Abstract
Social anxiety is an increasing mental health concern for adolescents in the international community, including China, where access to psychotherapy is still limited. Training in cognitive bias modification of interpretation (CBM-I) for ambiguous social situations has demonstrated efficacy in improving social anxiety. Smartphone-based CBM-I has the potential to be an accessible tool to help address the mental health needs of adolescents. However, no prior studies have explored smartphone-based CBM-I targeting social anxiety in adolescents. We examined the effect of an eight-session smartphone-based training of cognitive bias modification of interpretation (CBM-I) on the social anxiety of Chinese adolescents. Twenty-eight participants who scored in the top ten percent of Social Anxiety Scale (SAS-A) and the Brief Fear of Negative Evaluation (BFNE) were randomly assigned to the training group and the waitlist group. Both groups completed pre- and post-tests of interpretation bias and social anxiety. Participants in the training group logged into the smartphone-based CBM-I application twice a week for four weeks to receive the intervention. The waitlist group received the same pre-and post-tests only during the 4-week waiting time. Results revealed that the CBM-I training group significantly increased positive interpretation bias and decreased negative interpretation bias, social anxiety, and fear of negative evaluation. The waitlist group did not have any significant changes in the above measures. The eight-session smartphone-based CBM-I intervention showed the expected intervention effect for Chinese adolescents coping with social anxiety, demonstrating its potential as an effective tool for reducing social anxiety for the population.
Highlights
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Developed an 8-session smartphone-based training of CBM-I for social anxiety reduction.
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Developed culturally and developmentally adapted CBM-I training materials for Chinese adolescents.
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Found a significant reduction in social anxiety and fear of negative evaluation in the CBM-I training group.
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References
Abend, R., Rosenfelder, A., Shamai, D., Pine, D. S., & Bar-Haim, Y. (2019). Structural brain changes induced by attention bias modification training. Biological Psychology, 146, 107736. https://doi.org/10.1016/j.biopsycho.2019.107736.
Amir, N., & Taylor, C. T. (2012). Interpretation training in individuals with generalized social anxiety disorder: a randomized controlled trial. Journal of Consulting & Clinical Psychology, 80, 497–511. https://doi.org/10.1037/a0026928.
Amir, N., Prouvost, C., & Kuckertz, J. M. (2012). Lack of a benign interpretation bias in social anxiety disorder. Cognitive Behaviour Therapy, 41(2), 119–129. https://doi.org/10.1080/16506073.2012.662655.
Arjadi, R., Nauta, M. H., Chowdhary, N. & & Bockting, C. L. H. (2015). A systematic review of online interventions for mental health in low and middle income countries: a neglected field. Global Mental Health, 2, e12. https://doi.org/10.1017/gmh.2015.10.
Beard, C., & Amir, N. (2008). A multi-session interpretation modification program: changes in interpretation and social anxiety symptoms. Behaviour Research and Therapy, 46(10), 1135–1141. https://doi.org/10.1016/j.brat.2008.05.012.
Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy, 1, 5–38.
Beck, A. T. (2008). The evolution of the cognitive model of depression and its neurobiological correlates. American Journal of Psychiatry, 165, 969–977. https://doi.org/10.1176/appi.ajp.2008.08050721.
Beesdo-Baum, K., Knappe, S., Fehm, L., Höfler, M., Lieb, R., Hofmann, S. G., & Wittchen, H.-U. (2012). The natural course of social anxiety disorder among adolescents and young adults. Acta Psychiatrica Scandinavica, 126, 411–425. https://doi.org/10.1111/j.1600-0447.2012.01886.x.
Beidel, D. C., Tuerk, P. W., Spitalnick, J., Bowers, C. A., & Morrison, K. (2021). Treating childhood social anxiety disorder with virtual environments and serious games: a randomized trial. Behavior Therapy, 52, 1351–1363. https://doi.org/10.1016/j.beth.2021.03.003.
Beidel, D. C., Turner, S. M., & Young, B. J. (2006). Social effectiveness therapy for children: five years later. Behavior Therapy, 37(4), 416–425. https://doi.org/10.1016/j.beth.2006.06.002.
Boettcher, J., Leek, L., Matson, L., Holmes, E. A., Browning, M., MacLeod, C., Andersen, G., & Carlbring, P. (2013). Internet-based attention bias modification for social anxiety: a randomised controlled comparison of training towards negative and training towards positive cues. PLoS ONE, 8, e71760. https://doi.org/10.1371/journal.pone.0071760.
