A Specific Internet-based Cognitive Behavior Therapy for Adolescents with Social Anxiety Disorder: Three-armed Randomized Control Trial

doi:10.21203/rs.3.rs-2123795/v1

The present study aims to develop a specific cognitive behavior therapy (ICBT) for social anxiety disorder (SAD) in adolescents based on previous researches’ suggestions. An ICBT was developed with two generic and specific approaches. The sample included 45 adolescents aged 14 to 18 with social anxiety disorder. Participants were randomly assigned to three groups: specific, generic, and waiting list. All the outcome measures were conducted in four stages: pre-test, mid-test, post-test, and 3 months follow-up. The results showed a significant improvement in favor of ICBT with a specific approach on the score of the Social Anxiety Scale for Adolescents SASA (p ≤ 0.01) and its two subscales including Anxiety and Fear of Negative Evaluation AFNE (p ≤ 0.01) and Tension and Inhibition in Social Interaction TISC (p ≤ 0.001). The specific ICBT developed in this study was an effective intervention for adolescents with SAD. The changes were also maintained at a 3-month follow-up.

Social anxiety disorder

adolescent

cognitive-behavior therapy

Internet-based CBT

Internet intervention

Social anxiety disorder (SAD) is one of the most prevalent, early-onset disorders in teens [1,2], usually starting between 8 and 15 years of age [3]. The 12-month prevalence is 3.4% and 8.6% of the adolescent population fulfill diagnostic criteria at some point between the age of 13 and 18 years [4].

Feared social situations in youth usually include talking in front of the class, asking the teacher a question, performing in front of others, requesting help in shops or at school, and meeting new people [5]. Meeting the therapist face-to-face as a special social situation is accompanied by great fear and anxiety for socially anxious people [6]. Therefore, individuals with social anxiety are unlikely to seek face-to-face psychotherapy due to their social fears, as a study showed only about 10% of them seek help from a therapist, and very few receive treatment [7]. These social fears seem to cause them to take years to contact a therapist [7,8]. Whereas, if SAD during adolescence is left untreated, it tends to persist, and also will have harmful social, educational, and psychological consequences [5]. Therefore, early treatment will prevent more severe and irreconcilable problems [2], such as depression, suicide, substance, and alcohol dependence [1].

Internet-based treatments could motivate individuals with SAD to seek help, since they may feel less embarrassed, less under scrutiny [9], and also have a greater sense of confidentiality [10]. Additionally, This innovative form of therapy requires less therapist time per patient, can be delivered despite geographical distances, and decrease the possible risk of stigma, also the treatment goes forward without missing school [11] .

CBT, with a structured, problem-focused approach, and highly action-oriented intervention is the first-line treatment for social anxiety [12,1]. Also, it could be implemented in a sequential format, therefore it’s considered well suited for the delivery of internet-based treatment [9]. Internet-delivered CBT (ICBT) for social anxiety has been proven to affect the same as face-to-face CBT [8, 13, 14]. In youth, ICBT is effective for mixed anxiety disorders with similar effects as face-to-face CBT, suggesting that ICBT could be a suitable treatment for adolescents with SAD [1].

Most studies examining the efficacy of CBT on anxiety disorders have a generic approach that contains causal and maintaining problems common to a wide range of anxiety disorders [2]. However, several findings suggest that interventions with a generic approach have weaker outcomes in adolescents with social anxiety than in other types of anxiety disorders [2,15, 16, 17, 18]. Therefore, there is a need to investigate specific interventions for SAD in young people [2].

A randomized control trial, despite adding some specific factors related to SAD, showed no significant difference between generic and specific treatments [7]. Some strategies were suggested to eliminate the problems, including more sessions with content on cognitive and behavioral skills, increasing adolescents' motivation to participate in sessions, homework, and therapeutic exercises, Therefore, it is necessary to enrich the content of the specific protocol to increase the effectiveness of this treatment [2]. We aimed to develop a specific ICBT for adolescents with social anxiety problems.

Intervention Development

Two ICBT interventions with a generic (ICBT-G) and specific (ICBT-S) approach to social anxiety were developed for adolescents using the basic structure of CBT and the content was expanded in consistent with other ICBT programs for anxiety disorders including social anxiety disorder [2,19,20,21]. Each protocol contains 10 weekly sessions for adolescents and 9 sessions for parents, followed by a 3- month follow-up. Each participant completes one module per week and was given a quiz and homework at the end of each session. Contents are shown in Table1 & Table2.

