The present study examined the effectiveness of a transdiagnostic intervention programme, Super Skills for Life (SSL), in children with clinical anxiety. SSL, in addition to the principles of cognitive and behavioral therapy, also incorporates video feedback and cognitive preparation as essential components of the treatment. The program was implemented in a clinical population in an NHS community child mental health unit. The sample consisted of 23 Greek-speaking elementary school children diagnosed with at least one Anxiety Disorder (AD). Each session was held once a week for 1 hour. The program consisted of 8 sessions. Children were video-recorded during a 2-min speech task in sessions 1 and 8. All the children completed a large battery of self-reported questionnaires targeting emotional and behavioral difficulties before and after participating in the intervention. There was an immediate improvement in participants after the completion of the intervention. Regarding the behavioral indicators of anxiety during the 2-minute speech task, improvements were observed and recorded by both the children themselves and external observer assessments. Thus, behavioral improvement was detected regarding children’s social competence and self-concept from pre-treatment to post-treatment. The present study used an open clinical trial design, had a small sample size, and did not provide evidence regarding the long-term sustainability of the program’s beneficial effects after the intervention’s completion. This study provides preliminary exploratory results regarding the effect of video feedback on the improvement of social anxiety and self-perception of children with pathological anxiety. Additionally, it constitutes a useful therapeutic tool within the framework of applying SSL to this population.
Super Skills for Life (SSL) is a transdiagnostic clinical intervention protocol for children targeting mainly emotional but also other comorbid problems (e.g., low self-esteem, aggression, peer problems, psychomotor difficulties, lack of social skills). It was developed by Essau and Ollendick [
Video feedback technique involves using video recordings of a child’s social interactions to help them update their negative self-perceptions and improve social skills. By watching themselves in social situations, children can identify discrepancies between their self-image and how they actually appear to others, leading to a more realistic and positive self-perception [
Our study aimed to examine the clinical effectiveness of the transdiagnostic SSL program in a sample of children with pathological anxiety, with a specific focus on changes in social performance and self-perception following the delivery of the full intervention, which incorporates video feedback with cognitive preparation as integral components. We hypothesized that the particular intervention would reduce participants’ social and performance anxiety by correcting their self-concept and enhancing their social skills. This study is a preliminary part of a broader research project, where a large battery of questionnaires was administered to young participants who were administered SSL before, as well as after the completion of the intervention [
The intervention was delivered over a period of two years, between 3/2019-2/2021, and took place at the Mental Health Center of Athens General Hospital for Chest Diseases “Sotiria,” targeting children diagnosed with ADs. SSL was delivered by a special education teacher, who facilitated the sessions. The facilitator recruited the children after they were evaluated by a child psychiatrist using the Greek version of a reliable semi-structured interview [
The intervention included instruction in the following competencies: educating participants about emotions and feelings, reframing thoughts (cognitive reappraisal), problem-solving, increasing positive activities (behavior activation), using relaxation techniques, self-monitoring, and developing social competence. These competencies were delivered through a range of formats, including small-group and individual exercises, simulated scenarios (role-plays), activities, and games. To reinforce learning, assignments were issued at the end of each session, requiring the children to practice the skills they had been taught. Children who completed their assignments were awarded a colorful sticker at the close of every session [
In total, 23 children (mean age:10.2 ± 1.9 years; range: 6-12 years; 14 boys, 9 girls) participated in this open-label study. Participants were recruited from central Athens. All participants were Greek-born or/and Greek-speaking. The participating children were not receiving concurrent psychological treatment or had not initiated psychopharmacological treatment before the intervention. In this study, the children diagnosed with Intellectual Disability or Pervasive Developmental Disorder were excluded because the program is not designed to address the specific and complex needs associated with these conditions [
| Children were between 6 and 12 years of age (attending primary school). |
| Children had at least one diagnosis of an AD, confirmed by a child psychiatrist through a structured diagnostic interview. |
| Children and caregivers were able to understand, write, and read the Greek language. |
| Children agreed to attend all sessions and to complete the assigned questionnaires after the 8th session. |
| Children had a diagnosis of intellectual disability. |
| Children had a diagnosis of pervasive developmental disorder, the severity of which interferes with program implementation. |
| Children were concurrently undergoing psychological treatment. |
| Children had initiated psychopharmacological treatment prior to the intervention. |
All parents of participants were sent information that described the research project, along with an informed consent form to be completed and returned by their parents. Children’s participation was voluntary; they were informed that their responses to the questionnaires would be kept confidential, and they could withdraw from the research at any time. The SSL was delivered in the afternoon (after morning class). Children participated in the eight sessions of the SSL, with each session lasting for 60 min, once a week. The group size ranged from 6 to 8 children, with an average of 8 per group. All the children completed a large battery of self-reported questionnaires targeting emotional and behavioral difficulties before and after participating in the intervention.