Bowler, J. O., Mackintosh, B., Dunn, B. D., Mathews, A., Dalgleish, T., & Hoppitt, L. (2012). A comparison of cognitive bias modification for interpretation and computerized cognitive behavior therapy: effects on anxiety, depression, attentional control, and interpretive bias. Journal of Consulting and Clinical Psychology, 80, 1021–1033. https://doi.org/10.1037/a0029932.
Brosan, L., Hoppitt, L., Shelfer, L., Sillence, A., & Mackintosh, B. (2011). Cognitive bias modification for attention and interpretation reduces trait and state anxiety in anxious patients referred to an out-patient service: Results from a pilot study. Journal of Behavior Therapy and Experimental Psychiatry, 42, 0–264. https://doi.org/10.1016/j.jbtep.2010.12.006.
Burstein, M., He, J. P., Kattan, G., Albano, A. M., Avenevoli, S., & Merikangas, K. R. (2011). Social phobia and subtypes in the national comorbidity survey-adolescent supplement: prevalence, correlates, and comorbidity. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 870–880. https://doi.org/10.1016/j.jaac.2011.06.005.
Chen, X., & Chen, H. (2010). Children’s socioemotional functioning and adjustment in the changing Chinese society. In social change and human development: concept and results (pp. 227–244). SAGE Publications Inc. https://doi.org/10.4135/9781446252161.n10
Cohen Kadosh, K. (2011). What can emerging cortical face networks tell us about mature brain organization? Developmental Cognitive Neuroscience, 1(3), 246–255. https://doi.org/10.1016/j.dcn.2011.02.001.
Cohen Kadosh, K., Johnson, M. H., Dick, F., Cohen Kadosh, R., & Blakemore, S.-J. (2012). Effects of age, task performance, and structural brain development on face processing. Cerebral Cortex, 23(7), 1630–1642. https://doi.org/10.1093/cercor/bhs150.
Enock, P. M., & McNally, R. J. (2013). How mobile apps and other web-based interventions can transform psychological treatment and the treatment development cycle. The Behavior Therapist, 36, 56–66.
Enock, P. M., Hofmann, S. G., & McNally, R. J. (2014). Attention bias modification training via smartphone to reduce social anxiety: a randomized, controlled multi-session experiment. Cognitive Therapy Research, 38(2), 200–216. https://doi.org/10.1007/s10608-014-9606-z.
Fang, X. Y., Dai, L. Q., Fang, C., & Deng, L. Y. (2006). The relationship between parent-adolescent communication problems and adolescents’ social adjustments. Psychological Development and Education, 22, 47–52.
Giannini, M., & Loscalzo, Y. (2016). Social anxiety and adolescence: interpretation bias in an Italian sample. Scandinavian Journal of Psychology, 57, 65–72. https://doi.org/10.1111/sjop.12263.
Greca, A. M. L., & Lopez, N. (1998). Social anxiety among adolescents: linkages with peer relations and friendships. Journal of Abnormal Child Psychology, 26, 83–94. https://doi.org/10.1023/A:1022684520514.
Guo, X., Meng, Z., Huang, G., Fan, J., Zhou, W., Ling, W., Jiang, J., Long, J., & Su, L. (2016). Meta-analysis of the prevalence of anxiety disorders in mainland China from 2000 to 2015. Scientific Reports, 6, 28033. https://doi.org/10.1038/srep28033.
Haller, S. P., Raeder, S. M., Scerif, G., Cohen, K. K., & Lau, J. Y. (2016). Measuring online interpretations and attributions of social situations: links with adolescent social anxiety. Journal of Behavior Therapy & Experimental Psychiatry, 50, 250–256. https://doi.org/10.1016/j.jbtep.2015.09.009.
Hallion, L. S., & Ruscio, A. M. (2011). A meta-analysis of the effect of cognitive bias modification on anxiety and depression. Psychological Bulletin, 137, 940–958. https://doi.org/10.1037/a0024355.
Hauser, T. U., Iannaccone, R., Walitza, S., Brandeis, D., & Brem, S. (2014). Cognitive flexibility in adolescence: neural and behavioral mechanisms of reward prediction error processing in adaptive decision making during development. NeuroImage, 104, 347–354. https://doi.org/10.1016/j.neuroimage.2014.09.018.
Hirsch, C. R., Hayes, S., & Mathews, A. (2009). Looking on the bright side: accessing benign meanings reduces worry. Journal of Abnormal Psychology, 118, 44–54. https://doi.org/10.1037/a0013473.
Holmes, E. A., & Mathews, A. (2005). Mental imagery and emotion: a special relationship. Emotion, 5, 489–497. https://doi.org/10.1037/1528-3542.5.4.489.