Table1. The content of Generic treatment

Modules	Content
1	Psychoeducation on emotions, fear and anxiety, symptoms of anxiety
2	Psychoeducation on CBT/ICBT
3	An introduction to coping techniques (e.g. breathing and relaxation)
4	Psychoeducation on cognitive model of anxiety, an introduction to thought/ feeling /behavior
5	Psychoeducation on negative automatic thoughts and cognitive errors
6	Psychoeducation on avoidance cycle, Exposure hierarchy
7	Problem solving
8	Psychoeducation on a technique: worst accident
9	Writing and talking about anxiety
10	Summary of treatment, Relapse prevention program

Table2. The content of Specific treatment

Modules	Content
1	Psychoeducation on social anxiety disorder, CBT/ICBT
2	An introduction to coping techniques (e.g. breathing and relaxation)
3	Psychoeducation on Rapee and Heimberg Cognitive model of social anxiety
4	Psychoeducation on negative automatic thoughts and cognitive errors in social anxiety, cognitive reconstruction
5	Avoidance cycle, Exposure hierarchy with social anxiety example
6	Problem solving
7	Psychoeducation on social skills (e.g. eye contact)
8	Conversation skills
9	Assertive responding/ dealing with unreasonable requests
10	Summary of treatment, Relapse prevention program

At the next step, a focus group of 6 therapists with at least 2 years of clinical experience in the field of cognitive-behavioral therapy for adolescents or adults, approved the content descriptively in terms of structure, content, sessions arrangement, purposeful design, establishing a relationship with teens and suggestions for improvement.

The content then was converting to video by using VideoScribe 2.2.4. The first 21 videos were made for ICBT-G and then 20 videos for ICBT-S. The duration of all Generic and specific videos is 85 minutes. Fig.1. displays some screenshots from the videos.

The last step was using a Learning Management System (LMS) and preparing that by entering all the contents on it and designing the graphic parts. This system is registered as "Education Management system of School Software" that provides various services to the users. These users can have different roles, from pupils and students to teachers and the system administrator. There are dozens of other roles within the system as needed, such as therapist and client. This system is web-based and users can use it through the browser that exists on any laptop or computer through the internet connection. A screenshot of the LMS is shown in Fig.2.

Participants

A total of 45 adolescents aged between 14 to 18 years old with a diagnosis of SAD and their parents were included in the study via volunteer sampling method. Demographic information of participants is provided in Table3.

Table3. Demographic description of the participant

Variables	Total	ICBT-Generic		ICBT-Specific	Wait-list
Gender, n (%)
Male	9(25)	4 (33.3)		2 (16.7)	3(25)
Female	27(75)	8 (66.7)		10 (83.3)	9 (75)
Age
M (SD)	15.61 (1.46)	15.75 (1.42)		16.08 (1.50)	15 (1.34)
Range (age)	14-18	14-18		14-18	14-17
School Grade, n (%)
8	13 (36.1)	3 (25)		3 (25)	7 (58.3)
9	3 (8.3)	1 (8.3)		1 (8.3)	1 (8.3)
10	4 (11.1)	2 (16.7)		1 (8.3)	1 (8.3)
11	10 (27.8)	6 (50.0)		2 (16.7)	2 (13.3)
12	6 (16.7)	0		5 (41.7)	1 (8.3)
Earlier referral, n (%)	12 (33.3)	3 (25)		5 (41.7)	4 (33.3)
Taking medication, n(%)	2 (6.7)	0		2 (18.2)	0
Father education, n (%)
Secondary education	19 (52.77)	7 (19.44)		5 (13.88)	10(27.77)
College/university	17(47.22)	6(50.0)		6(50.0)	5(13.88)
PhD/Postdoc	1 (2.8)	0		1 (8.3)	0
Mother education, n (%)
Secondary education	17 (47.22)	4 (33.3)		4 (33.3)	9 (75)
College/university	18 (50)	7 (58.3)		8 (66.7)	3 (25)
PhD/Post-doc	1 (2.8)	1 (8.3)		0	0
Family size, n (%)
2 3 4 5 6	3 (8.3) 5(13.9) 20(55.6) 7(19.4) 1(2.8)	1 (8.3) 2)16.7) 5(41.7) 4(33.3) 0		2(16.7) 2)16.7) 6 (50.0) 1(8.3) 1(8.3)	0 (0) 1(8.3) 9(75.0) 2)16.7) 0
Birth Rate, n (%)
First	16(44.4)	3 (8.3)	5 (41.7)		8 (66.7)
Second	14 (38.9)	6 (50,0)	4 (33.3)		4 (33.3)
Third	2 (5.6)	1 (8.3)	1 (8.3)		0
Only child	4 (11.1)	2)16.7)	2 (16.7)		0

