INTRODUCTION:

The most distinctive feature of human life is its social character. All human beings have to interact with other human beings in order to survive. Aristotle, the great Greek philosopher, remarked that ‘Man is a social animal’. Both nature and necessity impel man to live in society. Man’s behavior in society is determined by two forces- physical and social which he has been trying to understand and control from time immemorial.

It is a social need for man to live in the company of his fellow human beings in order to develop his personality and individuality. Human nature is such that it cannot be developed without the help of other human beings.¹⁹ We a have strong need to be liked, valued, and approved of others. As a result, we have generated sophisticated social structures and hierarchies that greatly determine an individual’s value. Unpleasant emotional states and non- adaptive behaviors associated with social situations have historically been known as significant, life- affecting problems for many people. Given the social nature of human beings, and the functional nature of social relationships, discomfort associated with interacting with others is particularly difficult, as socialization cannot be easily avoided.⁸

Adolescent is a period of transition in which feelings and thoughts are primarily expressed through behaviour.¹⁵Adolescents respond intensely to people and events. They may be totally invested in one interest and then suddenly change to something different. These intense and unstable feelings can account for their extreme sensitivity to the response of others. They are easily hurt, disappointed and fearful of others.²¹ during this transition, it is common to experience a mixture of emotions, including anticipation, excitement, fear, anxiety, depression, stress and even feelings of loneliness and isolation.A major change from childhood to adolescence is the development of self-consciousness. Adolescents are aware of how others see them and react to them, and this awareness makes teenagers feel apprehensive and extremely self-conscious.¹⁵Adolescents are at a high risk for the development of problem behaviors that are distressing and socially disruptive. Anxiety disorders are the most common mental, emotional and behavior problems that occur during childhood and adolescence.¹⁸

Anxiety is a normal phenomenon, which is characterized by a state of apprehension or uneasiness arising out of anticipation of danger.

Normal anxiety becomes pathological when it causes significant subject distress and impairment of functioning of the individual.⁹Social anxiety is anxiety (emotional discomfort, fear, apprehension, or worry) about social situations, interactions with others, and being evaluated or scrutinized by other people. The difference between social anxiety and normal apprehension of social situations is that social anxiety involves an intense feeling of fear in social situations and especially situations that are unfamiliar or in which one will be watched or evaluated by others.²³Social evaluation and scrutiny by others are core features of social anxiety disorder. Individuals with social anxiety disorder perceive themselves as not meeting the expectations of others, and they believe others will evaluate them negatively as a result.¹¹

Alexander K. Kaeppler, Stephen A. Erath (2016), states that despite relatively universal feelings of discomfort in social situations, there is considerable evidence for diversity in the social behaviors and peer experiences of socially anxious youth. The study was conducted by linking social anxiety with social competence in early adolescence. Participants were a community sample of 123 fifth and sixth graders (Mage = 12.03). Social anxiety was measured globally and in the context of a lab-based peer evaluation situation, and social competence was assessed via teacher-reports. Physiological (i.e., skin conductance level reactivity, SCLR, and respiratory sinus arrhythmia reactivity, RSAR) and coping (i.e., disengaged) responses to social stressors were also assessed. Results indicated that SCLR and disengaged coping with peer victimization moderated associations linking global and context-specific social anxiety with social competence, such that social anxiety was associated with lower social competence at lower levels of SCLR and higher levels of disengaged coping with peer victimization. Thus, whether socially anxious preadolescents exhibit more or less competent social behavior may depend, in part, on how they respond to peer-evaluative stress. Inflexible physiological responses and disengaged coping responses may undermine social competence, whereas engaged responses may counteract socially anxious preadolescents’ tendency to withdraw from social interactions or focus primarily on threat cues.¹

