RUNNING HEAD: UNFAMILIAR PEER PARADIGM A Paradigm for Understanding Adolescent Social Anxiety with Unfamiliar Peers: Conceptual Foundations and Directions for Future Research Christopher J. Cannon1 Bridget A. Makol1 Lauren M. Keeley1 Noor Qasmieh1 Hide Okuno1 Sarah J. Racz1 Andres De Los Reyes1 1University of Maryland at College Park Author Notes Christopher J. Cannon, Bridget A. Makol, Lauren M. Keeley, Noor Qasmieh, Hide Okuno, Sarah J. Racz, and Andres De Los Reyes, Comprehensive Assessment and Intervention Program, Department of Psychology, University of Maryland, College Park, MD. Correspondence regarding this article should be addressed to Andres De Los Reyes, Comprehensive Assessment and Intervention Program, Department of Psychology, University of Maryland at College Park, Biology/Psychology Building, Room 3123H, College Park, MD 20742; Office: 301-405-7049; Fax: 301-314-9566; E-mail: [email protected]; Twitter: @JCCAP_Editor CITATION Cannon, C.J., Makol, B.A., Keeley, L.M., Qasmieh, N., Okuno, H., Racz, S.J., & De Los Reyes, A. (2020). A paradigm for understanding adolescent social anxiety with unfamiliar peers: Conceptual foundations and directions for future research. Clinical Child and Family Psychology Review. doi: 10.1007/s10567-020-00314-4 Author Contributions C.J.C: assisted with data analyses and wrote the paper. B.A.M.: assisted in executing the study, assisted with data analyses, and collaborated in editing the paper. L.M.K., N.Q., and H.O.: assisted in executing the study and collaborated in editing the paper. S.J.R.: collaborated in editing the paper. A.D.L.R.: designed and executed the study, planned and executed data analyses, and wrote the paper. Funding The second, third, fourth, and seventh authors’ work on this paper was supported by the Institute of Education Sciences, U.S. Department of Education, through Grant R324A180032 to University of Maryland at College Park. The opinions expressed are those of the authors and do not represent views of the Institute or the U.S. Department of Education. Compliance with Ethical Standards Conflict of Interest: The authors declare that they have no conflict of interest. Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Maryland at College Park’s Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent: Informed consent was obtained from all individual participants included in the study. Abstract Adolescents who experience social anxiety concerns often display symptoms and impairments when interacting with unfamiliar peers. For adolescent clients, reducing symptoms and impairments within these interactions comprises a key treatment target within exposure-based therapies for social anxiety. Recent work on mechanisms of change in exposure-based therapies highlights the need for therapeutic exposures to simulate real world manifestations of anxiety- provoking social situations. Yet, researchers encounter difficulty with gathering ecologically valid data about social interactions with unfamiliar peers. The lack of these data inhibits building an evidence base for understanding, assessing, and treating adolescent clients whose concerns manifest within these social interactions. Consequently, we developed a paradigm for understanding adolescent social anxiety within social interactions with unfamiliar peers. In this paradigm, we train peer confederates to interact with adolescents as if they were a same-age peer, within a battery of social interaction tasks that mimic key characteristics of therapeutic exposures. Leveraging experimental psychopathology and multi-modal assessment approaches, this paradigm allows for understanding core components of social interactions with unfamiliar peers relevant to exposure-based therapy, including stimuli variability, habituation, expectancy violations, peers’ impressions about socially anxious adolescents, and maladaptive coping strategies that inhibit learning from exposures (e.g., safety behaviors). We detail the conceptual and empirical foundations of this paradigm, highlight important directions for future research, and report “proof of concept” data supporting these research directions. The Unfamiliar Peer Paradigm opens new doors for building a basic science that informs evidence-based services for social anxiety, within clinically-relevant contexts in adolescents’ social worlds. Keywords: adolescent; assessment; social interactions; social anxiety; unfamiliar peers RUNNING HEAD: UNFAMILIAR PEER PARADIGM 4 Social anxiety is characterized by fear and avoidance of social interactions, particularly among unfamiliar individuals (American Psychiatric Association [APA], 2013). Those who experience social anxiety also experience profound impairments in social functioning, including difficulties with social relationships, as well as work and school performance (Stein & Kean, 2000). When left untreated, social