Treating Adolescents with Social Anxiety Disorder in Schools

Social anxiety disorder, characterized by significant discomfort and avoidance of social and/or performance situations¹ is among the most common mental disorders in children and adolescents. Recent estimates indicate that 6 % of children^2,3 and 12.1% of adolescents meet criteria for this diagnosis⁴. Social anxiety disorder starts as early as age 5 and peaks around age 12⁵. When untreated, it runs a chronic course into adolescence and eventually adulthood^6,7.

The high prevalence and chronicity is particularly concerning given the significant disability associated with social anxiety disorder. The clinical picture often involves fewer friends, difficulty participating in classroom activities (e.g., answering questions in class, working in groups), and avoiding social interactions (e.g., initiating conversations, joining school clubs or sports)^8,9,10. This social impairment is associated with loneliness, dysphoric mood¹¹ and long-term functional impairment, such as difficult life stage transitions, underemployment, suicidal ideation, and risk for substance abuse and depression^{12,13,14,15,16,17,18,19,20}.

Despite its negative impact, the majority of adolescents with social anxiety disorder are likely to remain untreated^{12,21,22,4,19}. Recent data estimates that less than 20% of adolescents with anxiety disorders receive treatment⁴, and fewer than 20% of those who do seek services receive interventions supported by scientific evidence^23,24. In contrast to behavior disorders, difficulties may be less apparent to teachers and parents because these children are less disruptive. Many parents do not recognize the extent of their child's impairment²¹ or believe that social anxiety is a stage that they will “grow out” of naturally²⁵. Due to the nature of the disorder, socially anxious adolescents may not seek help due to potential stigma associated with mental health issues and fear of negative evaluation. Delivering interventions in schools may address the barriers facing youth in need of treatment.

Advantages of School-based Treatment

Schools can play an important role in addressing the unmet mental health needs of youth by potentially increasing access to care in a cost-effective manner. This venue provides unparalleled access to youth^26,27 and exemplifies a single setting through which the majority of children can be reached²⁸. Social anxiety disorder is particularly suited to being treated in the school setting. First, due to the social nature of the disorder, group treatment may be ideal. Group treatment is logistically challenging in a clinical setting due to variability in diagnoses and scheduling among clients, whereas schools contain many socially anxious students needing intervention. Second, despite the high prevalence^29,19 and impairment associated with social anxiety disorder, these adolescents are rarely identified²¹ and, therefore, unlikely to receive help^12,4,19. Involving schools in the mental health needs of their students creates opportunities to increase identification and treatment of social anxiety disorder by educating teachers and parents about its symptoms and providing support for making appropriate treatment referrals. Finally, intervention implemented within the school setting allows for a real-world treatment approach. That is, the school environment provides opportunities for real-life exposures to commonly avoided situations (e.g., answering questions in class, eating in the cafeteria, speaking with teachers, initiating conversations with unfamiliar peers) and for practicing skills in realistic contexts. In addition, peers and teachers with whom socially anxious students routinely associate can be enlisted to support students' progress. When delivering treatment in a natural setting, it is expected that treatment gains may be enhanced and are more likely to generalize to other situations and environments.

Based on these potential advantages, Masia Warner and colleagues³⁰ sought to develop a treatment program that would draw from empirically-supported techniques and could be feasibly implemented in schools. The school-based program, Skills for Social and Academic Success (SASS)³⁰, was derived from Social Effectiveness Therapy for Children (SET-C)³¹, an empirically-supported, clinic-based treatment that consists of 12 individual sessions of behavioral exposures, 12 group sessions of social skills training, and unstructured peer generalization exercises, in which socially anxious children practice socializing with non-anxious peers. SET-C's emphasis on using peers to assist with generalization fit well with the natural availability of same-aged peers in the school environment. Clinical trials have demonstrated the efficacy of SASS for adolescents compared to a waiting list³² and even a credible attention control²².

