Cognitive Behavioral Therapy of Socially Phobic Children Focusing On Cognition: A Randomised Wait-List Control Study

Melfsen et al.
Child and Adolescent Psychiatry and Mental Health 2011, 5:5

http://www.capmh.com/content/5/1/5
RESEARCH Open Access
Cognitive behavioral therapy of socially phobic

children focusing on cognition: a randomised
wait-list control study
Siebke Melfsen1,2*, Martina Kühnemund3, Judith Schwieger3, Andreas Warnke1, Christina Stadler4, Fritz Poustka4,
Ulrich Stangier3
Abstract
Background: Although literature provides support for cognitive behavioral therapy (CBT) as an efficacious
intervention for social phobia, more research is needed to improve treatments for children.
Methods: Forty four Caucasian children (ages 8-14) meeting diagnostic criteria of social phobia according to the
Diagnostic and Statistical Manual of Mental Disorders (4th ed.; APA, 1994) were randomly allocated to either a newly
developed CBT program focusing on cognition according to the model of Clark and Wells (n = 21) or a wait-list
control group (n = 23). The primary outcome measure was clinical improvement. Secondary outcomes included
improvements in anxiety coping, dysfunctional cognitions, interaction frequency and comorbid symptoms. Outcome
measures included child report and clinican completed measures as well as a diagnostic interview.
Results: Significant differences between treatment participants (4 dropouts) and controls (2 dropouts) were
observed at post test on the German version of the Social Phobia and Anxiety Inventory for Children. Furthermore,
in the treatment group, significantly more children were free of diagnosis than in wait-list group at post-test.
Additional child completed and clinician completed measures support the results.
Discussion: The study is a first step towards investigating whether CBT focusing on cognition is efficacious in
treating children with social phobia. Future research will need to compare this treatment to an active treatment
group. There remain the questions of whether the effect of the treatment is specific to the disorder and whether
the underlying theoretical model is adequate.
Conclusion: Preliminary support is provided for the efficacy of the cognitive behavioral treatment focusing on
cognition in socially phobic children. Active comparators should be established with other evidence-based CBT
programs for anxiety disorders, which differ significantly in their dosage and type of cognitive interventions from
those of the manual under evaluation (e.g. Coping Cat).
Background development of other psychological disorders [4].