Holmes, E. A., Coughtrey, A. E., & Connor, A. (2008). Looking at or through rose-tinted glasses? Imagery perspective and positive mood. Emotion, 8(6), 875–879. https://doi.org/10.1037/a0013617.
Holmes, E. A., Lang, T. J., & Shah, D. M. (2009). Developing interpretation bias modification as a “cognitive vaccine” for depressed mood: Imagining positive events makes you feel better than thinking about them verbally. Journal of Abnormal Psychology, 118, 76–88. https://doi.org/10.1037/a0012590.
Huppert, J. D., Pasupuleti, R. V., Foa, E. B., & Mathews, A. (2007). Interpretation biases in social anxiety: response generation, response selection, and self-appraisals. Behaviour Research and Therapy, 45, 1505–1515. https://doi.org/10.1016/j.brat.2007.01.006.
Jefferies, P., & Ungar, M. (2020). Social anxiety in young people: a prevalence study in seven countries. PLoS ONE, 15(9), e0239133. https://doi.org/10.1371/journal.pone.0239133.
Jia, W., Chunyu, Z., Yadan, L., Song, X., Jinfu, Z., & Valsamma, E. (2015). Psychometric properties of the Chinese version of the fear of negative evaluation scale-brief (BFNE) and the BFNE-straightforward for middle school students. PLoS ONE, 10(3), e0115948. https://doi.org/10.1371/journal.pone.0115948.
Jiang, C. (2016). Counselor: where is our way ? Psychology and Health, 11(6), 13–15.
Klein, A. M., Salemink, E., De, E. H., Houtkamp, E., Papa, M., & Van, M. D. M. (2018). Cognitive bias modification reduces social anxiety symptoms in socially anxious adolescents with mild intellectual disabilities: a randomized controlled trial. Journal of Autism and Developmental Disorders, 3, 1–11. https://doi.org/10.1007/s10803-018-3579-9.
Klein, A. M., Voogd, L. D., Wiers, R. W., & Salemink, E. (2017). Biases in attention and interpretation in adolescents with varying levels of anxiety and depression. Cognition and Emotion, 1, 1478–1486. https://doi.org/10.1080/02699931.2017.1304359.
Lau, & Jennifer, Y. F. (2013). Cognitive bias modification of interpretations: a viable treatment for child and adolescent anxiety. Behaviour Research and Therapy, 51, 614–622. https://doi.org/10.1016/j.brat.2013.07.001.
Lau, J. Y. F., & Eley, T. C. (2010). Disentangling gene-environment correlations and interactions on adolescent depressive symptoms. Journal of Child Psychology and Psychiatry, 49, 142–150. https://doi.org/10.1111/j.1469-7610.2007.01803.x.
Lester, K. J., Field, A. P., & Muris, P. (2011). Experimental modification of interpretation bias regarding social and animal fear in children. Journal of Anxiety Disorders, 25(5), 697–705. https://doi.org/10.1016/j.janxdis.2011.03.006.
Li, W., & Li, Y. (2010). An analysis on social and cultural background of the resistance for China’s education reform and academic pressure. International Education Studies, 3(3). https://doi.org/10.5539/ies.v3n3p211
Macleod, C., & Mathews, A. (2012). Cognitive bias modification approaches to anxiety. Annual Review of Clinical Psychology, 8, 189–217. https://doi.org/10.1146/annurev-clinpsy-032511-143052.
Mathews, A., & Mackintosh, B. (2000). Induced emotional interpretation bias and anxiety. Journal of Abnormal Psychology, 109, 602–615. https://doi.org/10.1037/0021-843X.109.4.602.
Mathews, A., & Macleod, C. (2005). Cognitive vulnerability to emotional disorders. Annual Review of Clinical Psychology, 1(1), 167–195. https://doi.org/10.1146/annurev.clinpsy.1.102803.143916.
Miers, A. C., Blöte, A. W., Bögels, S. M., & Westenberg, P. M. (2008). Interpretation bias and social anxiety in adolescents. Journal of Anxiety Disorders, 22, 1462–1471. https://doi.org/10.1016/j.janxdis.2008.02.010.
Nelis, S., Vanbrabant, K., Holmes, E. A., & Raes, F. (2012). Greater positive affect change after mental imagery than verbal thinking in a student sample. Journal of Experimental Psychopathology, 3(2), 178–188. https://doi.org/10.5127/jep.021111.
