“… SAD has been specifically linked to educational underachievement, grade failure, school absence, and premature withdrawal from school …”
Adolescence is a stressful time period with increased academic demands, changes in physical appearance, and a focus on friendships and romantic relationships. It is normal for teenagers to be overly self-conscious and worry about fitting in and being liked.
However, some teenagers have more significant concerns about social situations that can cause them to avoid everyday encounters or endure them with great discomfort. They may be suffering with social anxiety disorder.
Social Anxiety Disorder in Teenagers
Social anxiety disorder (SAD) involves excessive fear and avoidance of social or performance situations. SAD is irrefutably one of the most common disorders in adolescents, affecting about 9% of teenagers. Students with social anxiety commonly fear and avoid situations such as speaking with unfamiliar people, speaking up in class, initiating conversations, inviting others to get together, communicating directly, musical or athletic performances, and joining sports teams, clubs or other school activities. Often their avoidance occurs across a wide range of activities causing disability in the quality of life, and placing teenagers at risk for depression and substance use. Unfortunately, most teenagers with SAD do not receive mental health services, partially due to the misunderstanding that social anxiety is part of a person’s natural personality or a normal experience in adolescence that will be outgrown.
“… schools are uniquely positioned to address social anxiety because many difficulties faced by students with social anxiety occur at school.”
Advantages of School-based Treatment of Social Anxiety
Schools are ideal for addressing social anxiety in adolescents for many reasons. First, schools provide a single location through which the majority of affected youth can be contacted and interacted with. Parents, teachers, and other school personnel can be educated about how to recognize social anxiety in teenagers and help students become connected to mental health treatment. In addition, schools are uniquely positioned to address social anxiety because many difficulties faced by students with social anxiety occur at school. Therefore, schools provide a natural environment in which to deliver treatment in real-life settings (e.g., school cafeteria, library) with a variety of individuals (e.g., peers, teachers, coaches).
Skills for Academic and Social Success
Dr. Masia Warner and colleagues developed a school-based, cognitive-behavioral intervention called Skills for Academic and Social Success (SASS) for social anxiety in teenagers. SASS is a twelve-week, group, evidence-based intervention that emphasizes teaching students to think more realistically about social situations, training students in social skills, and having students learn to engage in the social situations they are avoiding, called exposure.
Specifically, the SASS intervention consists of 12 weekly in-school group sessions (40 minutes each) that involve education about social anxiety, identifying negative predictions and evaluating their likelihood, social skills training (i.e., initiating and maintaining conversations, establishing friendships, listening and remembering, and assertiveness), exposure, and relapse prevention. Groups consist of up to 6 students. It also includes two individual meetings of only 15 minutes each and four social activities planned for weekends (e.g., laser tag, bowling) with pro-social, carefully selected school peers. Parents are offered two group meetings (45 minutes) in which they receive psychoeducation regarding social anxiety and learn techniques to manage their child’s anxiety and facilitate participation in social activities. Sessions for teachers can also be planned – sessions in which they are taught about social anxiety and are instructed how to help students increase their participation in classroom activities. The program usually is spread over 90 days and is flexible to take into account school schedules for testing periods, teacher institute days, vacations, and the like.
SASS was evaluated in two studies (Masia Warner et al., 2005; Masia Warner et al., 2007), and shown to be effective when delivered at school by outside doctoral level clinical psychologists. To make school-based programs accessible, they must be in the hands of available front-line school professionals (Ryan & Masia Warner, 2012). Typically, middle and high schools have several school counselors, but it is unknown whether school professionals, who have not had intensive training in specialized, evidence-based treatments, can deliver them effectively. Therefore, Dr. Masia Warner and colleagues (2016) conducted a study to answer whether school counselors can competently deliver SASS when they receive training and consultation from specialized, doctoral level clinical psychologists.
Can School Counselors Treat Social Anxiety Effectively Using SASS?