Social phobia is one of the most common psychological Although literature provides support for cognitive beha-
disorders in children and adolescents [1-3]. The disorder vioral therapy (CBT) as an efficacious intervention for
is characterized by a fear of being perceived as inade- social phobia in children and adolescents [5-7], more
quate in social or achievement situations, resulting in research is needed to improve treatments for children.
considerable problems. Furthermore, social phobia in Most of the initial investigations included children with
childhood and adolescence is a risk factor for the various anxiety disorders.
Kendall [8] developed the “Coping Cat program (Cat)”
that contains education, modification of negative cogni-
* Correspondence: siebke.melfsen@online.de tions, exposure, social competence training, coping beha-
1
Clinic and Polyclinic for Psychiatry, Psychosomatic and Psychotherapy for
Children and Adolescents, University of Wuerzburg, Fuechsleinstr. 15, 97080 vior and self-reinforcement. Different authors have used
Wuerzburg, Germany the program, making only slight changes [e.g. [9,10]].
Full list of author information is available at the end of the article
© 2011 Melfsen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Melfsen et al. Child and Adolescent Psychiatry and Mental Health 2011, 5:5 Page 2 of 12
Kendall [8] reports significantly less general anxiety and from external social cues and instead is excessively self-
improved coping behaviour as a result of the program, focused. Connected with this is a linked decrease in
even in a follow-up after 3.5 years [11]. observation of other people and their responses. (b) The
“Cognitive-behavioral group therapy for social phobia use of misleading internal information (feelings and
in adolescents (CBGT-A)” [12], is a specific group pro- images) to make excessively negative inferences about
gram. The first phase conveys information about social how one appears to others. (c) Extensive use of overt
phobia, and implements cognitive restructuring and and covert safety behaviors. Safety behaviors are strate-
social skill training. The second phase includes in vivo gies that are used to reduce anxiety or to hold off the
exposure and applied routines. Studies have demon- social threat [24]. Safety behaviors, however, are proble-
strated improvements at post test [13]. However, gains matic because they contribute to the maintenance of
were not maintained at a 1-year follow-up [14]. fear. Anticipatory as well as post-event thoughts (i.e.
The group program “Social effectiveness therapy for thoughts prior to and after the social situation) contri-
children” (SET-C) [15] puts its focus on exposure treat- bute to the persistence of social phobia. It was shown
ment, combined with social skills training and social that the inclusion of interventions targeting safety beha-
interactions with non-anxious peers, but does so without vior leads to an increased effectiveness of CBT [25]. (d)
cognitive interventions. Children and adolescents com- Problematic pre- and post-event processing [26]. The
plete one introductory educational session with their par- therapy program has proved to be superior compared to
ents, 1 group session, and 12 in-vivo exposure sessions treatment with SSRIs or placebo, even after 12 months
over a 12 week period to help them improve their social [26,27]. Higher effect sizes have been found compared
skills. The SET-C group sessions provide instructions to previous meta-analyses of cognitive-behavioral ther-
and practice, including activities where socially anxious apy in socially phobic adults. This result indicates a sig-
participants interact with non-anxious peers. The indivi- nificant increase of effectiveness [26-28].
dual in-vivo exposure component is designed to reduce Very often, cognitive interventions are conceived as
anxiety in destressing social situations by making them being inadequate for children due to their concrete
more familiar. Concurrently, parents use positive reinfor- thinking, time-limited perceptions and egocentric nature
cement and shaping sequencing to effectively assist the of thinking. It has, however, been suggested that chil-
progress of the SET-C program. Positive benefits have dren are quite capable of benefiting from cognitive
been achieved through use of this treatment protocol. interventions providing that educational and develop-
Elements from the SET-C protocol were included in a mental features are considered. According to Ronen [29]
school-based group behavioral treatment [15-19]. In one children can benefit from cognitive interventions pro-
of the longest follow-up assessment studies on youth, vided that two conditions are met: (1) The therapist
Garcia-Lopez et al. [20] reported maintenance of treat- should be able to adapt the treatment to the child’s per-
ment gains at the 5-year follow-up assessment. Masia et sonal cognitive style. Such adaptations include, for
al. [18] built on this new approach in their investigation example, translations of abstract terms to concrete ones,
of a 14-session group treatment in a school-setting which utilization of simple words, use of demonstrations,
focuses primarily on education, realistic thinking, social metaphors, and illustrations taken from the child’s own
skills training, exposure, and unstructured social situa- day-to-day life. (2) The treatment goals and procedures
tions to allow for practicing skills. In a pilot study of six should be suited to the child’s individual pace, as related
children, three of them no longer met criteria for social to age and cognitive level.
phobia [18]. Baer and Garland [21] used a modified ver- Hodson et al. [30] investigated the applicability of
sion of the SET-C program. The treatment involved Clark and Wells’ cognitive model to younger patients.
twelve sessions. The authors concluded that a briefer ver- High socially anxious children scored significantly
sion of group CBT was as effective as the more extensive higher than low socially children on all of the variables
research protocols. in Clark and Wells’ model: negative social cognitions,
Several reseachers posit that cognition plays an impor- self-focused attention, safety behaviours, and pre- and