In sessions 1 and 8, children were asked to give a 2-minute speech to the whole group and face a video camera. For the 2-minute speech tasks that were conducted at the first session, the children were asked to introduce themselves; for the 2-minute speech task at session 8 (i.e., post-intervention), children were asked to say something in front of the whole group about what they had learned from participating in SSL and the skills they found to be most helpful. Before showing the children their video during the 2- min speech tasks, they were once again instructed to pay attention to how they appeared during the speech, not to how they felt.
Therefore, before watching the videos, participants were asked to complete a questionnaire titled: “How I think I look like”, which contained questions as mentioned in
| My legs were shaking. | How strong and clear was your voice? |
| My hands were moving nervously. | How friendly did you see? |
| I was biting my nails. | Did you mix up your words? |
| My posture was relaxed. | Do you think you looked smart? |
| I was coughing out of embarrassment. | How much did you look at the camera? |
| I was laughing constantly. | How good was your speech? |
| I was pulling on my clothes. | Did you seem nervous? |
| I was losing my words or stuttering. | |
| I was biting my lips. | |
| I was focused on my speech. | |
Then, the facilitator invited them to watch their video, and subsequently to answer the items of the “the way I finally look like” questionnaire, which asked how, in their opinion, they ultimately looked on camera, as noted in
Therefore, the two questionnaires “How I think I look like in the video” and “The way I finally look like in the video”, were administered in the first (i.e., pre-intervention) and in the last or 8th session (i.e., post-intervention), before and after watching their two-minute videos. In total, the participants completed four questionnaires. The higher the score a child received, the more social anxiety he had and the lower his self-perception. It is important to note that these two questionnaires were not designed as standardized psychometric scales intended to measure a single latent psychological construct. Instead, they serve as task-specific behavioral tracking checklists embedded directly within the SSL video-feedback protocol. They aim to measure distinct, observable somatic and behavioral reactions to situational anxiety during a specific exposure task. Therefore, a 3-point scale was used before watching the video to keep tasks simple for children during high anxiety, while a 4-point scale was used after the video to capture more detailed self-observations. Since the two checklists were analyzed independently, the different scale formats did not affect the statistical analysis.
The same favorable results were obtained from the qualitative analysis of the measure Fydrich - Behavioral Assessment of Social Performance-modified. This concerns a behavioral assessment system designed to measure various key dimensions (gaze, quality of voice, discomfort, speech length, conversational flow) of social competence through video recordings [
In particular, the gaze of socially anxious children who score high on this assessment often differs from that of their peers and may display characteristic signs of hesitation or avoidance. Their gaze is often lowered or marked by brief, furtive glances. At times, it may appear frozen or vacant, while at other times they may dart about nervously or convey a sense of alertness and fear [
On the other hand, within the context of high social stress, the sympathetic nervous system affects breathing, laryngeal muscle tension, and airflow, causing the voice to reveal the child’s emotional state. Consequently, these children often speak softly, almost in a whisper, while at times their voice may sound flat, lacking natural intonation. Occasionally, the voice may crack or tremble slightly, especially at the beginning of speech or when the child addresses a group. In some cases, the child speaks with pauses, searching for the right words or attempting to avoid exposure [
Moreover, children with social anxiety often respond with single words or minimally elaborated comments (e.g., “
Regarding the discomfort exhibited by children with social anxiety, it stems from their fear of social evaluation, heightened self-monitoring, increased psychophysiological arousal, and lack of positive social experiences. At the same time, children with social anxiety often demonstrate limited conversational flow. Specifically, they show reduced initiative to start or engage in conversation, frequent pauses, limited reciprocity, and low spontaneity.
It is worth mentioning that two trained and independent observers rated the videos offline, indicating the frequency and the tension with which the children displayed these behavioural signs of anxiety. Both raters, who held a Master’s degree in Psychology, did not participate in the delivery of the SSL, and they were blind to the children’s scores on self-report questionnaires. The use of two independent observers enabled the senior researchers to assess how well their ratings agreed, thereby ensuring high inter-rater reliability. The mean score of the two raters was calculated for the analyses. The recording was divided into successive 30-second sample intervals in which the observers recorded whether each of the aforementioned behaviours was present.
