Cognitive therapy compared with CBT for social anxiety disorder in adolescents: a feasibility study

Health Technol Assess. 2021 Mar;25(20):1-94. doi: 10.3310/hta25200.


Background: Social anxiety disorder (SAD) is common, typically starts in adolescence and has a low natural recovery rate. Existing psychological treatments for adolescent SAD are only moderately effective. It is possible that recovery rates for adolescents could be substantially improved by adapting a psychological therapy that is highly effective among adults with SAD.

Objectives: To train child and adolescent mental health services (CAMHS) therapists to deliver cognitive therapy for SAD in adolescents (CT-SAD-A) and assess therapist competence. To estimate the costs to the NHS of training therapists to deliver CT-SAD-A and the mean cost per adolescent treated. To examine the feasibility of a randomised controlled trial (RCT) to compare CT-SAD-A with the general form of cognitive-behavioural therapy that is more commonly used.

Design: During the training phase of the study, it became clear that the RCT would not be feasible because of high staff turnover and unfilled posts within CAMHS and changes in the nature of referrals, which meant that few young people with primary SAD were accessing some of the participating services. The study design was altered to comprise the following: a training case series of CT-SAD-A delivered in routine CAMHS, an estimate of the cost to the NHS of training therapists to deliver CT-SAD-A and of the mean cost per adolescent treated, and qualitative interviews with participating young people, parents, therapists and service managers/leads.

Setting: Five CAMHS teams within Berkshire Healthcare and Oxford Health NHS Foundation Trusts.

Participants: Eight therapists received training in CT-SAD-A. Twelve young people received CT-SAD-A, delivered by six therapists. Six young people, six parents, seven therapists and three managers participated in qualitative interviews.

Interventions: Cognitive therapy for social anxiety disorder in adolescents (CT-SAD-A).

Main outcome measures: Measured outcomes included social anxiety symptoms and diagnostic status, comorbid symptoms of anxiety and depression, social and general functioning, concentration in class and treatment acceptability. Patient level utilisation of the intervention was collected using clinicians' logs.

Results: Nine out of 12 participants achieved good outcomes across measures (r ≥ 0.60 across social anxiety measures). The estimated cost of delivering CT-SAD-A was £1861 (standard deviation £358) per person. Qualitative interviews indicated that the treatment was acceptable to young people, parents and therapists, but therapists and managers experienced challenges when implementing the training and treatment within the current CAMHS context.

Limitations: Findings were based on a small, homogeneous sample and there was no comparison arm.

Conclusions: CT-SAD-A is a promising treatment for young people with SAD, but the current CAMHS context presents challenges for its implementation.

Future work: Further work is needed to ensure that CAMHS can incorporate and test CT-SAD-A. Alternatively, CT-SAD-A should be delivered and tested in other settings that are better configured to treat young people whose lives are held back by SAD. The new schools Mental Health Support Teams envisaged in the 2017 Children's Mental Health Green Paper may provide such an opportunity.

Funding: The National Institute for Health Research (NIHR) Health Technology Assessment programme. Individual funding was also provided for Cathy Creswell, David M Clark and Eleanor Leigh as follows: NIHR Research Professorship (Cathy Creswell); Wellcome Senior Investigator Award (Anke Ehlers and David M Clark); and the Wellcome Clinical Research Training Fellowship (Eleanor Leigh).


Plain language summary

Why did we do this study?: People with social anxiety disorder (SAD) are scared of social situations because they fear embarrassment or humiliation. SAD usually starts at around 13 years of age, typically does not go away without treatment, and leads to personal and social difficulties. Clark and Wells’ cognitive therapy for SAD in adults (CT-SAD) is a talking therapy that produces excellent outcomes. CT-SAD has not previously been adapted for or tested with adolescents.

What did we do?: We adapted CT-SAD so that it was suitable for adolescents (CT-SAD-A). We intended to compare this with current practice in child and adolescent mental health services (CAMHS). However, we were not able to complete the trial owing to a high staff turnover and a lack of young people with SAD coming into CAMHS. Instead, we examined outcomes for young people who received CT-SAD-A during the therapist training phase and explored the views of young people, their parents, the therapists and CAMHS managers about CT-SAD-A and the study.

What did we find?: Young people’s outcomes were very promising; for example, 10 out of 12 participants reported a reliable improvement in social anxiety. The young people and their parents were generally positive about the treatment. Therapists were also positive about the treatment, but they and their managers found it difficult to implement the treatment within their CAMHS teams. The cost to the NHS to treat young people with SAD within this study compared favourably with the cost of treating adults.

What does this mean?: We need to be careful about drawing conclusions from a small sample size, but we suggest that further work is needed to ensure that CT-SAD-A can be delivered and tested in CAMHS. Alternatively, CT-SAD-A should be delivered and tested in community or school settings that can treat young people whose lives are held back by SAD.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Child
  • Cognitive Behavioral Therapy*
  • Feasibility Studies
  • Humans
  • Phobia, Social* / therapy
  • Surveys and Questionnaires
  • Technology Assessment, Biomedical