Treating Social Anxiety in the School Setting

Overview of Skills for Academic and Social Success

The SASS intervention consists of 12 weekly in-school group sessions (40 minutes) depicted in Table 1., two group follow-up sessions to address relapse and remaining obstacles, and two brief individual student meetings (20 minutes). Additionally, four weekend social events (90 minutes; e.g., bowling, rollerblading) that include pro-social peers (called “peer assistants”) are included to provide real-world exposures and skills generalization. Parents are encouraged to attend two group meetings (45 minutes) during which they receive psychoeducation regarding social anxiety and learn techniques to manage their child's anxiety and facilitate participation in social activities. Meetings can also be provided for teachers in which they learn about social anxiety and the program, and receive instruction to help students practice classroom exposures. The program is designed to be flexible to accommodate school calendars (e.g., vacations and exams), and typically spans about 3 months.

Table 1. Skills for Academic and Social Success Session Components.

Session	Group
1	Learning About Social Anxiety
	Introductions, treatment structure, confidentiality and goals
	Psychoeducation about social anxiety (e.g. three component model)
2	Realistic Thinking
	Connection between thoughts, feelings and behaviors
	Practice challenging negative and unhelpful thoughts
3	Social Skill 1: Initiating Conversations
	Model friendly and open nonverbal behaviors
	Practice initiating conversations and provide feedback on nonverbal behaviors
4	Facing Your Fears 1: Rationale and Fear Ladder
	Present the rationale for exposure exercises
	Help adolescents construct graduated fear hierarchies
5	Social Skill 2: Maintaining Conversations and Establishing Friendships
	Learn how to keep a conversation going (e.g. when to change topics)
	Practice maintaining conversations and extend an invitation; provide feedback.
6	Facing Your Fears 2: Conduct Exposures as a Group
	Practice commonly feared situations (e.g., make telephone calls, sing aloud)
7	Social Skill 3: Listening and Remembering
	Explain how anxiety interferes with being able to effectively listen
	Practice listening and remembering using characters and personal information
8	Facing Your Fears 3: Conduct Exposures
	Practice commonly feared situations (e.g., start conversations in cafeteria)
9	Social Skill 4: Assertiveness Training
	Discuss how to refuse requests and practice
	Learn assertive expression of feelings and needs; practice using “I statements”
10	Facing Your Fears 4: Conduct Exposures
	Practice exposures higher on the fear ladder and target core fears
11	Facing Your Fears 5: Conduct Exposures
	Continue practicing exposures higher on the fear ladder
12	Review and Maintenance of Gains
	Review components of program through individual presentations
	Explain setbacks and relapse; devise a relapse prevention plan

Core Therapeutic Components

SASS treatment groups are small (three to six students), due to time constraints of school class periods, and can be facilitated by one or two group leaders. The group sessions cover five components: 1) psychoeducation, 2) realistic thinking, 3) social skills training, 4) exposure, and 5) relapse prevention.

Psychoeducation

Group leaders provide psychoeducation during the first group session, normalizing the experience of anxiety while presenting a description of the cognitive, physiological, and behavioral symptoms of social anxiety. Students are encouraged to identify their own anxiety symptoms (i.e., feelings of discomfort, worries or “stress”) surrounding various social situations and to consider how their social anxiety is maintained through the interaction of negative thoughts, physical sensations, and escape or avoidance. Another goal of session one is to introduce motivation for treatment by having each student privately identify which things they would like to change and situations in which they would like to feel more comfortable. Students, as might be expected, are typically reserved and participate minimally at the first group meeting; therefore, the most important goal of the first meeting is to make students feel comfortable.

Session One Tips for Success

To enhance the students' comfort at the initial group session, we recommend that the group leader introduces the group members to one another and avoids placing any students “on the spot.” Keeping the atmosphere light, remembering that students may have different areas of social difficulty, and using the word “uncomfortable” rather than “anxious,” are some effective strategies to ease students into the first session and encourage their return for session two.

Realistic Thinking

Group leaders focus on cognitive strategies during the second group session. The cognitive strategies, termed “realistic thinking,” were primarily adapted from Ronald Rapee's book (1998) “Overcoming Shyness and Social Phobia.” Group leaders highlight the relationship between thoughts, feelings, and behaviors. They then explain that adolescents with social anxiety tend to overestimate the likelihood of the occurrence of negative outcomes and exaggerate the consequences of those outcomes if and when they occur. For example, a socially anxious adolescent is likely to assume that, if he extends an invitation to an acquaintance, the acquaintance will reject him or think he is bold and presumptuous for asking, possibly because they are not close friends or for assuming he is worthy of his friendship. Students are taught to identify such negative expectations as unrealistic and to use specific questions to evaluate them more realistically (e.g., Am I exaggerating? How many times has this happened in the past? Am I being fair to myself?). Although this is the only group session focused entirely on identifying and challenging negative thinking, these strategies are practiced as needed, which typically occurs during each group and individual session.