Annette M. La Greca, et al (2016), conducted a study on preventing adolescent social anxiety and depression and reducing peer victimization: intervention development and open trial. Social anxiety disorder (SAD) and depression are common among adolescents, frequently comorbid, and resistant to change. Prevention programs for adolescent SAD are scant, and depression prevention programs do not fully address peer-risk factors. One critical peer-risk factor for SAD and depression is peer victimization. They describe the development and initial evaluation of a trans diagnostic school-based preventive intervention for adolescents with elevated symptoms of social anxiety and/or depression and elevated peer victimization. They modified Interpersonal Psychotherapy-Adolescent Skills Training for depression, incorporating strategies for dealing with social anxiety and peer victimization. Their open trial assessed the feasibility, acceptability, and preliminary benefit of the modified program (called UTalk) for adolescents at risk for SAD or depression and who also reported peer victimization. Adolescents (N = 14; 13–18 years; 79 % girls; 86 % Hispanic) were recruited and completed measures of peer victimization, social anxiety, and depression both pre- and post-intervention and provided ratings of treatment satisfaction. Satisfaction ratings were uniformly positive. Intention-to-treat analyses revealed significant declines in adolescent- and IE-rated social anxiety and depression and in reports of peer victimization. Additional secondary benefits were observed. Although further evaluation is needed, the UTalk intervention appears feasible to administer in schools, with high satisfaction and preliminary benefit.²

Shu Su, Gregory S. Pettit, Stephen A. Erath (2016), conducted a study on peer relations, parental social coaching, and young adolescent social anxiety. Links between peer relationship difficulties, parental social coaching, and social anxiety were examined among young adolescents (N = 80). Social anxiety was measured through both global- and context-specific reports. More socially anxious youths (1) experienced more peer rejection and (2) had parents who engaged in poorer quality coaching (i.e., lower prosocial advice, benign interpretation, and facilitation). Evidence of additive effects of peer problems and parenting was found, and the pattern of findings was similar after controlling for adolescent social skills. Results suggest that both negative peer experiences and parental coaching may need to be targeted to reduce social anxiety during early adolescence.³

Jose PE, Wilkins H, Spendelow JS (2012), Social anxiety in adolescence is manifested by anxiety about and avoidance of social interactions.⁴ Social anxiety in adolescents has frequently been linked to negative outcomes from social interactions.¹³ According to the “socio-meter theory”, social anxiety can arise well in advance of actual rejection if the “socio-meter” which is an early warning system detects potential relational devaluation.⁸Social anxiety is also related to impairments associated with the positive bio- behavioral system, including fewer positive life events, inhibited positive emotionality, and a poorer quality of life.⁸ Therefore, anxiety in different social situations cannot be overlooked as it can lead to serious complexities in future.⁴

Cakin Memik N, et al (2010), conducted a study to investigate the level of self-reported social anxiety in a community sample of Turkish adolescents and the relationship between social anxiety and some socio-demographic parameters. The study was a school-based cross-sectional study. Students in grades 6-8 (aged 10-16) from 12 schools in Kocaeli/Turkey were screened by the social anxiety scale for adolescents. A significant negative correlation was found between socioeconomic status and social anxiety level. Social anxiety scale for adolescents’ scores were higher in those with a low socioeconomic level.¹⁴

Peng ZW, Lam LT, Jin J, (2011), studied the factors associated with social interaction anxiety among Chinese adolescents. Information collected in the survey included demographics, self-perception on school performance, relationship with teachers and peers, satisfaction with self-image, achievements, and parenting style of the mother. The parent-child relationship, specifically the relationship between respondents and their mothers, is assessed. Lower family income, lower self-esteem, and hostility are significantly associated with social interaction anxiety among adolescents.⁵

Van Zalk N, Van Zalk MH, Kerr M. (2011), conducted a study on socialization of social anxiety in adolescent crowds. The study looked at whether social anxiety is socialized, or influenced by peers' social anxiety, more in some peer crowds than others. Adolescents in crowds with eye-catching appearances such as Goths and Punks (here termed Radical), were compared with three comparison groups. Using data from 796 adolescents (353 girls and 443 boys; M ( age ) = 13.36) at three time points, the results show that adolescents affiliating with the radical crowd tended to select peers from the same crowd group. Being a member of a crowd in itself did not predict socialization of social anxiety, but adolescents in the radical crowd were more influenced by their peers' social anxiety than adolescents who did not affiliate with the radical crowd group. The results suggest that through a bidirectional process, adolescents affiliating with radical crowds may narrow their peer relationship ties in time, and in turn socialize each other's social anxiety.⁶