Procedure

Participants were informed about the study through social media (Twitter, Instagram, Facebook, and Linkedin), and messenger software (Telegram channel and what’s up status). Individuals who were interested in the study completed a web-based SASA (N = 120). After screening by SASA, 85 of the participants were invited to a 30-minutes clinical interview performed by a psychiatrist via video call on Skype. Inclusion criteria were: (A) having access to a computer and the internet, (B) If any psychiatric medication is being taken, 3 months have passed and the effect has been established. The exclusion criteria were (A) not completing more than two modules during treatment.

Those who were diagnosed with social anxiety disorder and met inclusion criteria (45 adolescents) received a message with instructions to register on the ICBT program website (http://www.delaram.schoolware.ir/). Also written informed consent were obtained from both adolescents and a parent. In the agreement forms, children and parents received information about the research project. After registering, each participant completes pre-test web-based questionnaires consisting of SASA which was already completed, MHS-SR, MHS-PR, and APCS. Once pretreatment assessments were done, adolescents were randomly assigned to one of three conditions: ICBT-G, ICBT-S, and a waiting list. The CONSORT statement for participants is presented in Fig.3.

Measures

2.4.1. Diagnostic Interview: The clinical interview was conducted by a psychiatrist specializing in children and adolescents, in order to diagnose SAD based on the criteria of DSM-5. Duration of each interview depends of the participants was between 15 and 30 minutes.

2.4.2. Social Anxiety Scale for Adolescents (SASA): SASA measures adolescents' anxious feelings, worries, and behaviors in social evaluative situations [22]. The scale includes 28 items in five-point Likert from never to forever. SASA consists of two subscales of Fear of Negative Evaluation (AFNE) and Tension and Inhibition in Social Contacts (TISC). The internal consistency of this questionnaire has been confirmed in many studies [23,24]. In addition, the results of confirmatory factor analysis in Iran showed that the two-factor structure had a good fit with the data, while Cronbach's alpha coefficients for AFNE, TISC and the total grade of SAD have been calculated respectively as 0.84, 0.68 and 0.83 [25].

2.4.3. Mental Health Scale - Parent Report Form (MHS-PR): This measure has 96 items to identify high school students (12-18 years) with psychological problems using parental information. MHS-PR consists of 8 subscales including anxiety, depression, attention deficit hyperactivity disorder, impulsive behaviors, self-harming behaviors, child abuse risk, the deficit in self-regulation, and deficit in academic homework. Items are answered on a four-point Likert scale (absolutely = 0 and always = 4) and a high score on any subscale means a problem in that difficulty. The internal consistency of the subscales was reported between 0.78 (attention deficit hyperactivity) to 0.95 (deficit in homework and deficit in self-management) and 0.95 for the whole scale [26].

2.4.4. Mental Health Scale - Self-Reporting Form (MHS-SR): This self-report measure has 96 items used to identify mental health problems in high school students (12 to 18 years old). MHS-SR included 8 subscales of anxiety, depression, attention deficit hyperactivity disorder, impulsive behaviors, self-harming behaviors, child abuse risk, the deficit in self-regulation, and deficit in academic homework. Items are answered on a four-point Likert scale (absolutely = 0, always = 4), and a high score on any subscale means a problem in that difficulty. The internal consistency of the subscales was reported between 0.85 and 0.98 [27].

2.4.5. Adolescent Psychological Capital Scale (APCS): This 72-item self-report scale has been developed (inpress) based on the covitality model [28]. It has subscales in 4 areas: self-belief, belief in others, emotional competence, and being busy with life. Exploratory factor analysis showed the presence of four domains on the scale as well as three subscales in each domain. The alpha coefficients in the areas of self-belief, belief in others, emotional competence, and being busy with life are 0.84, 0.86, 0.73, and 0.82, respectively. The criterion validity of the scale also indicates the alignment of domains and subscales with the tools of the scale [29].

Intervention Implementation

The present study was approved by the University/Regional Research Ethics Committee of Shahid Beheshti University (IR.SBU.REC.1399.018). Treatments for each participant lasted for 2.5 months. The therapist's role during the sessions was to support the participant through monitoring progress, sending feedback on homework activities through the system mailbox, as well as answering their questions. Before the intervention commenced, a pretest assessment was performed by participants and parents, then in the fifth session, mid-test assessment, and at the end of the intervention, post-tests were completed. Then, a 3-month follow-up measurement was also conducted. After the treatment, participants in the waiting list group were offered half ICBT-S and half ICBT-G.