Ethical approval to conduct this research was obtained from the Ethical Board of the Sotiria Chest Disease Hospital of Athens, Greece.
Concerning self-perception assessment, non-parametric tests were selected due to the non-normal distribution of the data, aiming to identify statistically significant changes before and after the SSL intervention. In particular, the Wilcoxon matched-pairs signed-rank test was used to evaluate differences between the baseline and final scores for each questionnaire. A
Following the analysis of participant responses, the data showed that before watching their video, while at the beginning of the intervention the participating children expressed personal inadequacy in performing this task through their answers, as well as a greater expectation that they would appear anxious, at the end of the intervention (session 8), and before watching their video, this social adequacy and expectation was expressed with a statistically significant improvement in their corresponding score.
Furthermore, after participants watched their video recordings, the ratings they gave of their personal adequacy in performing this task also differed statistically significantly between the first and last sessions of the intervention (
| Spoken tasks self-ratings | Session 1 (pre-intervention) mean ± SD | Session 8 (post-intervention) mean ± SD | |
| “How do I think I look like (before watching the video)?” ( |
15.7 ± 0.7 (score A) | 11.3 ± 0.4 (score B) | 0.0001 |
| “How do I finally look like (after watching the video)?” ( |
20.5 ± 0.83 (score C) | 11.8 ± 1 (score D) | <0.0000 |
Abbreviations: N = 23; mean = mean value; SD = Standard Deviation; score A: How I think I look like (Session 1); score B: How I think I look like (Session 8); score C: How I finally look like (Session 1); score D: How I finally look like (Session 8).
| Participants | Gen | Age | Diag 1 | Diag 2 | Diag 3 | score A (Session 1) | score B (Session 8) | score C (Session 1) | score D (Session 8) |
| 1 | F | 12 | Soc Phob | SAD | GAD | 15 | 12 | 18 | 15 |
| 2 | M | 11 | GAD | Soc Phob | SAD | 16 | 9 | 23 | 10 |
| 3 | F | 12 | PD | IAD | N/A | 13 | 10 | 16 | 13 |
| 4 | M | 12 | Soc Phob | Gen Dysph | N/A | 24 | 11 | 24 | 8 |
| 5 | M | 10 | SocPhob | De | N/A | 13 | 11 | 15 | 10 |
| 6 | F | 12 | GAD | De | N/A | 17 | 12 | 21 | 19 |
| 7 | M | 9 | GAD | N/A | N/A | 14 | 10 | 19 | 17 |
| 8 | F | 12 | GAD | N/A | N/A | 15 | 12 | 18 | 15 |
| 9 | M | 12 | Soc Ph | N/A | N/A | 14 | 10 | 29 | 15 |
| 10 | M | 08 | SAD | LD | N/A | 20 | 11 | 21 | 7 |
| 11 | F | 11 | GAD | SocPhob | De | 12 | 11 | 16 | 14 |
| 12 | F | 12 | GAD | N/A | N/A | 15 | 12 | 18 | 15 |
| 13 | M | 6 | SAD | N/A | N/A | 14 | 11 | 20 | 18 |
| 14 | M | 9 | GAD | ADHD | LD | 17 | 15 | 20 | 7 |
| 15 | F | 8 | AD OS/U | ADHD | LD | 14 | 11 | 19 | 7 |
| 16 | M | 10 | AD OS/U | De | LD | 14 | 14 | 22 | 21 |
| 17 | M | 6 | GAD | N/A | N/A | 15 | 11 | 19 | 13 |
| 18 | M | 12 | GAD | N/A | N/A | 16 | 10 | 24 | 10 |
| 19 | M | 9 | AD OS/U | N/A | N/A | 18 | 12 | 19 | 17 |
| 20 | F | 12 | GAD | N/A | N/A | 12 | 9 | 15 | 12 |
| 21 | M | 9 | GAD | N/A | N/A | 19 | 9 | 25 | 14 |
| 22 | M | 10 | AD OS/U | LD | N/A | 13 | 15 | 16 | 12 |
| 23 | F | 10 | AD OS/U | De | N/A | 14 | 10 | 20 | 7 |
Abbreviations: score A: How I think I look like (Session 1); score B: How I think I look like (Session 8); score C: How I finally look like (Session 1); score D: How I finally look like (Session 8); M: Male; F: Female; Diag: Diagnoses; Gen: Gender; SocPhob: Social Phobia; PD: Panic Disorder; GAD: Generalized Anxiety Disorder; IAD: Ilness Anxiety Disorder; SAD: Separation Anxiety Disorder; De: Depression; AD OS/U: Anxiety Disorder Other Specified/Unidentified; LD: Learning Disability; ADHD: Attention Deficit Hyperactivity Disorder; Gen Dysph: Gender Dysphoria; N/A: (Extra Diagnosis) Not Available.