Blumenthal H et al (2011), adolescence is a key period in terms of the development of anxiety psychopathology.⁷Childhood and adolescence may be particular developmental periods in which transient social anxieties appear. Different forms of “social anxieties” exist along a continuum. The range of social anxieties/fears along this continuum is from no anxiety/fear to “normal” levels to psychopathological extremes. At the extreme, high levels of social fears and anxiety are psychopathological, and can be classified as clinical syndromes such as SAD (social anxiety disorder). Socially anxious people may be somewhat addressed by a conceptualization that acknowledges both “normal” social anxieties that are mildly to moderately intense, or transient and also their potential connectedness to social anxiety disorder, depending on potentially contributing environmental and individual factors.⁸A psychopathological (chronic and disabling) form of social anxiety is called social phobia or social anxiety disorder, and is a chronic problem that can result in a reduced quality of life.²³Social anxiety and Social anxiety disorder do not differ qualitatively but rather quantitatively.⁸

Social anxiety first occurs in infancy and is said to be a normal and necessary emotion for effective social functioning and developmental growth. Cognitive advances and increased pressures in late childhood and early adolescence result in repeated social anxiety. Adolescents have identified their most common anxieties as focused on relationships with peers to whom they are attracted, peer rejection, public speaking, blushing, self-consciousness, and past behavior. Negative experiences in life, and the way one handles and reacts to them, can also lead to the development of social anxiety. If one is consistently put in situations that make him or her feel inferior or fear the judgment of other people, he or she can begin to develop negative beliefs about himself or herself and the world that can cause social anxiety. If negative experiences continue, one may also begin to develop confirmation bias and tend to pay attention only to the actions and events that will reinforce negative beliefs.Avoiding more and more situations for fear of others' judgments will strengthen negative beliefs and prevent one from going into situations where he or she might actually enjoy himself or herself. As this pattern starts to interfere with overall functioning, the warning signs of social anxiety can become more apparent.²³

Social anxiety is studied in various guises like public speaking anxiety, speech anxiety, communication apprehension, fear of interpersonal rejection, dating anxiety, stage fright, fear of strangers, shame, embarrassment, social inhibition, social timidity- all of these and more fall under the umbrella of social anxiety. Social anxieties are expressed variably as shyness, fears of blushing in public, of eating meals in restaurants, of meeting men or women, of going to dances or parties or of shaking when the center of attention. Attention biases, sporadic memory biases, and interpretation biases seem to be responsible for the development and maintenance of social anxiety. Socially anxious individuals show a “vigilance-avoidance” pattern of information processing of threat-relevant information, which may contribute to the maintenance of the problem.⁸

An adolescent is highly influenced by the people in and around his own family, such as teachers and peer groups. He is influenced by the environment in which he is living. If it is positive, it leads to creative ideas, and if negative it may lead to destructive alternatives.¹⁰

Tomas Furmark, et al (2009), studied the use of Internet-delivered self-help programmes with added therapist guidance in social anxiety disorder. The study results indicated that pure bibliotherapy and the internet-based treatment were better than waiting list on measures of social anxiety, general anxiety, depression and quality of life. The internet-based therapy had the highest effect sizes, but directly comparable effects were noted for bibliotherapy augmented with online group discussions.¹⁶

Blumenthal Heidemarie, et al (2009), commenced a study on interactive roles of pubertal timing and peer relations in predicting social anxiety symptoms among youth. The interaction between early maturation and problematic peer relations in relation to social anxiety symptoms was examined among 167 adolescents aged 10–17 years. Results indicated that early-maturing youth with problematic peer relations evidenced elevated social anxiety symptoms.¹⁷

A large part of the problem is that social anxiety is often not taken seriously, and that’s how a person with it typically shrinks into the background and is usually not heard. The vast majority of adolescents with social anxiety know there is something “wrong” with them, but they do not know what it is. Most adolescents progress through their fears and meet the developmental demands placed on them but for others it may develop into grave disturbances.

As adolescence is the imperative phase of life where minute problems can lead to destructive consequences, a thorough interrogation is required to an enormous extent. In nursing a lot of emphasis is mainly laid on assessment, it therefore becomes the responsibility of the nurse to identify problems related to feared social situations in case of adolescents.

