.93 (0.85) 0.34 (0.87) 55.79 (1.26) 1.90 (1.99) 2.38 (2.28) 9.52 (4.18) 54.51 (1.72) 1.54 (1.23) 1.23 (1.75) 2.19 (1.75) a a b percieved competence * ** *** Intercept = pretest 1; Δ = pre-intervention period; Δ = intervention period; Δ = Follow-up period. Asterixis indicate a signiﬁcant within-group change ( p < 0.05, p < 0.01, p < 0.001). 2-1 3-2 4-3 Latent means in bold indicate that there was a signiﬁcant (p < 0.05) within-group difference between the intervention period and the pre-intervention period. Latent means in the same row that share subscripts indicate that there was a signiﬁcant (p < 0.05) difference between conditions Journal of Child and Family Studies children’s non-signiﬁcant change in the CM-condition cognitions and positive thoughts. Between Pretest 1 and (Δχ = 4.44, p < 0.05), but not signiﬁcantly larger than follow-up participants’ social threat cognitions reduced by children’s non-signiﬁcant change in the CR-condition an average of 3.88, which is broadly in line with a 5-point (Δχ = 1.32, p > 0.05). There were no signiﬁcant between- change following a full CBT intervention (Rapee et al., condition differences during the intervention period on any 2022) for youth with social anxiety disorder; positive of the other outcome measures. thoughts increased by an average of 2.61, comparable to During the follow-up period, children’s signiﬁcant previously reported change in anxious youth following improvement in avoidant behavior was signiﬁcantly larger treatment of 3.29 (Hogendoorn et al., 2013). in the EXP-condition than children’s non-signiﬁcant change in the CR-condition (Δχ = 9.08, p < 0.01), but not sig- niﬁcantly larger than children’s non-signiﬁcant change in Discussion the CM-condition (Δχ = 0.63, p > 0.05). Children’s non- signiﬁcant worsening of internalizing behavior during the This microtrial aimed to identify whether brief preventive follow-up period in the CM-condition was signiﬁcantly group interventions using exposure, cognitive restructuring, different from children’s non-signiﬁcant improvement on or both effectively reduced social anxiety in children with internalizing behavior in the EXP-condition and CR- emerging symptoms. We assessed changes in symptoms of 2 2 condition (Δχ = 4.63, p < 0.05, and Δχ = 5.32, p < 0.05, social anxiety and social-emotional outcomes that might respectively). Children’s signiﬁcant improvement in self- change by proxy of the reduction in social anxiety symp- perceived competence was signiﬁcantly larger in the CR- toms. Our ﬁndings show that exposure and cognitive condition than in the EXP-condition (Δχ = 4.42, p < 0.05), restructuring effectively improved social anxiety and related but not signiﬁcantly larger than in the CM-condition outcomes as single intervention components. Exposure (Δχ = 0.31, p > 0.05). There were no signiﬁcant between- improved children’s symptoms of social anxiety and all condition differences for any other outcome measures dur- related outcomes measured, except for self-efﬁcacy. Cog- ing the follow-up period. nitive restructuring also improved children’s symptoms of social anxiety and related outcomes, except for social skills. Clinical Relevance After intervention with exposure or cognitive restructuring, 69 and 78%, respectively, of the children scoring in the To give an indication of the clinical relevance of the clinical range of social anxiety at Pretest 1 returned to changes in the intervention conditions, we analyzed the “normal” levels of anxiety at Follow-up; this is in line with number of children scoring above the clinical cut-off on the previous studies (Kendall & Peterman, 2015). Overall, our SAS-A in the different conditions. Analyses showed that in ﬁndings demonstrate that exposure and cognitive restruc- the exposure condition, 59.3% (n = 48) of the participants turing are similarly effective in reducing social anxiety and scored above the clinical cut-off at Pretest 1, versus 40.0% related outcomes in children with emerging symptoms, (n = 30) at Posttest (χ [74] = 11.90, p < 0.001) and 22.1% which is in line with ﬁndings from previous research (e.g., (n = 15) at Follow-up (χ [67] = 7.062, p < 0.01). In other Peris et al., 2015; Rodebaugh et al., 2004). words, 69% of the participants that scored in the clinical Previous research has found that reductions in anxious range of social anxiety at Pretest 1 improved to “normal” self-talk are associated with reduced anxiety symptoms levels (i.e., below the clinical cut-off) of social anxiety at (Kendall & Treadwell, 2007). In line with that study, we Follow-up. In the cognitive