Interpretation Bias Modification for Youth and their Parents: A Novel Treatment for Early Adolescent Social Anxiety

Social anxiety is the most prominent anxiety disorder of late adolescence (Ollendick & Hirshfeld-Becker, 2002), affecting up to 15% of teenagers in the United States (Heimberg, Stein, Hiripi, & Kessler, 2000), and linked to many deleterious short- and long-term outcomes (Albano & Hayward, 2004). The lack of efficacious treatment for this widespread and debilitating disorder represents a significant public health problem. Only an estimated 20% of youth with clinically significant levels of anxiety and depression receive treatment (Collins, Westra, Dozois, & Burns, 2004), and of those who do, only 60% fully respond to the current gold standard treatment for social anxiety, cognitive behavioral therapy (Kendall, Settipani, & Cummings, 2012).
To help address these problems, this dissertation pilot tested the efficacy of a novel, online cognitive bias modification for interpretation (CBM-I) intervention for socially anxious youth and their parents. The CBM-I intervention targeted cognitive biases associated with early adolescents’ maladaptive beliefs regarding social situations, and with parents’ intrusive behavior, both of which have been theoretically linked with the maintenance of social anxiety in youth (Ollendick & Benoit, 2012). To investigate whether it is most effective to intervene with parents and/or children, clinically diagnosed early adolescents (ages 10-15; N = 18) and their mothers were randomly assigned to one of three conditions: the first targeted early adolescents’ cognitive biases related to social anxiety (Child-only condition); the second targeted parents’ biases associated with intrusive behavior (Parent-only condition); and the third targeted both youth and parents’ biases in tandem (Combo condition). Answering calls for more idiographic research in clinical science (Barlow & Nock, 2009), the use of a multiple baseline design allowed for the efficient assessment of causal links (Barlow & Hersen, 1984) between the intervention and reduction in social anxiety symptoms in youth, as well as the preliminary exploration of moderators and mediators of change (Rizvi & Nock, 2008) in anxiety symptoms. Further, participants’ user experiences as reported in exit interviews were examined to inform future research designs.
Results provided converging evidence indicating modest support for the efficacy of CBM-I, with no reliable differences across conditions. Specifically, approximately half of the sample showed clear reduction in social anxiety symptoms, and these reductions could be causally attributed to the intervention in approximately half of those cases. Further, effect sizes for change in social anxiety symptoms from pre- to post-treatment were large, though with the small sample size (typical of multiple baseline designs), the effect sizes should be interpreted cautiously. Effect sizes for change in interpretation bias from pre- to post-treatment were in expected directions, though smaller in magnitude than was expected. Exploratory analyses suggested that lower levels of child depression and parent anxiety symptoms were associated with greater reductions in child anxiety symptoms. In some cases, reductions in parent and child negative interpretation bias and increases in parent and child positive interpretation bias mediated reductions in child social anxiety. Themes that emerged from participant exit interviews suggested that the intervention raised parents’ awareness of their behaviors related to their child’s anxiety; “normalized” the experience of social anxiety for youth; and was ultimately helpful for most participants, perhaps partially owing to several unintended benefits of the assessments. Taken together, results suggest that online CBM-I holds promise as an effective and easily administered component of treatment for child social anxiety that deserves further evaluation in a larger trial.