Introduction

Learning to develop and maintain healthy interpersonal relationships is a critical developmental task for children and adolescents (here referred to as “youth”). Youth with anxiety and depression often have interpersonal difficulties, which may reflect limited understanding of social skills, problems with applying the skills in everyday life, or a combination of the two. These difficulties may arise in part because anxious and depressed youth often withdraw socially or react maladaptively, thus limiting their opportunities to learn and practice social skills and to establish healthy relationships. Anxious and depressed youth may increasingly face peer rejection and may experience vulnerability to bullying. Fortunately social skills can be learned and improved through practice.

Social skills training (SST) can be an important component of comprehensive cognitive behavioral therapy (CBT): it enriches interpersonal connections, which can matter so much to girls and boys with internalizing disorders and problems. SST typically addresses interpersonal engagement, building and maintaining friendships, communication and negotiation, assertiveness, and dealing with bullying (Sburlati, Schniering, Lyneham, and Rapee 2011). These components are included in evidence-based treatments (EBTs) for social phobia (Beidel, Turner, and Morris 1998), post-traumatic stress disorder (Cohen, Mannarino, and Deblinger 2006), transdiagnostic anxiety disorders (Rapee et al. 2006), and major depressive disorder (Clarke, Lewinsohn, and Hops 1990; Curry et al. 2003).

CBT methods of SST include psycho-education, therapist modeling, interactive discussions about hypothetical and real-life examples, behavioral rehearsal, imaginal and in vivo exposures, and homework assignments. These methods can be used in group, individual (caregiver or child), and joint caregiver–child sessions. Ideally, SST is tailored to each youth’s needs (e.g., specific knowledge deficits or performance issues), as informed by a social skills assessment (e.g., through interviews and observation). Throughout treatment, therapists should provide continual feedback and reinforcement to nurture young clients’ acquisition and use of the skills. In the next section we describe training in five key social skills, drawing from the aforementioned EBTs and our own clinical and research experience.

Key Features of Interpersonal Engagement Skills

Interpersonal engagement skills training improves youngsters’ ability to navigate social interactions using developmentally appropriate verbal and nonverbal behavior. This training can be useful for anxious and depressed youth in general, but it may be particularly valuable for youth with social phobia. Training focuses on using body language and voice quality, reading social cues, performing greetings and introductions, starting and maintaining conversations, listening and remembering what others have said, and joining and leaving group conversations (Beidel et al. 1998; Rapee et al. 2006). Methods for teaching these skills include didactic instruction, modeling, and behavioral rehearsal.

Therapists should begin by providing youth and their caregivers with a rationale as to the importance of interpersonal engagement skills (e.g., these skills help kids form friendships and have positive interactions with others); then they should describe which skills will be targeted. Therapists should also explain the need to practice social skills. In addition to noting that everyone can benefit from practice and that this is a good way to receive feedback about your strengths and areas for improvement, therapists may ask youth for examples of skills they have learned through practice (e.g., riding a bike, playing an instrument) – thus illustrating that learning interpersonal skills is like learning other skills youth have already mastered.

To help young clients better comprehend social cues and use body language and voice quality effectively, therapists should discuss nonverbal behavior that helps people communicate (e.g., facial expressions, eye contact, physical proximity). It can be beneficial to model inappropriate social behavior (e.g., frowning, looking and standing away from the conversational partner), and have youth identify nonverbal errors. Then therapists can model appropriate nonverbal behavior and request feedback, including asking which of the two people portrayed in the examples most kids would prefer to talk to, and why. Additionally, Weisz and colleagues recommend video-recording youth while they are presenting both a “negative” and a “positive” self. This video is then viewed with the youth to facilitate a discussion of differences in presentation style (Weisz, Thurber, Sweeney, Proffitt, and LeGagnoux 1997).

Assisting youth to perform greetings includes teaching them such simple skills as saying “hello” in a pleasant, audible voice and looking at the person when they speak. Another core skill is initiating and maintaining conversations; this involves knowing when to start a conversation (e.g., when first introduced to someone, when seeing a familiar person), how to start a conversation (e.g., smile, comment on something you have in common) with different types of people (e.g., strangers, familiar others), and how to choose an appropriate conversational topic. “Safe” conversational topics for youth include current events, school activities, and common interests (e.g., music and sports). Maintaining conversations involves asking open-ended questions (“What are you doing this summer?”), giving another person time to respond, and recognizing when and how to change topics (e.g., when there is a pause in conversation, use a transitional statement: “Another thing I wanted to talk about is…”). Because anxiety and depression can negatively impact concentration, training should also include practice in listening and remembering information (e.g., a person’s name and hobbies) during conversations. To train youth to join and leave group conversations, therapists should use role-plays of relevant real-world scenarios (e.g., joining adolescents at a lunch table, or walking away from children playing kickball).

Additional interpersonal engagement skills (e.g., giving and receiving compliments, talking on the telephone) can also be taught, depending on a youth’s particular areas of difficulty. During interpersonal engagement skills training, therapists should first model the skills and then have children engage in behavioral rehearsal, both in session and through therapeutic homework, while continually providing praise for effort and constructive feedback to help shape skill development.

Key Features of Friendship Skills

Friendship skills encompass ways to build and maintain healthy friendships (e.g., Beidel et al. 1998). Friendship skills are often taught to youth with social phobia or depression, and to others who have withdrawn from social interactions. Training in friendship skills involves discussing suitable places to meet friends, inviting children to social activities, reading social cues to gauge someone’s level of interest, maintaining consistent contact with friends, and communicating about how to treat others in friendships. Teaching friendship skills in a group format allows group members to work together, contribute their ideas, and role-play skills with others.