Katja Beesdo, et al (2007), has conducted an epidemiological survey in which the findings demonstrated an increased risk for individuals with social anxiety disorder (SAD) to develop depression have been challenged by discrepant findings from prospective longitudinal examinations in childhood and early adolescence. Cumulative incidence for SAD was 11.0%; for depression, 27.0%. Standardized person-years of incidence for SAD were highest for those aged 10 to 19 years (0.72%) and were low before (0.20%) and after (0.19%) that age range. Depression incidence was different, characterized by delayed and continued high rates. Social anxiety disorder was consistently associated with subsequent depression, independent of age at onset for SAD (relative risk range, 1.49-1.85, controlling for age and sex). Crude Cox regressions showed significant distal (eg, parental anxiety or depression, behavioral inhibition) and proximal SAD characteristics (eg, severity measures, persistence) as predictors. Most associations were attenuated in multiple models, leaving behavioral inhibition (hazard ratio, 1.30 [95% confidence interval, 1.04-1.62; P = .02]) and, less consistently, panic (hazard ratio, 1.85 [95% confidence interval, 1.08-3.18; P = .03]) as the remaining significant predictors²⁰_.

Eric A Storch, Carrie Masia-Warner (2004), examined the relationship of overt and relational victimization to social anxiety, loneliness, and prosocial behaviours in a sample of female adolescents. The Social Experience Questionnaire, Social Anxiety Scale for Adolescents, and Asher Loneliness Scale were administered to 561 girls in the ninth, tenth, and eleventh grades of an urban parochial high school. Consistent with prior work, overt and relational victimization were positively associated with fear of negative evaluation, social avoidance of general and new situations, and loneliness. In addition, prosocial behaviors’ from peers moderated the effects of relational victimization on loneliness. Implications of these findings for the role of peer victimization and prosocial behaviors in female relationships are discussed.²²

If the social anxiety is not prevented then it can evolve into a social anxiety disorder. Social anxiety disorder is an early, adolescent-onset disorder related to a substantially and consistently increased risk for subsequent depression. The demonstration of proximal and particularly distal predictors for increased depression risks requires further exploration to identify their moderator or mediator role. Along with previous evidence that comorbid SAD is associated with a more malignant course and character of depression, these results call for targeted prevention with the aim of reducing the burden of SAD and its consequences²⁰.

When the level of anxiety, avoidance, and impairment in functioning reaches clinical proportions, a diagnosis of social anxiety disorder. Assessment measures for social anxiety have typically been divided into two broad groups: behavioral assessment methods, which include role-playing procedures and self-monitoring, and cognitive assessment procedures, including thought-listing and information-processing paradigms. Primary among these is the fact that whether any given measure is considered a behavioral or a cognitive assessment procedure is more a function of one's theoretical perspective than of the measure itself. This is followed by a review of the most commonly used self-report questionnaires for social anxiety.¹²

The assessment of social anxiety is important as the psychopathological states and lifetime consequences can be prevented at an early phase. The present study is undertaken in order to explore the issue further and analyze the current situation of adolescents in relation to their anxiety regarding various social situations and interactions. Interventions to curb the problem are also not designed, thus, the need of the study can be determined by effectively administering the self- instructional module to the adolescents affected with varying levels of social anxiety. Furthermore, this would also prevent the occurrence of a social anxiety disorder at large.

STATEMENT OF THE PROBLEM:

A study to assess the effectiveness of self-instructional module on reduction of social anxiety among adolescents

OBJECTIVES:

1. To assess the level of social anxiety among adolescents

2. To develop a self instructional module to reduce social anxiety

3. To assess the effectiveness of self instructional module on reduction of social anxiety

ASSUMPTION:

1. There is social anxiety among adolescents.

2. The adolescents may need assistance in reduction of social anxiety.

3. The self instructional module can prove to be an effective self help guide to adolescents.

HYPOTHESIS:

1. H₀- There is no significant difference in social anxiety among adolescents after administration of self instructional module

2. H₁- There is a significant difference in social anxiety among adolescents after administration of self instructional module

DELIMITATIONS:

1. The study was restricted to adolescents of age group (13-16 years).

2. It was limited to only two Marathi medium and two English medium higher secondary schools with state board affiliation.

3. The administration of self- instructional module is restricted to adolescents with significant level of social anxiety.

MATERIALS AND METHODS:

Research Approach:

The researcher intends to assess the level of social anxiety among adolescents and then implement ways to reduce the social anxiety. The study was conducted in two stages. In the stage 1, the research approach selected was exploratory wherein all participants were assessed with the help of a questionnaire and the level of social anxiety was denoted. Then a self instructional module was developed.