According to the participants, one of the advantages of the ICBT is the time flexibility in completing the sessions. Individuals did not have to get online at a specific time and also, they had one whole week to complete each session. For each adolescent, one parent also participated in the treatment program. Most of the parents participating in the program were mothers. The therapist's role during the sessions was to support the participants by reviewing homework, and quizzes, sending feedback, answering questions, and troubleshooting.

Statistical Analysis

The continuous variables measured at the four assessment points (before, middle, after treatment, and 3-month follow-up) were analyzed with multivariate repeated measures, using IBM SPSS Statistics version 26.

In the present study, four measurements were used to evaluate the effectiveness of two Internet-based treatments, including specific and generic therapy, as well as a waiting list. Estimated means and standard errors for each group’s measures at each time are shown in Table A4.

Table4. Descriptive indices

				Groups
Condition		Specific		Generic		Waiting list
Measure	Time	M	SD	M	SD	M	SD
SASA	Pre-test	77.58	12.73	72.58	17.62	71.33	12.00
	Mid-test	65.50	8.52	68.67	9.53	69.67	10.08
	Post-test	63.58	4.60	65.17	11.01	66.08	11.85
	Follow-up	63.73	6.24	70.11	10.62	63.30	15.37
MHS-PR	Pre-test	74.25	47.91	75.08	37.80	71.92	27.79
	Mid-test	64.83	46.97	55.82	27.74	60.50	28.96
	Post-test	45.82	29.18	53.08	26.39	68.25	33.23
	Follow-up	35.56	15.38	47.73	31.22	77.50	47.89
MHS-SR	Pre-test	94.00	40.99	69.58	35.52	74.08	31.49
	Mid-test	82.08	20.42	67.50	34.98	72.25	23.63
	Post-test	76.83	24.96	62.33	29.56	72.25	18.95
	Follow-up	61.27	23.81	58.80	30.82	64.50	37.23
APCS	Pre-test	173.36	47.921	195.75	52.189	200.92	36.06
	Mid-test	186.42	34.71	203.75	55.00	199.09	27.67
	Post-test	197.33	42.15	207.83	48.00	214.67	32.56
	Follow-up	197.40	46.72	211.78	47.27	203.00	53.89

M=Mean; SD=Standard Deviation; SASA=Social Anxiety Scale for Adolescents, MHS- PR=Mental Health Scale - Parent Report Form; MHS-SR= Mental Health Scale - Self-Reporting Form; APCS= Adolescent Psychological Capital Scale.

The results of multivariate variance analysis of mean total scores of all the measures is shown in table5.

Table 5. Multivariate test

Measure	Effect	Test	Value	F	df	Error df	Sig	Eta
SASA	Time	Wilks’Lambda	.55	6.73	3.00	25.00	.002	.44
SASA	Time*Group		.79	1.04	6.00	50.00	.41	.11
MHS-SR	Time		.69	3.75	3.00	26.00	.02	.30
	Time*Group		.86	.63	6.00	52.00	.70	.06
MHS-PR	Time		.66	3.97	3.00	24.00	.02	.33
	Time*Group		.75	1.23	6.00	48.00	.30	.13
APCS	Time		.52	6.71	3.00	22.00	.002	.47
	Time*Group		.62	1.91	6.00	44.00	.10	.20

The contents of Table 5 showed that all the changes in the total score of the time factor have a significant difference based on Wilk’s multivariate significance index. This result means that the process of changes in the groups is different in the four stages of measurement. In neither of the measures, the interaction of time and group factors in the total scores is significant.

Table 6. The result of Repeat measure analysis of variance on four scales

Measure	SS	df	F	Sig.		Eta
SASA	1785.5	1.91	11.03	.001	.29
MHS-SR	3606.10	2.99	4.99	.003	.15
MHS-PR	6904.96	2.52	4.87	.006	.15
APCS	4543.63	2.62	4.31	.01	.15

SS= Sum of square, FNE= Fear of negative evaluation., TISC= Tension and inhibition of social contacts, ADH= Attention deficit and hyperactivity, IBA= Impulsive behavior & aggression, ANX=Anxiety, DEP=Depression, SHM=Self-harm behaviors, CHA=Child abuse, DSE= Deficit in self-efficacy, SB=Self-belief, EC=Emotional Competence

The result of repeated measures in Table 6 showed the effectiveness of ICBT-S group compared to ICBT-G on the average scores of the total number in all measures (p≥0.01). The improvements were also maintained for both intervention groups during the 3-month follow-up period.