Realistic Thinking Tips for Success

The main recommendation for this group is to ensure balance between verbal and active teaching. It is important to provide enough time to practice challenging negative thoughts in role-play scenarios (e.g., “You're walking down the hall at school and you see a friend walking toward you. As you pass, you say hello, but she says nothing back”), rather than relying on didactics to illustrate the concept to students. Typically, it is helpful to acknowledge that group members believe their unrealistic thoughts are absolutely true, because they are long standing patterns of thinking. Therefore, the group members are asked to trust the group leader(s)' past experience with similar students and suspend their doubt and judgment in order to try these realistic thinking strategies before deciding whether they are helpful.

Social Skills Training

Improving social skills is helpful for many adolescents with social anxiety, as the development of key social behaviors has often been hindered by inadequate socialization experiences. The four social skills sessions include: 1) Initiating Conversations, 2) Maintaining Conversations and Establishing Friendships, 3) Listening and Remembering, and 4) Assertiveness. For each skill, group leaders briefly introduce the concept and rationale and then facilitate group practice through role plays. The leaders choose situations relevant to adolescent experiences (e.g., being paired with another student to work on a project, or meeting new people through friends) and have the group members practice the skills repeatedly to learn the skill and habituate to the typically ensuing anxiety and awkwardness. Each student participates in at least two role-plays at each session.

Initiating conversations focuses on the simple ways to begin conversations (e.g., commenting on something around you or on something you have in common) and non-verbal communication skills. The second skill session, Maintaining Conversations and Establishing Friendships, focuses on topic transitions and extending an invitation. Socially anxious adolescents often become uncomfortable during conversations and sometimes change the topic of conversation prematurely, making conversations abrupt and awkward. Therefore, during conversational skill practice role plays, students are encouraged to remain on a topic until the group leader gives permission to switch topics. The third skill session involves listening and remembering, and its focus is conquering anxiety interference, which is the tendency to become preoccupied with feelings of anxiety or negative self-evaluations rather than attending to the person speaking. In this session, group members play a memory game in which they disclose social information about themselves to the group, and the group members try to recall that information. During this practice, it is typical for group members to make social mistakes and need to ask one another question to remember the information. Although they make many social mistakes, most group members anecdotally report enjoying the game and becoming more aware of anxiety interfering with their concentration. Finally, the fourth skill session focuses on assertiveness, which includes practice refusing requests and expressing feelings through the use of “I” statements (e.g. “I feel frustrated when you borrow my clothes without asking me first”).

For all skill practice, both group leaders and members provide feedback by praising positive aspects of role play performance and by providing suggestions for improvement, such as speaking in a louder voice or increasing eye contact. Specifically, socially anxious adolescents often look unfriendly or unapproachable because of unintended nonverbal behaviors, such as frowning or avoiding eye contact. To address this, all skills groups emphasize teaching students to become aware of these nonverbal messages to others, and to reinforce more “friendly” and confident behaviors (i.e., smiling, eye contact, speech volume, intonation, and relaxed and engaged body posture). Taking into account the specific needs of each group member and tailoring the skills training to meet the specific needs of socially anxious adolescents is intended to enhance the value of these sessions.

Social Skills Tips for Success

We offer the following strategies to help promote successful skill acquisition. First, group members who struggle with a specific skill may require initial accommodations to be successful (e.g. shorter role plays, pairing with more skilled group member, having group members call out alternative suggestions or proving ideas for what to say during the role play). In addition, group members less skilled at giving others feedback may benefit from the overt modeling of appropriate and sensitive feedback, in order to minimize offending fellow students and maintaining group cohesion. During skills training, socially anxious individuals can often become dependent on certain types of conversational questions or statements. Some common examples include: commenting on the weather, complimenting the other person, complaining. Therefore, it is important to train flexibility across skills by having group members generate different dialogues to the same role-play scenarios and brainstorm all the different ways a conversation could be started. Important for all skills taught is repeated practice. Thus, allow time for each group member to role play each skill at least twice in the session, and don't let discussion or questions (e.g., the rationale for the exercises) function as avoidance and prevent the full practice of the skills; when time is short, condense explanations and spend time on the practice of skills. Label group members' behaviors as a form of avoidance, when appropriate. Finally, use humor, warmth and empathy to keep the atmosphere light and pleasant.