When discussing where to meet friends, therapists should encourage brainstorming of different places and activities and should create a list of options. If needed, therapists can make suggestions (e.g., school) and youth can elaborate (e.g., on the school playground, or in art class). Other possible options are community centers, places of worship, and extracurricular programs.

Skill in inviting others to join activities must be complemented by skill in (i) reading social cues and using realistic appraisal of whether the other person is interested; (ii) identifying simple joint activities (e.g., going to a movie); and (iii) using interpersonal engagement skills (e.g., smile, eye contact) to extend an invitation. It is useful to role-play how to extend an initial invitation (e.g., “Want to shoot hoops later?”) and to help children determine another person’s interest level through nonverbal (e.g., facial expression) and verbal cues. Given that depressed and socially anxious youth often misinterpret cues and assume others are not interested, therapists should listen for overly negative or unrealistic interpretations of others’ neutral behavior and, if needed, help youth make more realistic appraisals. Instruction will also be needed in how to proceed depending on the other person’s response (e.g., if the response is affirmative, schedule a time for the activity; if it is neutral, ask at a later time; if it is negative, leave that person alone and consider asking someone else). It is beneficial for youth to discuss and practice how they would accept and decline invitations from others in a prosocial manner.

For training in maintaining friendships, therapists should remind their clients that, after making a friend, they need to take steps to maintain the friendship. Therapists can then teach skills for sustaining friendships (e.g., staying in regular contact, helping friends when they need support, letting friends have other friends), while also eliciting ideas from youth about how to maintain relationships.

Following discussions of these friendship skills, behavioral rehearsal is needed. Therapists can model how to invite someone to join in an activity; then they can encourage youth to role-play scenarios generated by the therapist (e.g., “When inviting your chemistry lab partner to get ice-cream, you say…”) and by themselves. Discussing and role-playing problematic social situations with friends can help facilitate skill application. After behavioral rehearsal, therapists should offer praise and corrective feedback and should request constructive comments from the youth participating in each role-play (e.g., ask each child what went well during the role- play: “Good job smiling and asking me to the game” – and what could be improved: “It would be helpful if you looked me in the eyes”). Homework assignments (e.g., inviting someone to an activity this week) will help youth practice these skills.

Peer generalization activities, which involve arranging interactions between youth learning social skills and socially adept peers, also provide opportunities to practice friendship and interpersonal engagement skills (see Beidel et al. 1998 for a more detailed description).

Key Features of Communication and Negotiation Skills

Youth with anxiety and depression may have difficulty communicating, negotiating, and building lasting relationships. Communication includes sending information to others (e.g., by speaking) and receiving information from them (e.g., by listening). Youth can be taught specific strategies to improve communication skills and to become a clearer speaker and a more active listener (Clarke et al. 1990; Curry et al. 2003; Rapee et al. 2006). Failure to say what you mean with accuracy, or to hear what others say without judgment, leads to communication failure and conflict. When conflict arises, youth should be taught to listen carefully, in order to understand others’ points of view. Listening does not mean that you agree; it simply means that you hear what the person is saying. To illustrate the rules of communication, we will use the example of Hannah telling Kate that she interrupts her. While the speaker (Hannah) is talking, the listener (Kate) should not ignore, interrupt, or give advice. Instead, Kate should try to understand Hannah’s feelings and point of view while being patient and respectful. Once Hannah is finished, Kate should respond by restating what Hannah said and summarizing how Hannah feels (e.g., “It sounds like you feel disrespected when I interrupt you”). Then Kate can explain her perception of the situation by describing how she feels (e.g., “I was excited to tell my story”), how she reacted (e.g., “I didn’t realize I interrupted you. I thought you were done talking”), and what happened – without giving an opinion (e.g., “I started telling my story before you finished”). After both parties share their experiences, Kate may offer to change her behavior (e.g., “I’ll try not to interrupt you”) or Hannah may suggest how Kate’s behavior could change (e.g., “Please try not to interrupt me”). This is but one example; therapists should encourage their young clients to practice communication skills using their own local idioms. By communicating clearly, youth can more effectively inform others of their feelings about an activating event, which may lead to behavior change as well as to fewer future conflicts.

Negotiation and compromise are critical to any relationship, whether between family members, friends, or romantic partners. Therapists should teach youth that the key to compromising is listening when there is conflict, identifying its source, and using problem-solving to resolve it (Clarke et al. 1990; Curry et al. 2003). The reader can consult the problem-solving chapter (Chapter 17) for a description of the five basic steps. When interpersonal disputes are being negotiated, each person involved should participate in solving the problem. For example, if an adolescent wants a later curfew, both the adolescent and caregiver should volunteer possible solutions. Additionally, Clarke and colleagues (1990) recommend that each person mark solutions with a plus or minus sign, to identify which ones are unanimously agreeable. Next, each person should identify strengths and weaknesses in every solution and whether or not (s)he favors it; and each person should be positive and fair in his/her assessment. The two parties must then agree on a solution, which, for one or both, will mean compromising. For instance, the adolescent may want curfew extended by an hour and the caregiver may not wish to extend curfew at all, but they agree to an extended curfew of 30 minutes. Finally, once a solution is reached, the exact details should be written in a contract (Clarke et al. 1990) that states what each person is expected to do, what will happen if either person defaults, and what length of time the agreement is for. Neither party can change the contract until it expires, as it may take time for the agreement to work. A contract for an extended curfew may read:

Alisha’s curfew is 10:30 p.m. on weekends. If she arrives at 10:31 p.m. or later, she can’t go out the next weekend. If not home by 10:45 p.m., Mom will call her cell phone to see where she is. If Alisha keeps her curfew for one month, Mom will consider extending her curfew.

Negotiation and compromise are particularly relevant to adolescents seeking greater independence (e.g., when they want to borrow the family car), but may also be applicable to younger children (e.g., when they want to spend the night at a friend’s house).