tant role in the maintenance of social phobia [22,23]. In post-event processing. Findings suggest that Clark and
an attempt to increase the overall response rate for cog- Wells’ model may be equally applicable to younger chil-
nitive-behavioral treatment, Clark and Wells [22] pro- dren with social phobia.
posed a cognitive model of the maintenance of social These findings have been confirmed by several studies
phobia and used the model to develop a new cognitive [31-34]. Results from a range of studies show that anxious
therapy (CT) program for socially phobic adults. The children interpret ambiguous situations more often as
four maintenance processes that are highlighted in the being hostile [35-37,31]. Muris et al. [38] showed a similar
model are: (a) Increased self-focused attention; This finding specifically with socially anxious children. Studies
means that in social situations, attention is shifted away of attention control substantiate these findings: They
confirm that the anxious child maintains a vigilant atten- anxiety coping, interaction frequency and comorbid
tion state for threatening cues [39-41]. Bell-Dolan and symptoms.
Emery [42] showed in a peer interaction task, that anxious
children were as accurate as non-anxious children at iden- Methods
tifying hostile intent in peer interactions, but they tended Design
to misinterpret non-hostile situations as hostile. In a study This was a single-center, parallel-group study with
by Johnson and Glass [43] socially anxious children, in balanced randomization. Patients were randomly
social or evaluation situations, also tended to focus their assigned to a cognitive behavioral treatment focusing on
attention primarily on themselves, for instance, on their cognition or a wait-list control group. Children placed
own physical reactions, instead of on the business at hand. in the wait-list control group were offered the full treat-
Very few studies have examined the memory capacity of ment at the completion of the wait-list period. At three
anxious children. In a study by Daleiden [44] anxious chil- time-points in the study, treatment group participants
dren more often remembered negative information, so that completed questionnaires and diagnostic interviews:
a selective memory capacity was presumed to exist. In prior to beginning treatment, immediately following the
terms of anticipation of future events by socially anxious final session and six months following termination of
children, Spencer et al. [45] found with 7- 14 year olds treatment. Wait-list participants completed measures at
that, in comparison to children in the control group, the pre-test, after 4 months and after 10 months. Results of
socially anxious children underestimated the probability of the follow-up data are in preparation. The ethics com-
future positive social events. Controlled studies of cognitive mittee of the German Psychological Association (DGPs)
treatment programs for socially phobic children are rare. had approved the project and written informed consent
Therapy with children differs from therapy with youth for the procedure was obtained from the children’s par-
and adults. First, very few children come to therapy on ents. The program was delivered in and around Frank-
their own volition. They are brought to treatment, furt am Main, Germany.
usually by their parents or caregivers. Second, unlike
adult therapy, which involves the rational modification Randomization
of thoughts, cognitive behavioral therapy for children Patients were randomly assigned to intervention or con-
focusing on cognition is more concerned with teaching trol by using a web based computerised randomization
appropriate skills and applying certain techniques. plan generator http://www.randomization.com. The pro-
The following study deals with the evaluation of a gram randomizes each socially phobic child to a single
new cognitive behavioral treatment program for treatment using the method of randomly permuted
socially phobic children focusing on cognition accord- blocks. A research assistant not involved in the delivery
ing to the model of Clark & Wells [22]. Although of the treatment program placed participants on the
overlapping with other empirically validated CBT pro- randomization list in the next available slot.
grams, CBT focusing on cognition has several distinc-
tive features: (a) the development of Clark & Well’s Participants
[22] model by using the child’s own thoughts, images, Forty four German socially phobic children and their
attentional strategies, safety behaviors, and symptoms, respective mothers participated in the study. Children
(b) experiential exercises in which self-focused atten- were recruited in and around Frankfurt am Main,
tion and safety behaviors are systematically manipu- Germany by means of advertisements and school con-
lated in order to demonstrate their adverse effects, tacts as well as through therapeutic institutions. The
(c) systematic training in externally focused attention, children were allocated to treatment on the basis of a
(d) techniques for restructuring distorted self-imagery, computer generated random sequence. In the treatment
including a specialized way of using video feedback group, there were 21 socially phobic children (Table 1).
and (f) the structuring of planned confrontation with The control group consisted of 23 socially phobic chil-
feared social situations as a behavioral experiment in dren. The unequal size of both groups arose from the
which children test pre-specified negative predictions random allocation to the groups.
while dropping their habitual safety behaviors and
focusing externally. A habituation rationale was not Measures
used [26]. The aim of the present research was to Intelligence
examine the efficacy of this treatment program for As a precondition for treatment, a measure of intelligence
socially phobic children with a focus on cognition. Our was administered in order to be able to exclude the possi-
hypotheses include reduction of socially phobic symp- bility that differences in outcome measures could be
toms and dysfunctional cognitions, improvements in attributed to differences in intelligence. The CFT-20 was
Table 1 Description of the children’s sample