Facing Your Fear

SASS includes five exposure sessions, referred to as Facing Your Fear sessions, which alternate with the social skill sessions. Group leaders present the rationale and procedure for exposure while emphasizing the role of avoidance in maintaining anxiety and the expectation that anxiety will diminish with increased exposure. Students develop a fear hierarchy, or “fear ladder,” that rank orders ten anxiety-provoking situations, beginning with the least-feared situation. In composing hierarchies, it is particularly important to tap into the “core fears” surrounding embarrassment, rejection, and negative evaluation (e.g., “I'm a loser”). Common items that target these specific concerns include: giving the wrong answer in class, inviting peers to get together, and making social mistakes, such as forgetting a person's name, tripping in front of a group, arriving late to class, and going to class with messy hair.

During exposure sessions, students practice entering into anxiety-provoking situations while in the group (e.g., giving a presentation) or around the school (e.g., surveying students in the library). Students are asked to provide Subjective Units of Distress (SUDS) ratings from 1 to 100 (1 = completely calm, 100 = absolutely terrified), before engaging in the exposure, when the exposure has ended, and ideally during the exposure. SUDS ratings are expected to decrease by at least 50% by the end of the exposure. If a student is reluctant to engage in the proposed exposure, negative thoughts about the student's expectations are explored briefly, and the feared outcome is compared to the actual outcome after exposure. Following exposure exercises, students discuss their experience and the group provides feedback. Students are given practice exposures between sessions, which are reviewed at the beginning of each session (see Practice Exercises).

Conducting exposure at school provides a meaningful opportunity to capitalize on the school environment by creating a realistic context for encouraging new and challenging behaviors. Being in the school context, we can tailor exposure situations based on the student's difficulties at school (e.g., meeting with a teacher for clarification of academic material, approaching a peer in the library or cafeteria), as well as those outside of school (e.g., calling a prospective job to inquire about the status of one's application). Exposures implemented during sessions involve other group members, and, because group participants are also school peers, relationships beyond the group may be easily facilitated. Exposure sessions also utilize various school locations. Some common exposures include sending students to the cafeteria to initiate conversations with peers or to purchase and return food, asking questions to the librarian, or visiting the main office to speak to administrative staff. Student pairs might be sent to various locations and return to group to discuss their experiences.

Treatment groups conducted in school also provide the therapist the opportunity to enlist the assistance of school personnel. Because many students experience anxiety talking to authority figures, some exposures might involve interaction with administrators. For example, students may schedule meetings to converse or to make suggestions or complaints. Group leaders facilitate this process by asking school administrators (e.g., principal, dean, assistant principal) to be available for these meetings. In addition, group members might deliver the morning school announcements, join a club with another group member, or seek assistance from a teacher who the student finds particularly difficult. Teachers may participate in classroom exposures involving students arriving unprepared or late to class, being reprimanded in front of others, and by assigning leadership roles in group activities. Finally, group members might approach club advisors and coaches to discuss joining clubs or teams.

Adolescents with social anxiety are often hesitant to engage in exposures with a higher potential for negative evaluation or rejection (e.g., inviting a peer to get together, attending a party or dance). Unlike traditional clinical settings integrating treatment into school allows for social risk-taking in a more controlled environment. Group leaders and supportive peers are present in the natural setting to encourage and assist students to overcome the anticipatory anxiety involved in attempting more challenging behaviors. This enhances the likelihood that the adolescent carries out the initial attempt at a particularly challenging situation, which increases the chance that the attempt is successful, thus, reinforcing future independent action. For example, group leaders might encourage a student to invite a school peer to get together, knowing that the peer will likely accept their invitation. Exposures conducted in this way optimize the utility of the school environment.