Comparison between generic and specific treatment

The result of the present study confirmed that an internet-based CBT with a specified content would be more effective than a generic approach in the treatment of social anxiety in adolescents. We enriched the content of the generic intervention based on suggestions in Spence et. al study (2017). For example, it was stated in the mentioned research that it is necessary to consider strategies to increase adolescents' participation in treatment homework and quizzes. Accordingly, in the present study, several attempts were made; to provide content with attractive graphic elements to increase the motivation of participation in adolescents. Also, duration of each video content was short enough to keep the participant engaged and not getting bored.

Another suggestion of Spence et al. (2017) was that the content of specific treatment should include components to reduce cognitive distortions and biases associated with social anxiety disorder. Social skills training and cognitive change strategies were also suggested. In addition, her research recommendation was that treatment includes strategies to reject beliefs, socially incompatible, and cognitive distortions. In the present study protocol, a whole session was devoted to teaching cognitive distortions, especially distortions related to social anxiety disorder and related exercises in daily life. Another suggestion mentioned in the study of Spence was the need to focus on the factors that cause and exacerbate this disorder. Among these factors are deficiencies in social skills that lead to rejection and inattention from peers. Accordingly, in the specific treatment protocol prepared in the present study, 3 of the last 4 sessions (sessions 7, 8, and 9) psychoeducation about social skills including eye contact, conversational skills, assertiveness, and the ability to say no were included. The result of the present study is consistent with [15,16,18, 30] in terms of the weak efficacy of generic CBT on socially anxious adolescents.

Clinical observations

In the present clinical trial, some participants, especially those who had comorbid diagnoses such as generalized anxiety disorder (GAD) or major depressive disorder(MDD) and were randomly assigned to the ICBT-S group, had other concerns and asked the therapist for more help. When it was explained to them that this treatment program specifically addressed only the problem of social anxiety, they seemed to show less motivation and enthusiasm in completing and continuing the sessions; One participant also withdrew from the study for this reason. Unlike transdiagnosed sample, those who had only been diagnosed with SAD and were assigned to a specific group were more motivated to complete the sessions. Also, after a few sessions, positive feedback was received from this group and their parents. Therefore, it might be assumed that cognitive-behavioral therapy with a specific approach is probably more suitable for adolescents with the main diagnosis of SAD and no comorbidity. Examining this hypothesis requires further research studies.

Another clinical observation related to comorbidities was the positive feedback received from adolescents and parents after the end of interventions. Most of the participants or parents who provided positive feedback did not have a comorbid disorder. The parents pointed out that their children were more assertive, overcoming the fear of being judged by others, and the treatment helped them increase their self-confidence.

The last clinical consideration was completing the questionnaires during the four-stage evaluations. It seemed that the primary outcome measure (SASA), which had fewer questions than the other questionnaires (28 questions), was probably completed more accurately but both MHS-SR (with 80 questions) and MHS-PR (96 questions) as well as the APCS (72 questions), which were longer, were answered with lower attention; some of these responses were identified as spam by the website through which the questionnaires were designed and completed. As a result, they were removed from the data set and statistical analysis process. This trend was especially noticeable in the mid-test and later stages when the questionnaires were repetitive. In particular, it seems that evaluation tools on the Internet should be shorter than face-to-face implementation, and apparently, people on the internet, especially adolescents, are not able to focus on one topic for a long time and have an obsessive desire to do various other activities [31]. This issue needs to be addressed in future research and raises the need to create better alternative methods for evaluating and measuring variables in trial interventions, especially internet-based ones.