restructuring condition, 74.0% found that cognitive restructuring positively affected chil- (n = 54) of the participants scored above the clinical cut-off dren’s cognition. Children reported more positive thoughts at Pretest 1, versus 28.6% (n = 16) at Posttest (χ and perceived less social threat after the intervention. This [56] = 4.82, p < 0.05) and 26.1% (n = 12) at Follow-up (χ was also found for exposure—noteworthy given that only [46] = 3.18, p = 0.07). Thus, 78% of the participants in this cognitive restructuring paid explicit attention to children’s condition improved to the non-clinical range of social cognition. Exposure might elicit self-administered cognitive anxiety from Pretest 1 to Follow-up. In the combination restructuring (Rodebaugh et al., 2004), and the exposure condition, 63.9% (n = 23) of the participants scored above exercises might have served as expectancy violation exer- the clinical cut-off at Pretest 1, versus 53.1% (n = 17) at cises by disconﬁrming children’s expectation of negative Posttest (χ [32] = 0.40, p = 0.53) and 39.1% (n = 11) at evaluation (Craske et al., 2014). In this way, exposure may Follow-up (χ [28] = 1.10, p = 0.29). Hence, 47% of the cause children to adjust their unhelpful thoughts without participants in this condition improved to the non-clinical explicitly focusing on the negative cognitions. This ﬁnding range of social anxiety from Pretest 1 to Follow-up. implies a possibility of improving children’s cognition In addition, the interventions showed clinically relevant within a four-week exposure-based intervention. If expo- change in the following outcome measures: social threat sure is effective in improving children’s self-perceptions — Journal of Child and Family Studies as our ﬁndings suggest— this relatively easy-to-execute avoidant behavior needs time to ‘internalize’, as positive component could be used to prevent the development of effects of the intervention only emerged in the follow-up maladaptive thoughts in at-risk children. This is important period. It may be that children’s avoidance of anxiety- given that research has shown that negative self-perceptions provoking situations only reduces after a reduction in mediate the longitudinal relationship between shyness and anxiety symptoms and distress in these situations has been social anxiety (Blöte et al., 2019). established. An alternative explanation may be that, in line The structure of the exposure and cognitive restructuring with the gradual nature of the exposure component, children intervention modules may explain their similar effect on continued to work towards engaging in anxiety-provoking many outcomes. As well as teaching children to adjust their situations, thereby reducing their avoidant behavior (e.g., unhelpful thoughts, the cognitive restructuring intervention Peris et al., 2015). might also prompt imaginal exposure by instructing chil- An important ﬁnding of this microtrial is that an inter- dren to visualize hypothetical social situations. This vention combining exposure and cognitive restructuring mechanism was previously found in research with adults was less effective in preventing social anxiety than either with post-traumatic stress disorder: visualizing a situation component alone. Although this ﬁnding should be inter- yielded a signiﬁcant change in anxiety levels (Bryant et al., preted with caution due to the small sample size of the 2003). The possibility that exposure exercises prompt combination condition, it is in line with previous research children to engage in self-administered cognitive restruc- (e.g., Rodebaugh et al., 2004). Stacking multiple interven- turing may suggest that it is impossible to rule out non- tion components may thus not necessarily yield greater targeted components in separate component interventions; intervention beneﬁts. In fact, our ﬁndings suggest that there might be some cognitive restructuring in an exposure- compared to a combined intervention, cognitive restructur- only intervention and vice versa. ing was superior in reducing children’s social anxiety, that However, the exposure and cognitive restructuring both exposure and cognitive restructuring outperformed the components had a differential effect on several outcomes. combined intervention in reducing children’s perceived Unlike exposure, cognitive restructuring did not improve social threat, and that exposure outperformed the combined children’s social skills, which might be due to the focus on intervention in increasing children’s social skills. Possibly, cognition. While exposure is focused more “outward” each component may need to be administered in a certain towards behavior, cognitive restructuring is focused more minimum dosage and a combination of exposure and cog- “inward” towards the child’s inner world, which may make nitive restructuring might only be effective when the a difference in improving social skills. Children may spe- separate components are implemented in the right dosage. ciﬁcally need to enact social situations that provoke anxiety The combination intervention included fewer exposure and practice improving their social skills (e.g., Miers et al., exercises and cognitive restructuring exercises than the 2011)—which was the case in the exposure intervention but time-equal separate interventions, which may explain the not the cognitive restructuring condition. We also found that apparent absence of effects for the combined intervention. exposure did not improve children’s self-efﬁcacy, whereas We cannot rule out that a higher dose of the combination of cognitive restructuring did. In addition, cognitive restruc- exposure and cognitive restructuring would have an addi- turing was more effective in increasing children’s positive tive positive effect on social anxiety symptoms; four ses- thoughts, and this increase in positive thinking may be sions might be too few to implement both exposure and instrumental to the improvement in self-efﬁcacy (i.e., chil- cognitive restructuring sufﬁciently. By the same token, the dren’s prediction of how well they will perform certain lack of effects in the combined intervention may be ascribed tasks). Also, children’s belief in their ability to restructure to the fact that children practiced with fewer social situa- unhelpful thoughts and thereby control their emotions in tions (i.e., two instead of three) in this intervention. Alter- anxious situations may increase their self-efﬁcacy (e.g., natively, exposure and cognitive restructuring may be more Goldin et al., 2012). potent in the absence of other intervention components The positive effects of both exposure and cognitive (Peris et al., 2015). restructuring were sustained until the three-month follow-up Interpretation of our ﬁndings must take into account that on all outcomes for which an intervention effect was found. all interventions developed for this study included psy- Exposure continued to have an effect on social anxiety, choeducation about anxiety. Previous research (de Mooij distress, and avoidance of social situations up to three et al., 2020) has shown this is an important component in months after the intervention ended, and cognitive restruc- enhancing intervention effects. Therefore, we cannot rule turing continued to have an effect on self-perceived com- out that this common element is responsible for our lack of petence up to three months after the intervention ended. In differences between the intervention conditions. Future contrast to these sustained effects during the follow-up research may consider a factorial design to assess treatment period, our ﬁndings suggest that the effect of exposure on order effects (Leijten et al., 2015). Journal of Child and Family Studies Our study is not without limitations. First, one may view 2017). Future research might also evaluate the effectiveness the group setting of the brief interventions as a form of of other components frequently included in social anxiety exposure in itself. Although the exposure condition expli- interventions, such as problem-solving. Assessing the citly targeted social exposure through speaking in front of a effects of a parent component in social anxiety interventions group, differences with the cognitive restructuring condition might also prove insightful, as research has shown parenting may be somewhat less optimal. However, research has to be an etiological factor that may predict social anxiety shown that group CBT (which included both exposure and (Spence & Rapee, 2016). cognitive restructuring) had similar effects to individual It was beyond the scope of this study to assess subgroup CBT (Silverman et al., 2008); thus, we do not expect the variability in the effectiveness of intervention components. group context to have confounded our ﬁndings. Second, we In line with research suggesting that social anxiety is more assessed all outcomes with self-report measures. Although prevalent in women (Asher et al., 2017), slightly more girls this is common in anxiety research, including parent reports, than boys from the baseline sample reported elevated levels teacher reports and observations could provide a more of social anxiety and