treatment group (n = 21) Wait-list group (n = 23)
age M (SD) 10.60 (1.64) 10.76 (1.90) F(1,41) = .94, p = .33
range 8 - 14 8 - 14
gender n (f/m) 8/13 13/10 Chi2(1, 0.95) = .91 p = .76
Caucasian n 21 23
Culture Fair Test
M (SD) 103.86 (13.41) 112.45 (12.23) F(1,41) = .09 p = .09
comorbid diagnosis
another anxiety disorders n 10 7
affective disorder 1 0
enuresis 1 0
oppositional defiant disorder 0 1
drop-outs 4 2
administered to every child [46]. This intelligence test is [49], a clinician-rated scale that assesses overall func-
the revised version of the “Culture Fair Test” and is tioning. The score can range between 1 and 100, with a
adapted for the age range of 8, 5 to 18 years. Norms are lower score representing a more severe impairment.
constructed so that a person of average intelligence would Interrater-reliability for the K-GAS was k = .85.
reach an IQ value of 100. All four subtests showed high Child-Completed Measures
loads on the factor “General Fluid Ability”. Correlations All of the scales presented in this study are validated
between CFT-20 and other intelligence tests have been scales.
found to be on average at a level of r = .64 with a range Social Anxiety The children were provided with the
from r = .57 to r = .73 (see table 1). German version of the Social Phobia and Anxiety Inven-
Clinician-Completed Measures tory for Children (German version: SPAIK) [50,51]. The
All of the children took part in a structured interview items refer to differences in frequency from 0 (“never,
for the diagnosis of mental disorders according to DSM- or hardly ever”), 1 ("sometimes”) or 2 (“most of the
IV criteria. For this purpose, the German version of the time, or always” rated), with possible total scores ran-
Anxiety Disorders Interview Schedule (ADIS) for Chil- ging from 0 - 52. The SPAI-K appears to be a reliable
dren (German version: DIPS-K) [47,48] was adminis- (a = .92; rtt = .84) and valid measure (r = .6) of child-
tered. Previous research has demonstrated satisfactory hood social anxiety.
interrater diagnostic reliability (r = .60) and test-retest Anxiety coping The German version of the “Coping
reliability (kappa = .50) and the measure has shown sen- Questionnaire - Child (German version: CQ-C)” [8] was
sitivity to treatment effects in studies of children and developed to assess the child’s self-perceived capability to
youth with anxiety disorders. Clinicians were trained by deal with specific anxiety-provoking situations. Mother
observing live and videotaped samples. They met an and child choose together 3 social situations in which the
initial reliability criterion of 100% with the primary and child experienced social fear. The child rated these on a
comorbid diagnoses on five consecutive live child-parent five-point scale from “It is not difficult for me at all” (1)
interviews. Further, the child and parent interviews were to “It is very difficult for me” (5). The test-retest reliabil-
videotaped. In order to get independent assessments, ity of the American version after two months in children
video recordings of all interviews at initial as well as with an anxiety disorder was given as rtt = .73 [8]. The
outcome assessments were viewed by an expert who German version has not been validated.
was blind to the treatment condition. The expert’s rat- Dysfunctional cognitions The German scale “Socially
ings were final measures of the outcome. Anxious Cognitions Scale for Children (SAKK)” [52]
Clinicians severity ratings The DIPS-K contains rating was administered to assess socially anxious cognitions.
scales (0-8-point) to assess the severity of disorder based The items are to be rated on a five-point scale with
on the clinicians’ views of the degree to which the “never,” “rarely,” “sometimes”, “mostly” or “always” as
child’s disorder(s) interfere(s) with overall functioning. reponse options. It appears to be a reliable (a = .84-.91;
Reliability for the clinician severity ratings has been rtt = .84) and valid measure (r = .64). Normative values
found to be satisfactory (79% agreement was obtained). for the SAKK are available for class levels 3-6.
Measure of overall functioning Clinicians also com- Interaction frequency A German behavior diary was
pleted the Children’s Global Assessment Scale (K-GAS) implemented to assess social interactions. The frequency
of telephone calls and activities with peers during a time as defined by DIPS-K interview with mother and child;
period of 14 days was recorded in the diary. This mea- (b) the child had experienced social phobia for a dura-
sure builds on everyday behavior of children. tion of at least 6 months; (c) social phobia was consid-
Comorbid symptoms The Children’s Depression Inven- ered to be the child’s main current problem; (d) the
tory (DIKJ) [53] is a German self-report measure of child was 8 - 13 years old, and (e) the child and parents
depressive symptoms. Severity of depressive symptoms agreed not to start any additional treatment during the
is rated on a scale from 0 (not exists) to 3 (strong trial. Exclusion criteria for participation in the trial were
expression). Scores obtained on the DIKJ have been psychotic symptoms, current suicidal or self-harming
found to correlate significantly with clinicians’ ratings of behavior or current involvement in other psychosocial
depression as well as with objective behavioral measures or psychopharmacological treatment for phobia and
of depression. Internal consistency coefficients range anxiety problems. The exclusion criteria were assessed
from a = .82 through a = .91. via interview (DIPS-K).
Treatment response We used several different outcome Children placed in a wait-list control group were
measures. Our primary outcome measure was clinical offered the full treatment at the completion of the wait-
improvement, assessed by a child-completed inventory list period. 17 of the 23 wait-list participants chose to
(German version of the Social Phobia and Anxiety attend these treatment sessions. The other six refused to
Inventory for Children). A second primary clinical out- participate. The reasons for refusal related to time bur-
come measure was the proportion of children who no den of the parents and lack of motivation on the part of
longer met criteria for social phobia. Secondary out- the socially phobic child.
comes included improvements in anxiety coping, Treatment
dysfunctional cognitions, interaction frequency and The treatment consisted of twenty 50-minute individual
comorbid symptoms. sessions and 4 parent sessions [55]. The individual ses-
sions occured weekly. 20 treatment sessions represents a
Procedure lengthy intervention. “Children” is far from a homoge-
Assessment and Diagnosis nous category, and treatments that ignore important
Two advanced doctoral level graduate students con- developmental differences in child comptencies are
ducted all screening interviews as well as the implemen- likely to be too “generic” for optimal effectiveness [56].
tation of the intervention. However, video recordings of Instead of group treatment, we used individual settings.
all interviews at initial as well as outcome assessments A benefit of the one-on-one setting is a stronger adjust-
were viewed by an expert who was blind to the treatment to the individual characteristics of the patient.
ment condition. The expert’s ratings were final measures Furthermore, children with very high social anxiety par-
of the outcome. At the phone interview phase 121 chil- ticipate least in group work or avoid attendance alto-
dren were assessed between 2004 and 2006 for possible gether. Studies point out that in an individual setting,
inclusion in the trial. The DIPS-K was scheduled follow- comparable [57] or even better [58,59] results can be
ing initial phone contact with parents expressing interest achieved than in a group setting. The present treatment
in the study. The administration of the assessment mea- manual (see Table 2) does not include social-skills train-
sures was conducted in two separate sessions. This was ing. Social deficits do not seem to play a central role in
done prior to beginning treatment as well as immedi- social phobia [60,32]. Instructions on situation-specific
ately following the final session (treatment group) and social skills were given to four children before beha-
at 0 and 4 months after recruitment for the children on vioral experiments were carried out.
the wait-list. Because of limited capacity and the shorter The treatment pursued the following objectives
attention span of children, assessment measures could 1. Education about social phobia, behaviours like
not be performed in one session. During the first ses- avoidance and safety behaviours.
sion, children and mothers were administered the DIPS- 2. Externalisation of attention and regulation of
K and the questionnaires. Mother and child interviews attention towards task-specific aspects.
were conducted separately and endorsement of the diag- 3. Verification of anxious beliefs such as misleading
nostic criteria for social phobia by either mother or internal information (feelings and images) if they
child was required for inclusion in the study. In the sec- give up safety behaviors.
ond session, children and parents completed the 4. Cognitive restructuring, differenciating anticipa-
remaining questionnaires. 77 children were excluded tory and post-event thoughts.
(Figure 1 summarizes the reasons; additional file 1).
Children were offered inclusion if they met the follow- The following interventions were used to imple-
ing criteria: (a) the child met DSM-IV (American Psy- ment the objectives (for more details see additional file
chiatric Association, 1994 [54]) criteria for social phobia, 2: Appendix A):
121 Referrals
77 Excluded
Reasons for exclusion