Treatment adherence

The completion rate of online sessions by participants, a highlight of the present study, was the highest in comparison to those reported in previous trials: 2.9 out of 9 sessions (39%) in Tillfors trial (2011), 4.4 out of 10 sessions (44%) In Spence study (2017), 5.9 out of 9 sessions (66%) and 7.5 out of 10 sessions (75%) in two Nordh studies (2020). In the current study, both treatment groups completed an average of 9.44 out of 10 sessions (94.4%). In other words, 25 out of 30 (83%) participants in the intervention groups completed the treatment. It could be stated that characteristics of adolescents’ internet users such as low concentration range [31] was being taken into account based on the findings and recommendations of previous research [13,32]. Some elements were predicted to increase the engagement of participants; among other things, in producing the video content of the sessions, an attempt was made to make the videos as short as possible (a total of 41 videos between 50 seconds and 6 minutes). Graphic elements were also chosen to be attractive and tangible to the adolescent age group while facilitating learning and encouraging them to complete sessions. It should be noted that once a week, the therapist reminded participants and their parents by sending a text message to complete the sessions, and it seems that this reminder was also effective in increasing the completion rate of the sessions. All the above factors each had a separate contribution in increasing the participation of the subjects in completing the treatment sessions of the current study.

Strengths and Limitations

The current study has several strengths. First, using an active comparator group (ICBT-G) instead of just having an experimental group and a waiting list, controlled the nonspecific aspects of treatment. Second, participant adherence was the highest among similar studies (94.4%) and data loss was low (<13%missing on all measures). Last, to the best of our knowledge, the study is the first development and evaluation of an ICBT intervention for young children with SAD in Iran.

There are also limitations in this study that need to be considered while interpreting the result. The most important one is that a sample size of 45 while giving adequate potency to distinguish differences between 2 active interventions and waiting list group, was relatively small when it comes to finding out potential differences between the two active clinical conditions. We had two main limitations regarding this issue: First, since this was a huge project and we had to develop two different programs and then perform the control trial, so the timeframe of the study was delayed longer than usual and we couldn’t spend more time on sample recruiting. We had also difficulties recruiting participants through mental health clinics or schools. Therefore, the sample was provided only from social networks and mainly on Instagram, so it is important to consider that the low sample size of the present study can affect the research results. It is suggested that this study be conducted with larger sample size and its results be compared with the present study.

Another limitation is the lack of controlling the rate of comorbid disorders. Since social anxiety disorder usually happens with comorbidity especially anxiety disorders (37% of young participants in this study), Future studies need to investigate the effect of comorbidity on the treatment of SAD and identify treatments that are most likely to be advantageous to young children with different comorbidity profiles including SAD.

Summary

The research gap answered in the current study was the inadequate effectiveness of cognitive-behavioral therapy (CBT) with a generic approach in adolescents with social anxiety according to several studies. In the present study, the content of the specific protocol was enriched based on the limitations and suggestions made by previous researchers. Two different treatments were designed in the present study: generic and specific ICBT for Iranian adolescents including 10 sessions for adolescents and 9 sessions for parents. Both programs were evaluated and approved by 6 CBT therapists. Treatment material consisted of text and videos implemented on a website. A randomized control trial has been conducted, comparing the effectiveness of generic and specific ICBT on adolescents with social anxiety. The sample was 45 adolescents aged 14 to 18 years with a diagnosis of social anxiety. Participants were randomly assigned to three groups: specific, generic, and a waiting list. All the scales were performed in four stages including pre-test (before intervention), mid-test (after the fifth session), post-test (after the completion of sessions), and 3 months follow-up (3 months after the end of treatment). The results showed a significant improvement in favor of ICBT with a specific approach to the score of the Social Anxiety Scale for Adolescents SASA (p≤ 0.01) and its two subscales including Anxiety and Fear of Negative Evaluation AFNE (p≤ 0.01) and Tension and Inhibition in Social Interaction TISC (p≤0.001) in comparison to generic ICBT. The therapeutic effects lasted up to 3 months after the end of treatment. This significant improvement in favor of specific ICBT was also observed in secondary outcome measures and most of their subscales. The changes sustained at a 3-month follow-up. Therefore, Internet-delivered cognitive behavioral therapy with a specific approach to SAD has the potential to help adolescents with social anxiety disorder and also increase the possible seeking of help for this patient group.

Funding Declaration

This research was supported financially by the Information and Communication Technology Park under grant number 000200-02-99-02. The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in the current study involving human were in accordance with the ethical standards of the institution at which the study was conducted. The trial was approved by the University/Regional Research Ethics Committee of Shahid Beheshti University (IR.SBU.REC.1399.018) in Tehran.

Author Contribution

Since the present study was based on the Ph.D. thesis of the first author, this paper was mostly done by her. All the authors have reviewed the manuscript.

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No competing interests reported.

A Specific Internet-based Cognitive Behavior Therapy for Adolescents with Social Anxiety Disorder: Three-armed Randomized Control Trial

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Abstract

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Introduction

Methods

Results

Discussion

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Additional Declarations

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