were selected for our interventions. comprehensive assessment of the children’s social anxiety Future research could assess what works for whom in social (Silverman & Ollendick, 2005). Third, there was an uneven anxiety interventions. Research has also shown that social distribution of participants across the conditions. Third, anxiety symptoms may differ based on ethnicity (e.g., fear implementation forms were not completed for all training of embarrassing oneself versus the other person), which groups, The workload of primary school teachers is high in may mean intervention components aimed at social anxiety the Netherlands, and as a result, many schools were reluc- are also differentially effective based on participants’ ethnic tant to participate in a study with multiple measurement backgrounds (Hofmann et al., 2010). A child’s level of occasions. Only a few schools randomized into the com- behavioral inhibition before the training (e.g., Clauss & bination condition agreed to participate, and thus only a Blackford, 2012) or the use of safety behaviors such as small number of children participated in the combined avoiding eye contact (e.g., Blakey & Abramowitz, 2016) condition. We could not include a no-treatment control may also inﬂuence intervention effectiveness. Social anxi- group for similar reasons, which limits our ability to con- ety is also often comorbid with other anxiety disorders and clude the effects of the brief interventions compared to no depression (Spence & Rapee, 2016). Future research might treatment. However, due to the use of two pretest mea- collect data on comorbid disorders to assess how this surements, we could compare pre-post intervention effects impacts intervention component effects. Insight into what to children’s natural development before the intervention’s works for whom regarding indicated prevention interven- implementation, which provides stronger conclusions tions could be valuable to better tailor interventions to a regarding intervention effects. Including a follow-up mea- child’s individual needs. surement allowed us to assess the sustainability of inter- These limitations notwithstanding, we were the ﬁrst to vention effects, and including multiple outcome measures assess components of social anxiety interventions sepa- related to social anxiety provided a detailed picture of the rately, and our ﬁndings provide valuable information about effectiveness of the interventions. Fourth, it should be taken separate and combined effects of exposure and cognitive into account that the study may be underpowered to detect restructuring. Our ﬁndings have several practical implica- small to medium effects for the number of outcome mea- tions, the most important being that a relatively brief, four- sures, hence it is important that our ﬁndings are replicated in week intervention could protect children from developing future studies. Finally, our ﬁndings should be interpreted in elevated levels of social anxiety and associated negative light of its mild to moderately symptomatic community consequences. Because we found the stand-alone exposure sample. It may be that the differences between the separate and cognitive restructuring approaches to be effective, we intervention components are more pronounced in a clinical conclude that practitioners can safely focus on exposure or sample of socially anxious children. cognitive restructuring alone if there is little time for a Future research using a microtrial approach might multicomponent intervention. include multiple informants and observational data to assess Our study provides preliminary evidence that exposure the moderating effects of common factors such as working might be the most valuable component regarding the breadth alliance and client and/or therapist motivation, a more of intervention effects, although cognitive restructuring evenly distributed sample, and a no-treatment control group. yielded positive effects too. From a prevention perspective, An observational measure, such as a role-play task, may be the effectiveness of short-term intervention modules is included as a real-world assessment of changes in children’s advantageous because they are easy to implement. The social behavior in school. Possibly, this could provide modules were highly structured, so future implementation by researchers with more insight into the generalization of the teachers or school-based clinicians might be feasible. More- effects of the intervention components (e.g., Le & Beidel, over, the regular school curriculum could integrate Journal of Child and Family Studies intervention module exercises, which could make addressing Bryant, R. A., Moulds, M. L., Guthrie, R. M., Dang, S. T., & Nixon, R. D. V. (2003). Imaginal exposure alone and imaginal exposure elevated social anxiety in children more cost-effective, and with cognitive restructuring in treatment of posttraumatic stress less burdensome for both children and parents as it could disorder. Journal of Consulting and Clinical Psychology, 71(4), reduce the need to visit clinical childcare facilities. 