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Social Anxiety Disorder in Children and Adolescents: Assessment, Maintaining Factors, and Treatment Rio Cederlund

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Social Anxiety Disorder in Children and Adolescents: Assessment, Maintaining Factors, and Treatment Rio Cederlund Social anxiety disorder in children and adolescents: assessment, maintaining factors, and treatment Rio Cederlund 1 ©Rio Cederlund, Stockholm University 2013 Cover illustration reprinted and edited with permission from Kristoffer Pettersson, kpfotografi.se Cover illustration edit by B. Nox ISBN 978-91-7447-764-1 Printed in Sweden by US-AB, Stockholm 2013 Distributor: Department of Psychology, Stockholm University 2 To life. 3 4 Abstract The present dissertation consists of three empirical studies on social anxiety disorder (SAD) in a sample of Swedish children and adolescents. Based on findings made in a large behavior treatment study, the thesis contributes to the field of research on childhood SAD by investigating a factor that main- tains the disorder, ways to assess and screen for diagnosis, and the treatment of the disorder. Study I investigated whether giving an educational course to the parents of socially anxious children would lead to a better outcome of a behavior-treatment study consisting of individual and group treatment com- ponents such as exposure in-vivo and social skills training, compared to a condition where children only were treated and the parents received no edu- cational course. Another purpose of Study I was to investigate what influ- ence, if any, co-morbidity has on treatment outcome. The results showed that there was no significant difference between the two treatment groups on any of the primary or secondary outcome measures. Further, the comorbid disor- ders did not impair the SAD treatment but was rather associated with further improvement, and despite the sole focus on SAD, there was significant im- provement in the comorbid disorders. Study II tested the psychometric properties of the Social Phobia and Anxiety Inventory for Children in a sam- ple of children with SAD. The results indicated that the instrument is a valid and reliable measure. Further, a three-factor solution represented the three areas of SAD commonly found in adult studies, i.e., fear of performance, observation, and interaction situations. Study III explored threat perception and interpretation bias by means of an ambiguous stories task. The results showed that children with SAD deviated significantly from a non-anxious control peer group with regard to their interpretations. Post treatment the threat perception bias was altered in a normal direction, and one year after treatment termination, the SAD sample ratings were comparable to those of the non-anxious children. 5 6 Acknowledgements It took me ten years to complete this thesis. Perhaps if there was a litmus test you could use to detect differences in clinical trials, I could have made it in five. But I’m not so sure. It’s been hard work – some hard times, and some very fun ones. Many people have been important to me during these years, and a few have been very important. Lars-Göran Öst: my supervisor. I don’t think I can find words. Lotta Reuterskiöld: a great work companion during the first half of this ad- venture, a great friend during the second half. So much fun we’ve had Lotta, and so many hours of sweat and tears. It was an unlikely friendship but I know it’ll last forever. Liv Svirsky, Ulrika Thulin: two more precious friends from the Department of Psychology. Jonas Ramnerö: my co-supervisor. I have not forgotten how you slashed my first manuscript to shreds. I am very grateful for being allowed to share the theoretical sharpness only you pos- sess, and your wits. Håkan Nyman: sharing your knowledge generously, ever since I wrote my Master thesis. Bertil Törestad: a mentor since the very be- ginning. Kia Åsberg and Erik Berntson: invaluable input and help with my manuscripts. Anonymous peer reviewers. Ann-Charlotte Smedler and Tomas Furmark, the not-so anonymous reviewers. Indebted to you all. Reidun Larsson and Kerstin Karlsson: friends from the five year Psycholo- gist programme. Do you remember that we did one of our first assignment together? Friendship love at first sight. Reidun… we cannot stop until we have at least reached RORR 66. Carl Wilkens/Val Kilkens: from the dusty assembly room of the student union headquarters, via Berlin and a few kick- ass parties, to Curçay-sur-Dive. Sten Skånby, Per Simonsson, Ulrika Berg Olofson, Caroline Olsson: all dear friends from my years at the student un- ion. My big family: parents, parents-in-law, siblings, siblings-in-law, and their spouses. S.Y. Very grateful for you. My daycare child minders: Eleni Kesisoglu, Susanne Larsson, Lena Magnusson, Susanna Bergström. You are invaluable and if it weren’t for you it would have taken me five more years to finish this thesis. 7 So many friends I am happy to have. Former and current colleagues that brighten my day and make me learn. Family away from home at Hamnen: Charlotte Hammerfeldt, Tora Nordström, Lotta Malm, Charlotte duRietz, Inger Hanérus. Thank you so much. My children: you continuously teach me what it means to be ‘good enough’ and by that, what it actually means to be a good enough mother. Will I make it all the way? (The million dollar question.) Yes, I will. Braeden: you found me when I was on my way to give in, and by some kind of magic you were able to pick me up and inject me with new hope. I can never thank you enough. Kaa, for all the support, thank you. So much love to Jóhann Freyr Björgvinsson: you are the definition of friendship. Thank you Tom Kaulitz for making me laugh, and Bill Kaulitz for making me remember. My greatest thank-you goes to you, Jens Eriksson. I don’t think I can find words. September 1, 2013 8 List of studies I. Öst, L.-G., Cederlund, R., & Reuterskiöld, L. (Manuscript). Behav- ioral treatment of social phobia in youth: Does parent education training improve the outcome? II. Cederlund, R. & Öst, L.-G. (2013). Psychometric properties of the Social Phobia and Anxiety Inventory-Child version in a Swedish clinical sample. Journal of Anxiety Disorders, 27, 503-511.* III. Cederlund, R. & Öst, L.-G. (2011). Perception of threat in children with social phobia: Comparison to nonsocially anxious children be- fore and after treatment. Journal of Clinical Child and Adolescent Psychology, 40, 855-863.* * Reprinted with permission from the publishers 9 10 Contents Abstract ....................................................................................................................... 5 Acknowledgements ..................................................................................................... 7 1. Introduction ........................................................................................................... 15 2. The disorder .......................................................................................................... 17 2.1. Prevalence .......................................................................................................................... 20 2.2. Gender ................................................................................................................................ 21 2.3. Age of Onset ...................................................................................................................... 21 2.4. Clinical course ................................................................................................................... 22 2.5. Comorbidity ....................................................................................................................... 23 3. Etiology ................................................................................................................. 26 3.1. Genetic factors ................................................................................................................... 26 3.2. Neurobiological factors ...................................................................................................... 26 3.3. Temperament ..................................................................................................................... 27 3.4. Biological factors ............................................................................................................... 28 3.5. Parent factors ..................................................................................................................... 29 3.7. Social learning ................................................................................................................... 31 3.8. Parenting style .................................................................................................................... 31 4. Assessment ........................................................................................................... 33 5. Threat perception and threat interpretation ........................................................... 36 6. Cognitive-behavioral treatment............................................................................. 38 6.1. Randomized controlled studies .......................................................................................... 39 6.2. The Randomized controlled studies with parent involvement ............................................ 44 6.2.1 Benefit from parent involvement ................................................................................ 44 6.2.2 Trend towards enhanced benefit from parent involvement ......................................... 47 6.2.3 No benefit from parent involvement .......................................................................... 48 7. Aims of the study .................................................................................................
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