60 too mild
17 social phobia not main problem
44 Randomized
21 Allocated to CBT with focus on cognition 23 Allocated to Wait

i i
15 completed Treatment 21 completed Wait

6 dropped out
Reasons for drop outs Reasons for drop out:
1 Quick initial success 2 Time burden on the family
2 Time burden on the family
3 Family misfortunes such as unemploy-
ment, parental separation or a parent’s
depression
15 Assessed 21 Assessed
0 Declined 0 Declined
Figure 1 Flowchart of patients’ progress through phases of the trial. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th
ed.; American Psychiatric Association, 1994); CBT = cognitive behaviroal therapy, focus on cognition; WAIT = Wait-list control condition.
Therapy with children is generally based on an experi- 3: Behaviour experiments are implemented. Role plays
mental here-and-now-approach. Children learn by with video feedback are used as preparation for the
doing. Action in therapy is enlivening. Children’s moti- behavior experiments. Explicit reinforcement is a central
vation increases when they are having fun [61]. part of our work with socially phobic children.
1: The therapist elicits information concerning the 4: Furthermore, the child has to recognise unhelpful
development of social phobia, situational determinants and anxiety-provoking self-statements and expectations
and temporal course. Several child-friendly techniques in relation to social interactions.
which make use of multiple sensory modalities are All sessions were videotaped, and a sample of 25% of
administered, e.g. drawing, songs, puppet play, games, the sessions was selected for review in order to deter-
storytelling, use of metaphors and craft work. These mine adherence to the treatment protocol. The treat-
techniques add fun to therapy with children, increasing ment was carried out from 2004 to 2007.
the reinforcing value of the sessions.
2: Attention training exercises enhance the shifting of Statistical Analysis
socially phobic children’s attention from themselves to Statistical Power
the social situation in order to learn the externalisation Results of studies exploring the effectiveness of cognitive
of attention and the regulation of attention towards treatment programs in socially phobic patients [27,28]
task-specific aspects to ease the intake of corrective available at the time of the study were used for power
information from the environment. analyses. These studies demonstrated a high effect size
Table 2 Content of the sessions

Session Content Material
No.
1-5 psycho-education (goals: relationship to the child, the child’s Therapeutic story as part of each session, hand puppets, puzzles,
motivation, the externalization of anxiety, normalization of fears, pictures, songs, stories, games, information sheets about social
information on social anxiety, target setting, creating an anxiety anxiety
hierachy, strategies for overcoming fears)
6-8 cognitive restructuring: negative thoughts in advance of social Picture stories, stories, games and encouragement to discourage
situations and subsequent re-evaluations ‘bad’ thoughts
9-18 Preparation of behavioral experiments with gradually increasing Various role-playing, some with video feedback, “Angstopoly”
difficulty, assessment of safety and avoidance behavior, discussion of (board game with the implementation of social practice)
potential obstacles, attention training, behavioral experiments in vivo
19 Summary and conclusion of the therapy, dealing with relapses
20 Booster Session
Parents Parent sessions: Information on social anxiety in children, video-based
assessment for the caregivers on how to deal with the child’s fears,
information about behavioral experiments and possibilities for
supporting the child Closing session
for outcome measures (d = 1.2 - 2.4). The analyses indi- Results