anxiety often portends the development of additional mental health concerns, including major depression and substance use and abuse (e.g., Grant et al., 2005; Kessler et al., 2005; Kessler et al., 2012; Dryman et al., 2016). Social anxiety is not only one of the most prevalent mental health concerns, it also most commonly emerges during or before the adolescent period (e.g., Kessler et al., 2005; Mash & Barkley, 2014). Thus, adolescence is a key period in which to innovate approaches for assessing and understanding social anxiety (Garcia-Lopez, Salvador, & De Los Reyes, 2015; Deros et al., 2018). When assessing social anxiety, a crucial element involves detecting symptoms as they manifest within the specific contexts where clients experience impaired functioning (Beidel, Rao, Scharfstein, Wong, & Alfano, 2010; Bögels et al., 2010). Indeed, not all clients experience social anxiety in the same way and within the same contexts. In line with this notion, adolescent clients vary considerably in the contexts in which their social anxiety concerns manifest (Alfano & Beidel, 2011; Raggi, Samson, Felton, Loffredo, & Berghorst, 2018). In particular, adolescent clients encounter elevated levels of distress within social situations with unfamiliar peers, such as unstructured situations with unclear expectations for social engagement (e.g., parties and other social events; Glenn et al., 2019; Hofmann et al., 1999). More broadly, perhaps the most robust finding in the developmental psychopathology literature involves the impact of same-age peers on adolescent development (e.g., Ingersoll, 1989; La Greca & Lopez, 1998; Prinstein, 2017; Prinstein & Giletta, 2016; Rudolph, 2014). In fact, adolescents’ exposures to aversive RUNNING HEAD: UNFAMILIAR PEER PARADIGM 5 experiences with same-age peers factor prominently in the development and maintenance of social anxiety and a host of other mental health concerns (e.g., attention-deficit/hyperactivity disorder, conduct problems, depression, suicide; Epkins & Heckler, 2011; Jarrett & Ollendick, 2008; Miller & Prinstein, 2019; Prinstein et al., 2018; Prinstein & Dodge, 2008). Thus, assessments designed to detect adolescent clients’ social anxiety concerns and facilitate planning treatment must quantify concerns within the contexts in which they may benefit from care. The need for context-sensitive assessment approaches dovetails with emerging work on mechanisms of change in exposure-based therapies for anxiety (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). Broadly, this work calls for increased attention to matters relevant to ensuring that exposures conducted within therapy validly reflect the contexts within which clients encounter distress (Mystkowski, Craske, & Echiverri, 2002). In this way, exposures conducted within therapy need to anticipate elements of clients’ social environments outside of therapy―and their reactions to these environments―that might inhibit treatment response and/or the maintenance of treatment gains. For instance, exposure-based therapies have long been thought to yield positive benefits for clients primarily by demonstrating to them―through repeated exposures designed to elicit distress related to anxiety-provoking stimuli (e.g., asking directions from strangers)―that they eventually habituate to the stimuli that provoke their anxiety (i.e., distress gradually decreases during exposures; Raggi et al., 2018). Recent work finds that, in addition to habituation, therapeutic exposures need to test clients’ expectancies about the stimuli that provoke their anxiety (Sewart & Craske, 2020). For example, if an adolescent client believes a same-age peer with whom they would like to be friends will ignore them every time they say “hello,” then exposures designed to reduce social anxiety in these situations should allow the client to test that belief. Needless to say, expectancies for social RUNNING HEAD: UNFAMILIAR PEER PARADIGM 6 contexts may vary considerably depending on the client and the contexts within which they encounter distress. Thus, effectively infusing exposures with opportunities for an adolescent client to experience habituation and learn from expectancy violations hinges on tailoring exposures to the goals of therapy and the client’s developmental level (Alfano & Beidel, 2011). A key aim of this paper is to describe a paradigm designed to improve our understanding of mechanisms of change in exposure-based therapies with adolescents. Specifically, the paradigm we describe focuses on social interactions with unfamiliar peers, a social context germane to treating adolescent social anxiety that has been historically under-represented in research on assessing and understanding the condition. To be clear, current evidence-based approaches to assessing adolescent social anxiety arguably highlight some of the contexts in which adolescent