In the stage 2, the interventional group of adolescents having moderate level of social anxiety was provided with self instructional module. The participants were instructed to refer it as and when they anticipate socially stressful situation. After three months of intervention a post test was conducted.

Research design:

The research design selected for the present study was experimental one group pre test post test design. The researcher assessed the level of social anxiety and then developed a self- instructional module as per the common needs of the participants. The researcher then administered the self- instructional module to the adolescents with moderate social anxiety in order to assess its effectiveness.

Variables of the study:

Dependent variable:

Social anxiety in adolescents

Independent variable:

Self instructional module on reduction of social anxiety

Research setting:

The study was conducted in selected English and Marathi medium higher secondary schools of Pune city.

Population:

The population for the present study was adolescents between the age group of 13-16 years studying in selected higher secondary schools of Pune city.

Sample:

Stage 1: The sample consisted of 210 adolescents including both boys and girls of the selected higher secondary schools of Pune city.

Stage 2: Intervention group of 23 adolescents with moderate level of social anxiety were taken.

Sampling technique:

Stratified random sampling was used in the stage 1, to explore the social anxiety level of adolescents. In the stage 2, purposive sampling was used to assess the effectiveness of self instructional module on reduction of social anxiety.

Development of tool:

A questionnaire to collect the demographic data, checklists to obtain the relevant information regarding the home and school environment and a rating scale to assess the level of social anxiety was developed. The common needs of adolescents were found out by using the above mentioned assessment tools and a self instructional module was developed with the help of review of literature, personal experience and discussion with experts from various fields.

Description of the tool:

Tools are prepared in English and Marathi.

SECTION I: Questionnaire to assess demographic and socio-economic information:

A) Questionnaire to assess the demographic data

B) Questionnaire to assess the parental and economic profile

C) Checklist to assess the home environment

The checklist consists of 13 items related to the home environment with ‘Yes’ and ‘No’ as options. Every ‘Yes’ response is marked as ‘1’ and ‘No’ response is marked as ‘0’ respectively. The scoring was done as follows: 0-4 = Poor, 5-9 = Average, 10-13 = Good

D) Checklist to assess the school environment

The checklist consists of 10 items related to the school environment with ‘Yes’ and ‘No’ as options. Every ‘Yes’ response is marked as ‘1’ and ‘No’ response is marked as ‘0’ respectively. The scoring was done as follows:

0-3 = Poor, 4-7 = Average, 8-10 = Good

SECTION II: Rating scale to assess social anxiety (Social Anxiety Scale):

Under this section, 39 items related to social anxiety were included under three domains of the behavioral, cognitive and physical symptoms.

To assess the symptoms of social anxiety total 39 statements were included out of which 28 were on assessment of behavioral symptoms, 4 statements on the cognitive symptoms and 7 statements to assess the physical symptoms.

The statements were scored on the range of 0-4 as follows:

0 = Not at all, 1= A little bit, 2 = somewhat, 3 = Very much, 4 = extremely.

Further to assess the level of social anxiety the score is grouped into categories such as none, mild, moderate and severe.

The scoring key is as follows:

SCORE	0- 39	40-78	79-117	118-156
SEVERITY	NONE	MILD	MODERATE	SEVERE

Self Instructional Module:

The self instructional module was developed in both English and Marathi language. The module consisted of detailed information regarding social anxiety including its forms, signs and situations that cause social anxiety. Thereafter the self help strategies to overcome the social anxiety were emphasized in the module. This self instructional module was validated by experts from the various fields of Nursing, Psychiatry, Psychology and Education.

Data Collection Procedure:

In the stage 1, a formal permission was obtained from the respected authorities of the selected English and Marathi medium higher secondary schools. The study was commenced from 15/11/2011 to 30/11/2011. The subjects were selected on basis of the inclusion criteria by using stratified random sampling. Each sample was given a clear explanation regarding the purpose of the study and a written consent was taken. Maintenance of confidentiality was assured to the subjects. The tool was administered to the subjects and social anxiety levels were assessed. Taking into consideration the moderate levels of social anxiety in adolescents, in the stage 2, the self instructional module was developed. It took around three months to generate a useful module on reduction of social anxiety, which was constructed and validated by experts from various fields. Once again, a formal permission was obtained from the school authorities. From 05/03/2012- 10/03/2012 the stage 2 of the study was conducted. Purposive sampling was used and the module was administered to the adolescents as a self help tool. They were made to understand its content and utility. For another period of three months the participants were instructed to use the self instructional module when they anticipated any socially anxious situation. On completion of the given time, from 26/06/2012- 30/06/2012, the effectiveness of self instructional module on reduction of social anxiety was assessed.