Facing Your Fears Hierarchy Building Tips for Success

When constructing the fear hierarchies, we have found several strategies to be helpful. First, if students have difficulty identifying social situations that make them nervous, ask about situations that they usually avoid, as often they will not consider these situations to be anxiety-provoking. Also, group leaders should assist students in identifying specific contexts that make a situation on their hierarchy more or less difficult. For example, if a student is nervous initiating conversations, the group leader should determine whether speaking to someone more familiar or less familiar (e.g., friend versus acquaintance), or older or younger (e.g., adult versus peer), makes the student more or less comfortable. For a performance situation, the group leader should determine if a familiar versus unfamiliar, or a small versus large audience, is more or less difficult. The situations should then be placed on the hierarchy, with the least distressing variation placed lowest and practiced first. Finally, the first exposure should be constructed to ensure that the student is capable of handling it with minimal difficulty and that it will be a successful and positive experience.

Facing Your Fears Practice Tips for Success

When helping students to practice exposure situations on their fear hierarchies, it is valuable to keep in mind that students may not be accurate in the fear ratings they assign to each situation, due to lack of experience with the feared scenario. Therefore, when conducting exposures, it is important to monitor the student's level of distress and, if the exposure is much more difficult than expected (e.g., appears to be an “8 out of 10” even though the student had initially rated it lower), modify the task to make the experience more manageable. This strategy can also be helpful when an adolescent is extremely resistant to the initially proposed exposure. More specifically, briefly explore the cognitions that may be contributing to the hesitation and, if the reluctance persists, propose a similar exposure that the adolescent finds less daunting. For example, if a student is resistant to the idea of approaching an unfamiliar peer in the cafeteria to start a conversation, a more structured version of this exposure, such as asking the unfamiliar peer survey questions as a mock class assignment, may be an acceptable alternative. Finally, be aware of excessive time spent engaging in cognitive restructuring or discussions about the usefulness of a proposed exposure (e.g. “But I'll never need to ask the librarian for assistance”), because these discussions may function as avoidance, squandering time needed for exposure practice.

Practice Exercises

Each group session ends with the assignment of practice exercises. These exercises are designed to help students apply the skills they have learned in group to situations that occur between group sessions. Practice exercises, such as practicing realistic thinking, starting conversations, refusing requests for favors, and performing a step on the fear ladder, are critical for extending skills practiced in group to additional situations inside and outside of school and fostering a structure for long-term success. Although formal worksheets are provided, typically students do not complete these, and it appears sufficient to have students report specific recollections of skill use during the prior week. The group leader asks the group member what they were expecting to happen prior to engaging in the practice and what they experienced during and after engaging in the practice. This level of review appears to increase accountability for completing practice exercises between sessions; however, for group members who consistently fail to practice skills between sessions, the group leader should use the individual meeting to help the student problem solve any obstacles to practice. Being in the school environment lends additional benefits, as group leaders can provide additional support to students' between-session practice by eliciting the assistance of school personnel, such as informing a teacher that the group member will be asking for clarification of academic material, or having a pro-social peer remind the group member that their club meets today.

Relapse Prevention

The final group focuses on maintenance of gains and relapse prevention. During the final group session, each member gives a speech about their experience in the program focusing on what they have learned and accomplished, and areas for continued improvement. Following the presentations, group leaders discuss how to maintain gains, goals for continuing progress, and how to manage inevitable setbacks in order to avoid relapse. Group members outline the warning signs of emerging symptoms and strategies for reversing them. We have found that it is important to highlight the inevitability of setbacks while instilling confidence in the students' capability to handle the situations as they were able during the group.

Individual Sessions

Students attend one or two 15-minute individual sessions to discuss treatment goals, complete fear hierarchies, and address any issues that may be interfering with progress that they are not comfortable discussing during the groups. In addition, these meetings may be used for customized cognitive restructuring, review of social skills that are particularly challenging, individual exposures (e.g., calling to invite someone to get together), or additional exposures that the student has been avoiding. These meetings provide opportunities to strengthen rapport between the student and group leader and to identify potential stressors other than social anxiety (e.g., being bullied, academic difficulties, parental divorce) that may be impacting group participation or their ability to practice outside of session.

Follow-up Sessions

Group follow-up or booster sessions are conducted monthly for one or two months after termination. The intention of these sessions is to monitor progress, problem-solve obstacles to continued improvement, and encourage and sustain practice. Additional exposures may be performed during group booster sessions.