clients experience concerns (e.g., Bögels et al., 2010). For example, diagnostic definitions of social anxiety disorder account for social context to some degree, most notably a subtype of the diagnosis focused on symptoms and impairments that manifest specifically within performance-based contexts like speech-giving (APA, 2013). Consequently, a key component of best practices for evidence-based assessments of adolescent social anxiety involves gathering data from multiple assessment modalities to characterize adolescents’ concerns, plan treatment, and monitor treatment response (De Los Reyes, Thomas, Goodman, & Kundey, 2013; Silverman & Ollendick, 2005). Two assessment modalities often factor prominently in current evidence- based assessments of adolescent social anxiety. First, adolescent self-reports of social anxiety play an integral role in all elements of care, including characterizing or diagnosing adolescents’ concerns, planning treatment, monitoring treatment response, and identifying evidence-based techniques for treating the condition (De Los Reyes & Makol, 2019). Second, as mentioned previously, adolescents may vary considerably in the social contexts in which they display social RUNNING HEAD: UNFAMILIAR PEER PARADIGM 7 anxiety concerns. Further, the social contexts within which adolescents might display social anxiety concerns, by definition, include interactions with other people. Recent work indicates that the impressions that socially anxious individuals make on others may profoundly impact their ability to form adaptive social bonds and thus reduce impairments stemming from their concerns (for a review, see Piccirillo, Dryman, & Heimberg, 2016). Thus, assessments should incorporate data from a second set of informants beyond adolescent self-reports, namely observers or information sources with direct access to observing adolescents within the social contexts in which their concerns manifest. In particular, researchers as well as mental health providers often collect social anxiety reports from significant others in adolescents’ lives (Hunsley & Mash, 2007). For assessments of social anxiety and a host of other mental health domains (e.g., generalized anxiety, depression, conduct problems, attention and hyperactivity), parents serve as core informants in that they provide crucial information that informs clinical work with adolescents (De Los Reyes et al., 2015). This is not surprising given that parents are often key stakeholders who seek out care for adolescents’ concerns (e.g., Hunsley & Lee, 2014). Additionally, parents commonly report about adolescent social anxiety for the purpose of monitoring treatment response (Weisz, Jensen Doss, & Hawley, 2005), and provide incrementally valuable information about adolescent social anxiety, relative to other informants (e.g., adolescent self-reports and teacher reports; for a review, see Silverman & Ollendick, 2005). In sum, evidence-based assessment research supports the use of reports taken from both adolescents and parents to measure adolescent social anxiety. Yet, two key factors support the notion that these assessment modalities provide incomplete data for understanding adolescents’ concerns, and in particular those stemming from interactions with unfamiliar peers. First, adolescence is a developmental period typified by less time spent in the home context relative to RUNNING HEAD: UNFAMILIAR PEER PARADIGM 8 earlier developmental periods (Ingersoll, 1989). Relative to children from earlier developmental periods, parents tend to have reduced understanding or knowledge of their adolescent’s whereabouts, activities, and relationships with same-age peers (Smetana, 2008). As mentioned previously, adolescents’ social anxiety concerns often manifest within interactions with unfamiliar peers, and these concerns often drive adolescent clients’ needs for care (Hofmann et al., 1999). Further, parent reports of adolescent social anxiety and related domains (e.g., fears of negative and positive evaluation; safety-seeking behaviors) often fail to predict adolescents’ perceived experiences in interactions with unfamiliar peers (Deros et al., 2018; Karp et al., 2018; Qasmieh et al., 2018). Coupled with evidence cited previously about the importance of considering observers’ impressions of adolescent social anxiety (Piccirillo et al., 2016), the extant data indicate that parents cannot provide a complete account of how key observers in adolescent clients’ lives perceive their social anxiety concerns. Second, an emerging body of work highlights reasons why the main assessment modalities used in evidence-based assessments of adolescent social anxiety―parent reports and adolescent self-reports―cannot sufficiently characterize adolescents’ concerns in a way that maximally informs our understanding of mechanisms of change in exposure-based