cated that for power = 90 with an alpha = 0.05, 20 parti- Characteristics of Patients
cipants per group would be required for child outcome The patients’ mean age was 10.60 (SD = 1.64) in the
measures. Given the expected high rate of drop-outs treatment group and 10.76 (SD = 1.90) in the wait-list
and loss for participants in the study, the number of group, with an age range from 8 to 14 years. All patients
participants recruited to the intervention and the wait- had the generalized subtype of social phobia. In the
list groups was increased to 46, ensuring that the treatment group there were 8 girls and 13 boys, in the
required sample size was achieved. wait-list group there were 13 girls and 10 boys. The
Statistical Analysis main comorbid disorders were other current anxiety dis-
All statistical analyses were conducted using SPSS 14.0. orders (treatment group: n = 10; wait-list group: n = 7)
Intervention efficacy was assessed by comparing the out- (Table 1). Four patients in the treatment group and 2
comes of the wait-list control and the intervention con- patients in the wait-list group were classified as
dition at post-test. Missing outcome data were imputed. dropouts.
Analyses were intention-to-treat with the last available
data point carried forward, if necessary. In order to Pre-treatment differences between groups
identify any differences between the CBT treatment To determine the presence of pre-existing differences
focusing on cognition and the wait-list, we compared between participants in the wait-list and treatment
scores for both groups using one-way analyses of var- group, a series of independent samples t-tests (for inter-
iance (ANOVAs) for the primary outcome measure and val or ratio data), chi-square analyses (for nominal data)
for all secondary outcome measures. Potential con- and ANOVAS were conducted (Table 3). The treatment
founds (e.g. socioeconomic status) and moderators (e.g. and control groups were comparable with respect to
child gender) were explored. age (F(1,41 = .94 p = .33), gender c2(1, 0.95) = .91 p =
The proportion of participants who no longer met cri- .76) and intelligence (F(1,41) = .09 p = .09) assessed
teria for the social phobia diagnosis at post-test in the two with the CFT-20. Participants in the treatment and con-
conditions was examined using c2 tests of independence. trol groups did not differ in terms of initial severity and
Effect sizes are given as Hedges’ G throughout the psychopathology as assessed by the K-GAS (F(1,42) =
paper. Like Cohen’s d, Hedges G is calculated by divid- .49 p = .58), SPAIK (F(1,42) = 3.71 p = .06), CQ-C (F
ing the difference between treatment and wait list con- (1,42) = .01 p = .94), DIKJ (F(1,42) = .68 p = .41), and
trol group means at endpoint by the pooled standard behavior diary (F(1,32) = .50 p = .48) with all p > .05.
deviation, but it uses a slightly different formula to cal- However, the wait-list group showed a significantly
culate the latter, correcting for biases that can occur in higher SAKK-score for the subscale “negative self-eva-
smaller sample sizes [62]. To describe the magnitude of luation” (F (1, 28) = 12.77, p < .001) and a lower
effect sizes, we have used criteria from Cohen [63]. SAKK-score for the subscale “positive self-evaluation” (F
Cohen [63] proposed a threefold classification of effect (1, 28) = 12.99, p < .001). There were no differences
sizes: small (0.20 - 0.49), medium (0.50 - 0.79), and between dropouts and participants in demographic
large (0.80 and above). variables.
Table 3 Effects of CBT focusing on cognition for primary and secondary outcome measures across time
Treatment group (n = 21) Wait list (n = 23)
M (SD) M (SD) Group effect
CHILD-COMPLETED PRIMARY OUTCOME MEASURES
Social Phobia and Anxiety Inventory for Children, German version (SPAIK)
Pre-treatment 24.47 (7.23) 20.60 (6.09) F(1,42) = 3.71 ns
Post-treatment 12.30 (9.13) 18.41 (8.53) F(1,42) = 5.26*
CLINICIAN-COMPLETED PRIMARY OUTCOME MEASURES
Severity (DIPS-K)
Pre-treatment 5.33 (1.24) 5.17 (0.58) F(1,42) = .31 ns
Post-treatment 3.43 (2.44) 4.96 (0.42) F(1,42) = 6.33*
CHILD-COMPLETED SECONDARY OUTCOME MEASURES
Coping Questionnaire - Child (CQ-C)
Post-treatment 1.77 (1.19) 2.27 (0.89) F(1,42) = 2.57 ns
Socially Anxious Cognitions Scale for Children (SAKK)
Positive Self-evaluation
Pre-treatment 19.83 (7.67) 13.23 (6.64) F(1,37) = 8.21**
Post-treatment 24.52 (8.14) 14.98 (6.11) F(1,35) = 16.56***
Negative Self-evaluation
Pre-treatment 8.85 (6.14) 13.68 (6.29) F(1,37) = 5.90*
Post-treatment 7.78 (6.26) 12.15 (7.23) F(1,36) = 3.92*
Coping ideas
Pre-treatment 14.25 (6.33) 11.89 (7.73) F(1,37) = 1.09 ns
Post-treatment 17.68 (7.02) 11.94 (6.16) F(1,38) = 7.60**
Behavior Diary
Post-treatment 19.21 (7.55) 19.84 (6.49) F(1,36) = .076 ns
Children’s Depression Inventory (DIKJ)
Post-treatment 9.71 (9.06) 11.22 (6.80) F(1,42) = .39 ns
CLINICIAN-COMPLETED SECONDARY OUTCOME MEASURES
Overall functioning
Post-treatment 61.19 (14.31) 55.43 (5.62) F(1,42) = 3.19 p = .08
Note: *p < .05; **p < .01: ***p < .001 ns not significant; scores for both groups were compared with one-way analyses of variance (ANOVAs) for the primary
outcome measure and for all secondary outcome measures.
Effects of Treatment on Social Phobia seven of the children no longer showed social phobia,
Primary outcome results 10 of the children significantly improved, 4 other chil-