Plan for Data Analysis:

The data analysis plan includes descriptive and inferential statistics. Considering the objectives of the study, the section I and section II: Demographic and socio-economic information and social anxiety scale was analyzed by using frequency and percentage presented in the form of tables and graphs. The effectiveness of the self instructional module was assessed with the help of the ‘t’ test.

RESULTS:

STAGE 1: Assessment of social anxiety

Section I: Distribution of sample in relation to demographic and socio-economic information

A) Out of 210 samples (50%) adolescents belong to the age group of 13-14 years, (50 %) were males, (34.29 %) were from 8^thstandard, and (62.86 %) adolescents were from English medium. However (67.14%) adolescents were from nuclear family, (57.14%) had one sibling and (44.76%) adolescents considered school as the most enjoyable place.

B) Out of 210 samples, (28.57%) adolescents’ father’s education was higher secondary, (35.71%) adolescents’ mother’s education was higher secondary and (39.05%) had family monthly income as Rs > 13500.

C) Out of 210 samples, (58.10%) adolescents had an average home environment, (40.95%) had good home environment and (0.95%) had poor home environment.

D) Out of 210 samples, (84.76%) adolescents had an average school environment, (12.86%) had good school environment and (2.38%) adolescents had a poor school environment.

Section II: Data analysis to assess the level of social anxiety

The findings revealed that 99 (47.14%) adolescents have mild social anxiety, 88 (41.90%) have no social anxiety, 23 (10.95%) have moderate social anxiety and none have severe social anxiety.n = 210

Fig 1 Bar diagram showing social anxiety score wise distribution of adolescents in study group.

STAGE 2: The 23 (10.95%) adolescents who experienced moderate level of social anxiety was administered the self instructional module. The effectiveness of self instructional module on reduction of social anxiety among adolescents was assessed.

Table Comparison showing the reduction of social anxiety levels in adolescents and the effectiveness of self instructional module n = 23

Groups

Mean

Table value

P value0.001

Pre test

91.5

9.98

2.12

28.18

3.46

Post test

67.09

9.53

0.866

The interventional group of 23 (10.95%) adolescents having moderate level of social anxiety has shown a marked reduction in the anxiety levels after using the self instructional module. The effectiveness was assessed by using ‘t’ test which was significant at (P < 0.001) Thus the self instructional module has been an effective measure to reduce the social anxiety among adolescents.

DISCUSSION:

In the present study as per the common needs of the participants a self instructional module was prepared and administered. The effectiveness of the module in reduction of social anxiety was assessed by using‘t’ test which was significant at (P < 0.001). Hence the self instructional module has proven handy and economic for use in adolescents. The module also was well appreciated by the participants and the school authorities as a pertinent tool for curbing social anxiety.

CONCLUSION:

As per the findings of the study, mild to moderate levels of social anxiety was present among the adolescents. The moderate level of social anxiety was reduced with the help of the self instructional module. The adolescents reported that the module has been detrimental in decreasing the anxiety levels and can be extensively used in any socially stressful situations. Thus the social anxiety can be effectively lowered to mild levels.

RECOMMENDATIONS:

1. A study can be done to assess the effectiveness of cognitive- behavior therapy on social anxiety among adolescents.

2. A study can be done to assess the effectiveness of drama based instruction on social anxiety among adolescents

3. A study to assess the effectiveness of structured teaching programme on social anxiety among adolescents

4. A study to assess the effectiveness of internet-delivered self-help programmes on social anxiety among adolescents.

5. A study to assess the effectiveness of bibliotherapy on social anxiety among adolescents.

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Received on 08.09.2016 Modified on 17.11.2016

Asian J. Nur. Edu. and Research.2017; 7(3): 348-356.

DOI: 10.5958/2349-2996.2017.00070.2