therapies. Specifically, when compared, parent and adolescent reports yield discrepant estimates of social anxiety (for a review, see Achenbach, 2017). For example, in a clinical assessment, the parent might report significantly higher levels of social anxiety symptoms relative to the adolescent’s self-reported symptoms (De Los Reyes et al., 2012). These informant discrepancies occur across assessment contexts (e.g., outpatient clinics, inpatient settings, schools), reasons for assessment (e.g., diagnosis and referral, treatment planning, treatment outcome), cultures, and measurement modalities (e.g., De Los Reyes et al., 2015, 2019a; Rescorla et al., 2017). Consequently, RUNNING HEAD: UNFAMILIAR PEER PARADIGM 9 informant discrepancies often have significant cascading effects on multiple stages of treatment. For instance, parents and children/adolescents often hold discrepant views on mental health domains to target in treatment (e.g., internalizing vs. externalizing concerns, depression vs. anxiety; Yeh & Weisz, 2001). These informant discrepancies create considerable uncertainties for decision-making surrounding treatment planning, including how to structure specific aspects of treatment (e.g., exposures that focus on speech-giving vs. parties; Hawley & Weisz, 2003; Hoffman & Chu, 2015). Further, informant discrepancies may serve as markers of poor treatment response (e.g., Becker-Haimes, Jensen-Doss, Birmaher, Kendall, & Ginsburg, 2018). With regard to social anxiety, if an adolescent client’s self-report disagrees with their parent’s report, an assessor might see this as reflecting a core feature of the adolescent’s social anxiety―essentially not wanting to “look bad” during the evaluation―and thus a sound rationale for downplaying the utility of the client’s self-report (see also Deros et al., 2018; DiBartolo et al., 1998). Not surprisingly then, when confronted with clinical assessments that yield discrepant reports from parents and children/adolescents, assessors often make judgments that most closely align with parent reports (e.g., Brown-Jacobsen, Wallace, & Whiteside, 2011; De Los Reyes, Alfano, & Beidel, 2011; Grills & Ollendick, 2003; Hawley & Weisz, 2003; Youngstrom, Findling, & Calabrese, 2004). Importantly, assessors make these differential judgments in favor of parent reports without a compelling evidentiary basis. That is, assessors lack any strong, definitive data to support the idea that parents provide “more valid” information about adolescent social anxiety, relative to adolescent self-reports. Assessment factors prominently in constructing therapeutic exposures, insofar as a key principle underlying exposures involves using the best available data to tailor exposures to address clients’ specific areas of concern (e.g., Alfano & Beidel, 2011; Raggi et al., 2018; Sewart & Craske, 2020). This principle holds not only for RUNNING HEAD: UNFAMILIAR PEER PARADIGM 10 constructing exposures for the purposes of service delivery, but also for research designed to address basic questions on how exposures facilitate therapeutic change. Thus, if adolescents’ concerns require exposures focused on interactions with unfamiliar peers, then relying only on the reports of parents and adolescents in evidence-based assessments for adolescent social anxiety likely results in suboptimal data for decision-making in both research and service delivery settings. An additional information source focused squarely on providing valid information about adolescents’ experiences with unfamiliar peers might greatly inform research on mechanisms of change in exposure-based therapies for adolescent social anxiety. Why do we lack assessment technologies for gathering these crucial data? Indeed, it may seem straight-forward to solicit reports from an adolescent clients’ peers. Yet, this approach poses challenges due to ethical concerns (i.e., seeking out parental consent to collect peer reports; Card & Hodges, 2008), and because the kinds of peers who might be available to provide reports (e.g., close friends) would be familiar, not unfamiliar, to the adolescent. By definition, these reports would yield inaccurate data about unfamiliar peers’ impressions of the adolescents being assessed. Additionally, the most psychometrically sound approaches for gathering reports about peer functioning―nominations from familiar peers and naturalistic observations (Prinstein, 2007)―either involve collecting reports from those who know the adolescent they are rating, or leverage approaches that lack feasibility for assessing individual adolescents (i.e., for the purposes of constructing tailored exposures). Even if it were possible for an assessor to solicit reports directly from same-age unfamiliar peers, such an approach might also lack feasibility, particularly within geographic locales with low population density (i.e., difficulty recruiting