cognitive therapy, 2004.pdf

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R E S E A R C H U P D A T E R E V I E W

Cognitive-Behavioral Psychotherapy for Anxiety andDepressive Disorders in Children and Adolescents:

An Evidence-Based Medicine ReviewSCOTT N. COMPTON, PH.D., JOHN S. MARCH, M.D., M.P.H., DAVID BRENT, M.D.,

ANNE MARIE ALBANO, PH.D., V. ROBIN WEERSING, PH.D., AND JOHN CURRY, PH.D.

ABSTRACT

Objective: To review the literature on the cognitive-behavioral treatment of children and adolescents with anxiety and

depressive disorders within the conceptual framework of evidence-based medicine. Method: The psychiatric and

psychological literature was systematically searched for controlled trials applying cognitive-behavioral treatment to

pediatric anxiety and depressive disorders. Results: For both anxiety and depression, substantial evidence supports the

efficacy of problem-specific cognitive-behavioral interventions. Comparisons with wait-list, inactive control, and active

control conditions suggest medium to large effects for symptom reduction in primary outcome domains. Conclusions:From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and

depressive disorders in children and adolescents. Future research in this area will need to focus on comparing cognitive-

behavioral psychotherapy with other treatments, component analyses, and the application of exportable protocol-driven

treatments to divergent settings and patient populations. J. Am. Acad. Child Adolesc. Psychiatry, 2004;43(8):930959.

Key Words: outcome studies, children and adolescents with major depression and dysthymic disorder, children and

adolescents with anxiety disorder, literature review.

Due in part to a productive interplay between researchand clinical practice (Rutter, 1999), many clinical re-searchers now believe that cognitive-behavioral therapy

(CBT) administered within an evidence-based, multi-modal, multidisciplinary practice model is the psycho-therapeutic treatment of choice for youth withinternalizing disorders (Geddes et al., 1997; March and

Wells, 2003). In this context, the past 10 years wit-nessed the emergence of diverse, sophisticated, and em-pirically supported CBTs covering the range ofchildhood-onset anxiety and depressive disorders

(Bernstein and Shaw, 1997; Birmaher et al., 1996a,b).Using the tools of evidence-based medicine (EBM)(Sackett et al., 1997), this article provides a critical

review of CBT for these conditions. We do not addressobsessive-compulsive disorder and posttraumatic stressdisorder, for which recent critical reviews are available(Cohen et al., 2000; Franklin et al., 2002; March,1995), or bipolar disorder, for which cognitive-behavioral interventions are just now emerging (Mc-Clellan and Werry, 1997). The reader interested in ahow-to-do-it perspective may wish to pursue recentoverviews of CBT (Hibbs and Jensen, 1996; Reineckeet al., 2003) interventions for childhood-onset anxiety(Kendall et al., 1999, 2000, 2003; March and Mulle,1998; Rapee et al., 2000; Silverman and Kurtines,

1996) and depressive disorders (Brent et al., 1997;Clarke et al., 1990).

GUIDING THEORY

Although a comprehensive review of the theoreticalrationale of CBT is clearly beyond the scope of thisarticle (for a still cogent prcis, see Kendall, 1993; Ken-

Accepted November 17, 2003.

Drs. Compton, March, and Curry are with the Department of Psychiatry and

Behavioral Psychology, Duke University Medical Center, Durham, NC; Dr.

Brent is with Western Psychiatric Institute and Clinic, Pittsburgh, PA; Dr.

Albano is with New York University School of Medicine, NY; and Dr. Weersing

is with the Yale Child Study Center, New Haven, CT.

Correspondence to Dr. Compton, Duke University Medical Center, Box

3527, Durham, NC 27710; e-mail: [email protected].

0890-8567/04/430809302004 by the American Academy of Child

and Adolescent Psychiatry.

DOI: 10.1097/01.chi.0000127589.57468.bf

J. AM . A CA D. CH IL D AD OL ES C. PS YC HI AT R Y, 43 :8 , AU GU S T 20 04930


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dall and Panichelli-Mindel, 1995), a short overview isheuristically valuable. Historically, behavior therapy(the BT in CBT) evolved within the theoretical frame-

work of classical and operant conditioning, with cog-nitive interventions (the C in CBT) assuming a moreprominent role with the increasing recognition that

personenvironment interactions are mediated by cog-nitive processes (Van Hasselt and Hersen, 1993).Looked at in the context of situational and/or cognitiveprocesses, BT is sometimes referred to as nonmedia-tional (emphasizing the direct influence of situationson behavior) and CT as mediational (emphasizing thatthoughts and feelings underlie behavior). Hence, be-havioral psychotherapists work with patients to changebehaviors and thereby to reduce distressing thoughtsand feelings. Cognitive therapists work to first changethoughts and feelings, with improvements in func-tional behavior following in turn.