Social Events

Three to four weekend social events are considered helpful for skill generalization and practice. The events, such as bowling, miniature golf, rollerblading, and laser tag, are attended by group leaders, group members, and peer assistants from the students' high schools (see below). The activities provide group members the opportunity to practice social skills and allow for exposure to several commonly avoided situations (e.g., attending a social event without friends or with unfamiliar peers, initiating conversations, performing in front of others, etc.), while providing group leaders with a sample of the students' functioning in social situations. Group leaders actively facilitate the first event and encourage interaction between group members and peer assistants; however, at later events, group leaders limit their presence facilitating to only when a group member is having particular difficulty.

Social Events Tips for Success

When planning the first social event, we recommend picking a more structured activity (e.g. bowling), because they tend to be less intimidating and provide more support for group members who may be less practiced in certain social skills. As the group progresses, later social events should be less structured (e.g., going to a restaurant, having a board game party) to challenge the group members to use their skills. Exposures can be built into every kind of social event. For example, group leaders may encourage group members to order the food at the event, offer food or drinks to others, divide up players to make teams, and approach unfamiliar peers. Finally, picking a venue that is less public or scheduling the event during a time that classmates not involved in the group will be less likely to be present may increase participation by group members who are sometimes concerned about confidentiality. Alternately, to make students more comfortable and address confidentiality concerns when outside of school, it might be helpful to give the group a club name (e.g. Peer Leadership Club) and consider the group leader accompanying the students to be the club's advisor.

Peer Assistants

Peer assistants are helpful, friendly, and pro-social students identified by school personnel to assist with the SASS program. After the first year of the program, peer assistants are ideally students who have previously completed the SASS program. The primary role of peer assistants is to create a positive experience for group members at social events. Peer assistants bring enthusiasm and energy to the events and ensure that all students are integrated in the group activities. Peer assistants may also facilitate peer support within the school environment through assisting with exposures and skill practice, such as bringing a group member to join a school club or having conversations in the cafeteria or hallways.

Selecting Peer Assistants Tips for Success

We recommend briefly interviewing each student who is identified as a potential peer assistant. During the interview, we suggest asking about their involvement in extracurricular activities, how the student responds to bullying, and what they would do if they noticed a shy student sitting by themselves during an activity. In our experience, the best peer assistants are not necessarily the most extroverted students but rather are students who are caring and empathic.

Parent Meetings

Two parent meetings are conducted during the intervention. These meetings are essential since many parents have a limited understanding of the symptoms and impairment associated with social anxiety. Parents are often frustrated and overwhelmed by their children's avoidance behaviors (e.g., refusing to order food in restaurants) and fail to understand the extent of their suffering. Therefore, the first meeting provides psychoeducation about social anxiety, whereas the second meeting addresses skills being taught in the SASS program and how parents can support their children's skill use. Psychoeducation helps parents to better understand their children's experiences and the anxiety underlying avoidance behavior. Parental behavior is also discussed in a nonjudgmental way (e.g., it is natural for parents to remove their children from distressing situations or to assist them when they are struggling), as it plays a role in the development and maintenance of anxiety. The first parent session concludes by explaining the SASS program structure and rationale.

During the second parent meeting, common parental reactions to children's anxiety are reviewed. Throughout the second parent meeting, unhelpful and helpful ways to react to children's anxiety are contrasted. Through a facilitated discussion, parents are encouraged to allow for increased autonomy (which leads to more effective coping and problem solving skills) and discontinue providing excessive reassurance, being overly directive, and allowing avoidance of social interactions. Parents are instead instructed to encourage positive coping, prevent avoidance, and to communicate empathy. Helping children to feel more confident and competent is vital for nurturing a successful transition into young adulthood.

Parent Meetings Tips for Success

The main recommendation for conducting the parent meeting is to be empathic and supportive to parents regarding two common extremes, either desiring to protect their child and allowing their child to avoid distressing situations or alternatively becoming frustrated and being too direct and harsh when pushing their child. We suggest validating the parents' attempts to be helpful and focus on more effective strategies to prevent avoidance without being overly directive. For instance, rather than providing their children scripts of what to say or structuring their children's social plans, parents may prevent avoidance more successfully by offering to provide transportation to an event or encouraging contact with friends. Often parents do not realize the messages their protective behaviors are sending to their child, (e.g., the world is a scary place or you can't handle this without my help). Being compassionate and validating regarding parents' unhelpful behaviors is the key to a successful parent meeting.