The study included 138 high school students with SAD. They received one of three interventions:
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- SASS delivered by school counselors
- SASS delivered by specialized clinical psychologists
- A general school counseling group providing support and relaxation skills delivered by school counselors
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The results indicated that SASS delivered by trained school counselors had more benefit for students in reducing social anxiety and improving their functioning than the general school counseling group. Benefits from SASS implemented by school counselors were equivalent to those obtained from specialized psychologists.
Conclusion
School counselors, who are appropriately trained, can provide effective treatment to adolescent students with social anxiety, yielding benefits comparable to those obtained by specialized clinical psychologists. Being treated by counselors at school may have additional benefits. For example, adolescents in the study receiving SASS from their school counselors were the least likely to drop out of treatment, and showed additional improvements five months after treatment ended. Having intervention delivered by counselors with whom students can have continued access may enhance treatment compliance, and may provide a sustained therapeutic resource even after the formal treatment program terminates.
“With training, school counselors are effective treatment providers to adolescents with social anxiety …”
Challenges remain regarding whether schools will be able to continue to identify students with SAD and provide high quality treatment implementation without external research support. Despite challenges, school-based intervention may be essential for SAD because school environments provide a rich context for active rehearsal of social skills and for social exposures, thereby reducing social avoidance, a core difficulty in SAD.
The Nuts and Bolts: How Can I Bring SASS To My School?
SASS is a group intervention that occurs one school period per week for about 12 weeks. The most essential component for bringing SASS to a school is to have at least a few school professionals (e.g., school counselors, psychologists, social workers, or nurses) who are committed to being trained in SASS and implementing the intervention with high quality. We refer to these individuals as program champions, who might then train and supervise other school staff.
Because social anxiety in teenagers tends to go unrecognized, there also has to be a feasible and systematic way to identify students in need of assistance. Possibilities may be a brief questionnaire during guidance meetings or in health education classes. However, implementing procedures to identify affected students and conducting SASS groups may feel unworkable to school personnel who are already overburdened by large caseloads and several demands. Therefore, it is important to obtain the support of school administrators, who might be able to reassign responsibilities, reduce caseloads, or provide protected time.
It helps to educate school administrators and personnel on the connection between social anxiety and educational priorities. For example, SAD has been specifically linked to educational underachievement, grade failure, school absence, and premature withdrawal from school, likely due to excessive nervousness at school, lack of school engagement, limited relationships with peers and teachers, and difficulty paying attention and speaking up in class. In addition, social anxiety acts as a precursor to depression and substance use, and therefore, these disabling outcomes can be prevented through early identification and intervention.
If your school is interested in learning how to implement SASS, you can contact Carrie Masia Warner, Ph.D. at William Paterson University.
Joshua Cohen is a clinical psychology doctoral student at William Paterson University. He received his Bachelor of Arts degree in Psychology, and certificate in Child Advocacy and Policy from Montclair State University in 2015. His primary clinical and research interests focus on early intervention and treatment of anxiety disorders.
Catherine E. Stewart B.A. is a doctoral student in the Clinical Psychology PhD program at the University of Connecticut. She investigates the impact of peer and school factors on functioning as well as treatment for anxious youth.
Eric Tracy is an undergraduate student in the Psychology Department at William Paterson University. He is currently conducting a psychology internship with Dr. Masia Warner on research testing an innovative service model connecting pediatrics to schools.
Dr. Carrie Masia Warner specializes in pediatric anxiety disorders. She received her Ph.D. from West Virginia University in 1998, followed by an NIMH postdoctoral fellowship in the Department of Child Psychiatry at Columbia University. Prior to joining the faculty at Montclair State University, Dr. Masia Warner was on faculty in the Department of Child and Adolescent Psychiatry at New York University’s Langone Medical Center. She is well-known for enhancing access to services for children and adolescents with internalizing disorders by training frontline professionals to implement interventions in schools and pediatric medical settings. She has published extensively in the area of evidence-based interventions for anxiety and is a national and international expert in this area.