Nelson, E. E., Leibenluft, E., Mcclure, E. B., & Pine, D. S. (2005). The social re-orientation of adolescence: a neuroscience perspective on the process and its relation to psychopathology. Psychological Medicine, 35, 163–174. https://doi.org/10.1017/S0033291704003915.
Neubauer, K., von Auer, M., Murray, E., Petermann, F., Helbig-Lang, S., & Gerlach, A. L. (2013). Internet-delivered attention modification training as a treatment for social phobia: a randomized controlled trial. Behaviour Research Therapy, 51(2), 87–97. https://doi.org/10.1016/j.brat.2012.10.006.
Otkhmezuri, B., Boffo, M., Siriaraya, P., Matsangidou, M., Wiers, R. W., Mackintosh, B., Ang, C. S. & Salemink, E. (2019). Believing is seeing: a proof-of-concept semiexperimental study on using mobile virtual reality to boost the effects of interpretation bias modification for anxiety. JMIR Mental Health, 6(2), e11517. https://doi.org/10.2196/11517.
Paus, T., Keshavan, M., & Giedd, J. N. (2008). Why do many psychiatric disorders emerge during adolescence. Nature Reviews Neuroscience, 9, 947–957. https://doi.org/10.1038/nrn2513.
Peng, Y. N., Xi, J. Z., & Zuo, Z. H. (2017). The application, strengths, disadvantages and development of mobile APP in psychological practice. Chinese Mental Health Journal, 25, 333–336. https://doi.org/10.16128/j.cnki.1005-3611.2017.02.029.
Pfeifer, J. H., & Allen, N. B. (2012). Arrested development? Reconsidering dual-systems models of brain function in adolescence and disorders. Trends in Cognitive Sciences, 16, 322–329. https://doi.org/10.1016/j.tics.2012.04.011.
Pfeifer, J. H., Masten, C. L., Moore, W. E., Oswald, T. M., & Dapretto, M. (2011). Entering adolescence: resistance to peer influence, risky behavior, and neural changes in emotion reactivity. Neuron, 69, 1029–1036. https://doi.org/10.1016/j.neuron.2011.02.019.
Pictet, A., Coughtrey, A. E., Mathews, A., & Holmes, E. A. (2011). Fishing for happiness: the effects of generating positive imagery on mood and behaviour. Behaviour Research and Therapy, 49(12), 885–891. https://doi.org/10.1016/j.brat.2011.10.003.
Pine, D. S. (1999). Pathophysiology of childhood anxiety disorders. Biological Psychiatry, 46(11), 1555–1566. https://doi.org/10.1016/S0006-3223(99)00115-8.
Reuland, M. M., & Teachman, B. A. (2014). Interpretation bias modification for youth and their parents: a novel treatment for early adolescent social anxiety. Journal of Anxiety Disorder, 28, 851–864. https://doi.org/10.1016/j.janxdis.2014.09.011.
Salemink, E., Kindt, M., Rienties, H., & Den Hout, M. A. (2014). Internet-based cognitive bias modification of interpretations in patients with anxiety disorders: a randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 45(1), 186–195. https://doi.org/10.1016/j.jbtep.2013.10.005.
Salum, G. A., Gadelha, A., Polanczyk, G. V., Miguel, E. C., & Rohde, L. A. (2018). Diagnostic operationalization and phenomenological heterogeneity in psychiatry: the case of attention deficit hyperactivity disorder. Salud Mental, 41(6), 249–259. https://doi.org/10.17711/SM.0185-3325.2018.037.
Scherf, K. S., Behrmann, M., & Dahl, R. E. (2012). Facing changes and changing faces in adolescence: a new model for investigating adolescent-specific interactions between pubertal, brain and behavioral development. Developmental Cognitive Neuroscience, 2, 199–219. https://doi.org/10.1016/j.dcn.2011.07.016.
Shafiei, H., & Zare, H. (2019). Effectiveness of attention bias modification by computerized attention training on reducing social anxiety of adolescents. Advances in Cognitive Sciences, 21(2), 108–120. https://doi.org/10.30699/icss.21.2.108.
Shen, H. Y., Wang, Z. C., Lu, X. J., Wu, H. M., Wang, Y. P., & Gao, H. Y., et al. (2011). Anxiety and depression of junior middle school students before examination(in Chinese). China Journal of Health Psychology, 19(10), 1248–1249.
Song, S. S., Wu, J. S., & Zhang, F. (2019). Mediating role of resilience between stress and social anxiety in military medical university students (in Chinese). Academic Journal of Second Military Medical University, 40(3), 346–349.