Involvement of Teachers

Another benefit to school-based intervention involves educating teachers about social anxiety and obtaining their collaboration to assist shy students. Group leaders can meet with two or three of a student's teachers and their school counselor to educate them about social anxiety and the rationale for exposure exercises. Teachers are often aware of students who have difficulties participating in class or giving oral presentations and are glad to be involved. The group leader can ask teachers to collaborate on appropriate and graded exposures (e.g., answering questions in class) and to continue communication with the clinician conveniently through e-mail or by phone to provide updates and feedback regarding the student's progress. For instance, if a student fears answering questions in class, the teacher may initially provide the student with the answer to a question prior to class, followed by providing the student with the question but not the answer, until eventually the student practices answering questions more spontaneously. Teachers can provide feedback about students' progress and identify additional areas to be targeted.

SASS with the Individual

Although SASS was designed to be implemented as a group treatment, there are many strategies that a school counselor or a practitioner in the community can utilize with individual clients within the school environment. The ultimate goal of treatment is to change the adolescent's unrealistic thoughts and avoidance and escape behaviors and to encourage socialization and instill confidence. Most of the session content described can be modified and adapted for an individual in the school environment. For example, exposures can be planned individually with the help of the school counselor or another school contact throughout various settings in school. Some examples of individual exposures include: 1) meeting with the principal to discuss the formation of a new club, 2) approaching another student in the library to ask a question, 3) emailing a teacher to set up a meeting time, 4) texting an acquaintance to make plans for the weekend. Should more support be necessary, the school counselor might enlist the support of a pro-social peer to assist with the student's exposures or for assistance in bringing the student to extracurricular activities. The school counselor is likely aware of a few pro-social peers in the student's school that would embrace the opportunity to encourage a shy student to become more involved in school and social activities. Teachers, once educated by the school counselor, could also assist students with gradual exposures as described previously. Thus, should a group not be feasible, many of the strategies described could be flexibly executed with some minor adjustments.

Feasibility

A fundamental aspect of the SASS treatment program, whether conducted as proposed in a 12-session group format or adapted for individual students, is to involve school personnel. Essential to conducting a school-based intervention is support from the school environment. To successfully conduct the SASS program, it is important to gain the support of school leadership (e.g., superintendent, principal, director of guidance) and school personnel (e.g., school counselors and teachers), as well as to understand the organizational structure of the school. When working with an individual student, the challenges to engage school personnel are on a smaller scale but may involve more initiative and energy from the individual counselor. School counselors who have previously conducted the SASS program have recommended having two counselors act as co-leaders, enabling shared responsibility of program implementation (e.g., alternate leading groups and attending social events).

Future Directions

Clinical trials have demonstrated that SASS is markedly efficacious when delivered by doctoral-level clinical psychologists³³, even when compared to an attention control condition²². In order for SASS to be accessible to socially anxious adolescents on a larger scale, front-line school practitioners are the logical interventionists. Therefore, a next step toward dissemination and sustainability is to determine if school counselors can implement SASS effectively. Currently, we are conducting a federally-funded investigation to evaluate the clinical utility of SASS when delivered by school counselors. Also important will be studies on the type and level of training needed for school personnel with limited or no background in cognitive behavioral therapies (CBT) and ways to maintain treatment fidelity in school settings without the involvement of specialized CBT psychologists. This knowledge would inform the dissemination and sustainability of SASS in community contexts, as well as cognitive-behavioral interventions for other childhood conditions.

Implications for Practitioners

Based on our experience working with schools, we have found that educating school personnel and parents about social anxiety, including the warning signs (e.g. asking to be excused from a class presentation, avoiding school events or parties) and the long term consequences of untreated social anxiety, may increase recognition of socially anxious adolescents, who can sometimes be overlooked. Clinicians should impart to parents, teachers and school counselors, who may wish to “protect” students from anxiety, that escape and avoidance of anxiety provoking situations may result in increased anxiety and avoidance. The priority for practitioners is to engage school contacts, such as school counselors, to assist in social skills practice and gradual exposures in the classroom and the social milieu. Allowing socially anxious youth to practice in the natural environment enhances the effectiveness of the skills (e.g. realistic thinking, initiating conversations) and the key to the skills being taught in treatment.