706–712. https://doi.org/10.1037/0022-006X.71.4.706. Campbell, M. K., Mollison, J., Steen, N., Grimshaw, J. M., & Eccles, M. (2000). Analysis of cluster randomized trials in primary care: Acknowledgements This study was funded by ZonMw “Effectief a practical approach. Family Practice, 17(2), 192–196. https:// werken in de Jeugdsector”, project number 729300011. doi.org/10.1093/fampra/17.2.192. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. Compliance with Ethical Standards In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment, and treatment (pp. 69–93). Guilford Press. Conﬂict of Interest The authors declare no competing interests. Clauss, J. A., & Blackford, J. U. (2012). Behavioral inhibition and risk for developing social anxiety disorder: a meta-analytic study. Consent to Participate Written informed consent was obtained from Journal of the American Academy of Child & Adolescent Psy- the parents or legal guardians of participants. chiatry, 51(10), 1066–1075. https://doi.org/10.1016/j.jaac.2012. 08.002. Ethics Approval This study was performed in line with the principles Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. of the Declaration of Helsinki. Approval was granted by the Ethics (2014). Maximizing exposure therapy: an inhibitory learning Committee of the University of Amsterdam (24-04-2017/No. 8033). approach. Behaviour Research and Therapy, 58,10–23. https:// doi.org/10.1016/j.brat.2014.04.006. Publisher’s note Springer Nature remains neutral with regard to Crawley, S. A., Beidas, R. S., Benjamin, C. L., Martin, E., & Kendall, jurisdictional claims in published maps and institutional afﬁliations. P. C. (2008). Treating socially phobic youth with CBT: differ- ential outcomes and treatment considerations. Behavioural and Cognitive Psychotherapy, 36(4), 379–389. https://doi.org/10. Open Access This article is licensed under a Creative Commons 1017/S1352465808004542. Attribution 4.0 International License, which permits use, sharing, Donders, W., & Verschueren, K. (2004). Zelfwaardering en acceptatie adaptation, distribution and reproduction in any medium or format, as door leeftijdsgenoten: Een longitudinal onderzoek bij basis- long as you give appropriate credit to the original author(s) and the schoolkinderen. Kind en Adolescent, 25,45–54. https://doi.org/ source, provide a link to the Creative Commons license, and indicate if 10.1007/BF03060906. changes were made. The images or other third party material in this Fordham, K., & Stevenson-Hinde, J. (1999). Shyness, friendship article are included in the article’s Creative Commons license, unless quality, and adjustment during middle childhood. Journal of indicated otherwise in a credit line to the material. If material is not Child Psychology and Psychiatry and Allied Disciplines, 40(5), included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted 757–768. https://doi.org/10.1111/1469-7610.00491. Fredrick, J. W., & Luebbe, A. M. (2022). Prospective Associations use, you will need to obtain permission directly from the copyright Between Fears of Negative Evaluation, Fears of Positive Evaluation, holder. To view a copy of this license, visit http://creativecommons. and Social Anxiety Symptoms in Adolescence. Child Psychiatry org/licenses/by/4.0/. Hum Dev https://doi.org/10.1007/s10578-022-01396-7 Furmark, T. (2002). Social phobia: overview of community surveys. 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Journal of Child and Family Studies – Springer Journals

Published: Feb 1, 2023

Keywords: Social anxiety; Exposure; Cognitive restructuring; Microtrial; Intervention components

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What Works in Preventing Emerging Social Anxiety: Exposure, Cognitive Restructuring, or a Combination?

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What Works in Preventing Emerging Social Anxiety: Exposure, Cognitive Restructuring, or a Combination?

What Works in Preventing Emerging Social Anxiety: Exposure, Cognitive Restructuring, or a Combination?

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