According to Qualitative analysis of Fydrich, the two observers noted that, during their final video recording at session 8, in comparison with the evaluation of videos at session 1, the children had more consistent and stable eye contact with the facilitator and the camera; their speech had flow, meaning, and liveliness, their voice tone was steady without hesitation, and the duration of their speech was very satisfactory; they were now able to stand comfortably in front of the camera and speak for two full minutes without pauses, interruptions, or signs of discomfort.
The main objective of the present study was to investigate the effectiveness of the SSL intervention in a clinical sample of children with pathological anxiety, emphasizing the changes in social performance and self-perception following delivery of the full version, which incorporates video feedback with cognitive preparation as integral components. The intervention’s results demonstrated a potential overall immediate improvement in participants, in both behavioral indicators of anxiety,, social competence and self-perception. These trends were observed both through the children’s self-reports and evaluations by independent external observers.
These preliminary findings are consistent with previous research supporting the role of video feedback and cognitive preparation in addressing social anxiety and improving social performance [
The improvement in performance assessed on the pre- and post-video questionnaires in favor of the last session over the first suggests that the SSL intervention may have played a key role in fostering an increased sense of competence and more realistic expectations regarding participants’ performance. This is further supported by the independent observers’ evaluation, which recorded improvements in specific behavioral indicators, such as voice quality, speech flow, and a reduction in discomfort. These initial findings underscore that the improvement was probably not merely subjective but also reflected an objective change in the children’s behavior.
Despite these encouraging results, the present study has certain limitations. It used an open clinical trial design with a small sample size drawn from a single community unit, recruited without randomization (N = 23). The open-trial design without a parallel control group precludes firm conclusions regarding causality, as non-specific therapeutic factors, time-related maturation effects, or expectancy biases cannot be fully ruled out. Albeit, it is important to note that the children who participated in the study had strict entry criteria: they could not be receiving any concurrent psychosocial treatment. Moreover, trait-like factors like social competence and social self-perception do not remit spontaneously or evolve rapidly, so the improvement observed in the study may not solely attributable to the passage of time. These speculations reduce the likelihood that the observed improvement is attributable to confounding factors, such as the passage of time or external therapy. On the other hand, the small sample size limits the generalizability of the findings beyond this context and statistical power. Furthermore, the study did not provide evidence regarding the long-term sustainability of the program’s beneficial effects after its completion. This is also a major limitation of our study, since there was no funding for the researchers to cover the long-term maintenance of treatment benefits. At the same time, the sample was largely drawn from the central, low-income suburbs of Athens. It involved economic migrants, i.e. a population that is typically mobile and difficult to re-approach [
In conclusion, this open pilot study provides preliminary indications of the feasibility and potential benefits of video feedback and cognitive preparation for children with clinical anxiety. Given the absence of a control group and the small sample size, these findings should be interpreted with caution and require confirmation through larger randomized controlled studies.
The authors would like to pay tribute to the memory of the Dr. George Freris, Director, and express their gratitude to the staff of the Mental Health Center of Athens General Hospital for Chest Diseases “Sotiria” for their valuable cooperation in taking the participants’ initial histories and providing their workspaces to the research team.
Anna Tsourdini was the basic researcher of the project. Ioannis Syros wrote the manuscript. Xenia Anastassiou-Hadjicharalambous supervised the project, provided critical feedback, and helped shape the research, analysis, and manuscript. Blossom Fernandes contributed to the statistical analysis.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors state that there are no conflicts of interest regarding the publication of this paper.
We declare that while working on this manuscript, we employed the assistance of AI tools at various stages to help with fundamental grammar, language enhancement, and English translation of the text. We assert that all scientific content, data analysis, and conclusions were created independently by the author. The authors have meticulously examined and revised the text produced with AI assistance to guarantee its precision and take complete responsibility for the manuscript’s content.