Spence, S. H., & Rapee, R. M. (2016). The etiology of social anxiety disorder: an evidence-based model. Behaviour Research and Therapy, 86, 50–67. https://doi.org/10.1016/j.brat.2016.06.007.
Sportel, B. E., Hullu, E. D., Jong, P. J. D., & Nauta, M. H. (2013). Cognitive bias modification versus CBT in reducing adolescent social anxiety: a randomized controlled trial. PLoS ONE, 8(5), e64355. https://doi.org/10.1371/journal.pone.0064355.
Steinman, S. A., & Teachman, B. A. (2015). Training less threatening interpretations over the internet: does the number of missing letters matter? Journal of Behavior Therapy and Experimental Psychiatry, 49, 53–60. https://doi.org/10.1016/j.jbtep.2014.12.004.
Stevenson, C. E., Kleibeuker, S. W., De, D. C. K. W., & Crone, E. A. (2014). Training creative cognition: adolescence as a flexible period for improving creativity. Frontiers in Human Neuroscience, 8, 827. https://doi.org/10.3389/fnhum.2014.00827.
Vassilopoulos, S. P., & Banerjee, R. (2012). Social anxiety and content specificity of interpretation and judgemental bias in children. Infant and Child Development, 21, 298–309. https://doi.org/10.1002/icd.746.
Wang, M., Wu, X., & Wang, J. (2021). Paternal and Maternal Harsh Parenting and Chinese Adolescents’ Social Anxiety: the different mediating roles of attachment insecurity with fathers and mothers. Journal of Interpersonal Violence, 36, 9904–9923. https://doi.org/10.1177/0886260519881531.
Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting & Clinical Psychology, 33, 448 https://doi.org/10.1037/h0027806.
Wichers, M., Simons, C. J., Kramer, I. M., Hartmann, J. A., Lothmann, C., Myin-Germeys, I., van Bemmel, A. L., Peeters, F., Delespaul, P., & van Os, J. (2011). Momentary assessment technology as a tool to help patients with depression help themselves. Acta Psychiatrica Scandinavica, 124(4), 262–272. https://doi.org/10.1111/j.1600-0447.2011.01749.x.
Wong Sarver, N., Beidel, D. C., & Spitalnick, J. S. (2014). The feasibility and acceptability of virtual environments in the treatment of childhood social phobia. Journal of Clinical Child and Adolescent Psychology, 43, 63–73. https://doi.org/10.1080/15374416.2013.843461.
Xu, J., Ni, S., Ran, M., & Zhang, C. (2017). The relationship between parenting styles and adolescents' social anxiety in migrant families: a study in Guangdong, China. Frontiers in Psychology, 8, 626. https://doi.org/10.3389/fpsyg.2017.00626.
Zhang, Q. Y., & Li, S. Q. (2011). A path analysis of parenting style impacting on children’s peer relationships. Chinese Journal of Clinical Psychology, 19, 240–243.
Zheng, Y., Rijsdijk, F., Pingault, J. B., McMahon, R. J., & Unger, J. B. (2016). Developmental changes in genetic and environmental influences on Chinese adolescents anxiety and depression. Psychological Medicine, 46, 1829–1838. https://doi.org/10.1017/S0033291716000313.
Zhou, X., Xu, Q., Cándido, J. I., María, D. H., & Greca, A. M. L. (2008). Reliability and validity of the Chinese version of the social anxiety scale for adolescents. Child Psychiatry & Human Development, 39(2), 185–200. https://doi.org/10.1007/s10578-007-0079-0.
Acknowledgements
The authors want to thank all participants and parents for their support to the study, and thank Shruti Patel for her careful review of the readability of the manuscript for native English speakers. The authors also want to acknowledge the significant contributions of the reviewers to the improvement of the quality of the manuscript through their constructive comments.
Author contributions
N.M. and T.L. contributed equally to this work. N.M. and T.L. carried out most aspects of data collection and data analysis. R.D. was responsible for the operation and programming of the software. Q.Z. edited the paper in English. L.C. directed the entire research project and wrote the paper. C.L. thoroughly reviewed and revised the paper.
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This research was funded by Beijing Philosophy and Social Science Planning Program and Social Science Research Key Program of Beijing Municipal Commission of Education (SZ202210028012), the National Natural Science Project of China (31571143).
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Mao, N., Li, T., Li, C. et al. Smartphone‐Based Training of Cognitive Bias Modification: Efficacy for Reducing Social Anxiety in Chinese Adolescents. J Child Fam Stud 32, 2394–2405 (2023). https://doi.org/10.1007/s10826-023-02619-8
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DOI: https://doi.org/10.1007/s10826-023-02619-8