Child-completed measures (Table 3) Analysis of the dren had been dropouts. This difference was significant
child-completed measures indicated that CBT focusing (c2 (1, 0.95) = 12.0714, p ≤ .001).
on cognition was associated with significant pre-treat- Hedges G [62] was used to calculate effect sizes com-
ment-to-post-treatment improvement. The Social Pho- paring the treatment with the wait-list condition. The
bia and Anxiety Inventory for Children (SPAIK) showed measures of social phobia showed medium to large
a significant decrease in social phobia symptoms effect sizes (clinician social phobia severity ratings,
(F(1,42) = 5.26 p ≤ .05). No harm occured. DIPS-K: G = 0.89, SPAIK: G = 0.94).
Clinician-Completed Measures (Table 3) At the post- Secondary outcome results
treatment assessment, social phobia was assessed in all Child-completed measures (Table 3) Significant
children on the wait-list group. In the treatment group, improvements were observed in the inventory assessing
dysfunctional cognitions (SAKK): The children from the that CBT packages result in around 56% of children
CBT treatment group showed a significant increase in being free of either the principal or any anxiety disorder
positive self-evaluation (F(1,35) = 16.56 p ≤ .001) and after treatment [64]. Therefore, reduction of anxiety
coping ideas (F(1,38) = 7.60 p ≤ .01) and a significant diagnoses at posttreatment of our study was not within
decrease in negative self-evaluation (F(1,36) = 3.92 p ≤ the range of those reported in CBT trials of children
.05). The inventory assessing dysfunctional cognition with different anxiety disorders.
(SAKK) showed large effect sizes: Positive Self-evalua- 2) Participation in our therapy decreased anxiety
tion: G = 1.34, Negative Self-evaluation: G = 1.41; cop- symptoms of social phobia and related symptoms such
ing ideas: G = 0.86). as negative feelings of self-worth. The results showed
No significant changes were found in the behavior that the prevalence of comorbid symptoms like self-
diary assessing interaction frequency (F(1,36) = .08 p = reported depression was not reduced as much as core
.78), in the Coping Questionnaire (CQ-C) (F(1,42) = symptoms by the treatment. However, we did not test
2.57 p = .12) and in the Depression Inventory for Chil- whether symptoms of other anxiety disorders were also
dren (DIKJ) (F(1,42) = .39 p = .54). reduced. Further studies should examine whether the
Clinician-Completed Measures (Table 3) There was effect of the treatment was specific to the disorder of
no significant difference, but a tendency towards social phobia.
improvement (F(1,42) = 3.19, p = .08) in overall func- 3) Decreased dysfunctional cognition as assessed by
tioning between pre-treatment and post-treatment, as the SAKK suggests that the young children benefiting
assessed by the K-GAS. from our study were developmentally prepared to parti-
cipate in a cognitive behavioral treatment focusing on
Discussion cognition. Results from the Socially Anxious Cognitions
The objective of this therapy efficacy study was to deter- Scale for Children (SAKK) with its Subscale of Negative
mine whether socially phobic children in the treatment Evaluation, Subscale of Positive Evaluation and Subscale
group differed from socially phobic children in the wait- of Coping Ideas, corroborate the overall results. Large
list group at the end of a newly developed cognitive effect sizes could be seen in this inventory (SAKK): g =
behavioral therapy program focusing on cognition. The 1.34 for Positive Self-Evaluation, g = 1.41 for Negative
innovation of the newly developed treatment consisted Self-evaluation and g = 0.89 for Coping Ideas.
in the following: (a) using the child’s own thoughts, Despite improvement in positive symptoms there was
images, attentional strategies, safety behaviors, and no improvement in K-GAS and behaviour diary ratings.
symptoms, (b) systematic manipulation of self-focused There seems to be an inconsistency between positive
attention and safety behaviors, (c) systematic training in symptom improvement but lack of functional improve-
externally focused attention, (d) techniques for restruc- ment. However, changes of interaction may follow posi-
turing distorted self-imagery and (f) behavioral experi- tive symptom improvement. The follow-up study will
ments in which a habituation rational was not used. show whether such improvements may be observed.
Three important conclusions can be drawn from the
study: Limitations
1) The study provides preliminary evidence that the The study represents a first step to clarify whether CBT
outcome of CBT focusing on cognition is better than with a focus on cognition is an effective therapeutic
the natural course of the condition. At post-assessment, approach in the treatment of socially phobic children.
children who received CBT treatment focusing on cog- Further studies are necessary, however, to investigate
nition compared to children in the wait-list group whether the results can be replicated and whether the
showed a significantly greater decrease of social phobia underlying theoretical model is adequate for socially
symptoms on the Social Phobia and Anxiety Inventory phobic children. The significant results in the inventory
for Children (SPAIK). Significant improvement could assessing dysfunctional cognition show preliminary evi-
also be seen on the severity ratings (DIPS-K). All chil- dence, but have to be supported in further studies.
dren from the CBT treatment group showed a lower Further studies are also needed to examine whether
severity of social phobia compared to the waitlist group CBT focusing on cognition is superior or comparable to
after the treatment. In addition, 30% of the children in a general CBT approach and to examine which thera-
the treatment group were free of diagnosis after treat- peutic approach is better suited to which patients.
ment, whereas in the waitlist group all of the partici- One of the study’s major limitations is that two
pants held their diagnosis. This suggests that the CBT advanced doctoral level graduate students conducted all
treatment focusing on cognition was able to produce screening interviews as well as the administration of the
clinical improvement in our sample of socially phobic intervention. As the children should not be unduly bur-
children. However, recent review articles have concluded dened, assessment and intervention were thus carried
out by the same person. Consequently, there is no inde- another active treatment. Wait-list control has been
pendent assessment. Therefore, on the one hand, there argued to not be a true comparative control group as it
is the risk that the children responded in ways to please may not produce a placebo effect. A study with an
the familiar interviewer. On the other hand, however, active treatment group is needed in order to determine
unfamiliar interviewers are likely to cause social anxiety. whether the additional cognitive elements were superior
It follows that socially phobic children very often would or comparable to conventional CBT.
indicate less social anxiety by avoiding to talk to inter-
viewers who are unfamiliar to them. However, video Additional material
recordings of all interviews were reviewed by an expert
who was blind to the treatment condition. Additional file 1: CONSORTchecklist. information on the manuscript
Another major limitation concerns treatment design. according to the CONSORT checklist.
Similar to many first trials of new CBT protocols for Additional file 2: Appendix A: Cognitive behavioral therapy of
socially phobic children focusing on cognition. Information on the
anxiety, we conducted this initial trial using a wait-list treatment course.
control condition. This approach provides preliminary
evidence that the outcome of the proposed intervention
is better than the natural course of the condition. It Acknowledgements
should be further evaluated against other interventions We thank the German Research Foundation for the support of this project
in subsequent trials. (STI 297/1-1) and the University of Wuerzburg for the support through a
scholarship
Furthermore, the trial has not been registered.
Six patients dropped out of our study, four of whom
participated in the treatment group. However, compared Author details
1
Clinic and Polyclinic for Psychiatry, Psychosomatic and Psychotherapy for
to drop-out rates in other studies, the rate of drop-out in Children and Adolescents, University of Wuerzburg, Fuechsleinstr. 15, 97080
the present treatment program is not noticeably high: Wuerzburg, Germany. 2Department of Child and Adolescent Psychiatry,
According to Lincoln [65] and Turner et al. [66], only University of Zurich, Switzerland. 3University of Frankfurt, Department of
Psychology, Germany. 4Clinic and Polyclinic for Psychiatry and Psychotherapy
approximately 40% to 50% of the socially phobic adult for Children and Adolescents, University of Frankfurt, Germany.
patients seeking treatment actually completed and bene-
fited from it in the end. There are further problems in Authors’ contributions
SM, MK and JS carried out studies and drafted the manuscript. AW and US
the treatment of children, as not only the child must be have made substantial contributions to conception and design. CS and FP
motivated to participate in the treatment. According to have made substantial contribution to acquisition of data. All authors read
the parents, therapies were discontinued for various rea- and approved the final manuscript.
sons: quick initial successes, which seemed sufficiently Competing interests
high, time burden on the family, family misfortunes such The authors declare that they have no competing interests.
as unemployment, parental separation or a parent’s
Received: 5 May 2010 Accepted: 28 February 2011
depression led to the premature termination of their Published: 28 February 2011
child’s therapy. Thus, it was not always the children who
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doi:10.1186/1753-2000-5-5
Cite this article as: Melfsen et al.: Cognitive behavioral therapy of
socially phobic children focusing on cognition: a randomised wait-list
control study. Child and Adolescent Psychiatry and Mental Health 2011 5:5.
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Melfsen et al.

Child and Adolescent Psychiatry and Mental Health 2011, 5:5

RESEARCH Open Access

Cognitive behavioral therapy of socially phobic

Background development of other psychological disorders [4].

Table 1 Description of the children’s sample

Reasons for exclusion

21 Allocated to CBT with focus on cognition 23 Allocated to Wait

15 completed Treatment 21 completed Wait

Table 2 Content of the sessions

for outcome measures (d = 1.2 - 2.4). The analyses indi- Results

57. Scholing A, Emmelkamp PM: Exposure with and without cognitive

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