Although CBT is often referred to as a unitary treat-ment, it is actually a diverse collection of complex andsubtle interventions that must each be mastered andunderstood from the social learning perspective. Sub-sequently, a cognitive-behavioral case formulationguides the therapist in administering treatment tech-niques in a flexible manner for the patient presenting

with any one disorder or comorbid presentation ofmental disorders (for an overview of a modular ap-proach to CBT interventions, see Curry and Reinecke[2003]). Nonetheless, despite their seeming differences,cognitive-behavioral interventions typically share fivequalities: (1) adherence to the scientistclinicianmodel, whereby treatments are chosen based on dem-onstrated evidence or are applied within a case evalu-ation format to determine efficacy; (2) a thoroughidiographic assessment (e.g., functional analysis) of tar-get behaviors and the situational, cognitive, and behav-ioral factors that have established or are maintainingthe symptoms of interest (for a detailed overview ofhow to conduct a functional analysis, see Haynes andOBrien [1990]); (3) an emphasis on psychoeducation;(4) problem-specific treatment interventions designed

to ameliorate the symptoms of concern; and (5) relapseprevention and generalization training at the end oftreatment. For example, using cognitive restructuringand exposure-based interventions, CBT for anxiety dis-orders encourages cognitions and behaviors designed topromote habituation or extinction of inappropriatefears. Likewise, CBT for depression directly confronts

maladaptive depressogenic cognitions, including help-lessness, hopelessness, and hostility, and aims behavior-ally to reconstitute pleasant relationships, be theyintrapsychic, interpersonal, school, or spiritual. As evi-dence-based therapies, each is supported by a more orless robust research literature, and manuals are usually

available to guide practitioners in using CBT for spe-cific problems. Thus, CBT fits nicely into the currentmedical practice environment that appropriately valuesempirically supported, brief, problem-focused treat-ments.

From this vantage point, CBT represents a develop-mentally sound approach to pediatric mental illness.Children normally acquire social-emotional (self andinterpersonal) competencies across time. The failure todo so, relative to age, gender, and culture-matchedpeers, may reflect capacity limitations, individualdifferences in the rate of skill acquisition for specific

competencies, environmental factors, and/or the devel-opment of a mental illness. In CBT, the task of themental health practitioner is to understand the present-ing symptoms in the context of child-specific con-straints to normal development and to devise a tailoredtreatment program that eliminates those constraints sothat the youngster can resume a normal developmentaltrajectory insofar as is possible.

To the extent that symptom relief occurs, it can beassumed that improvement reflects concurrent changes(e.g., learning) in the CNS (Andreason, 1997; Hyman,2000). Thus, the cognitive-behavioral treatment of pe-diatric mental illness can be thought of as partiallyanalogous to the treatment of, for example, juvenile-onset diabetes, with the caveat that the target organ, thebrain in the case of major mental illness, requires in-terventions of much greater complexity. Althoughmedications are of importancein diabetes, insulin,and in the anxiety or affective disorders, a serotoninreuptake inhibitorthe critical point is that each alsoinvolves crucial psychosocial interventions that work inpart by biasing the somatic substrate of the disordertoward more normal functioning (Hyman, 2000). In

diabetes, the behavioral intervention of choice is dietand exercise, and in the anxiety or affective disorders, itis cognitive-behavioral psychotherapy.

METHOD

EBM has emerged as a promising paradigm for medical practice(for a comprehensive review, see Sackett et al. [2000]) and is clini-

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cally akin to the scientistpractitioner model in academic psychol-ogy (Barlow, 1993). EBM deemphasizes the more typical relianceon unsystematic clinical experience as a sufficient ground for clini-cal decision making. Instead, EBM stresses the examination of evi-dence from systematic diagnostic assessment technologies andclinical research as a tool to inform clinical practice, and it providesa heuristically valuable organizing focus for the individual clinicianseeking to transition efficacy and effectiveness studies into clinical

practice at the level of the individual patient (Geddes et al., 1997).Using established EBM criteria for assessing the validity of treat-

ment studies as guides to clinical practice (Guyatt et al., 1993,1994, 1999), a search for relevant literature was conducted viaMedline and PsycINFO, using the following text terms: anxiety,depression, cognitive therapy, and behavior therapy. Only random-ized, controlled trials (RCTs) for individuals with a specific disorderwere included. Additionally, to be included, articles must have metthe following criteria: published in an English-language, peer-reviewed journal between 1990 and 2002; included children be-tween the ages of 8 and 18; included an outcome measure of knownclinical significance; and used an analytic strategy consistent withthe study design. A follow-up assessment was preferred but notrequired. Excluded from consideration were articles concerning thetreatment of obsessive-compulsive disorder, posttraumatic stress

disorder, or bipolar disorder; included were articles concerning thetreatment of specific phobias, social phobia, selective mutism, over-anxious disorder, separation anxiety disorder, panic disorder, gen-eralized anxiety disorder, major depression, and dysthymia.

The text of this article is supported by a series of tables thatsummarize the main findings of each study identified during theliterature search. The tables are organized by type of disorder (anxi-ety versus depression); within each disorder, separate tables sum-marize findings at post-treatment and at long-term follow-up.

The information presented in each table includes study citation(studies are listed in alphabetical order by first author), researchdesign (type, control condition, analysis sample), sample informa-tion (total number, age range, percentage of males, and ethnicity),the diagnoses targeted by the intervention, brief details about theintervention, primary dependent measures (both categorical andscalar), sample size in each treatment condition, proportion ofsample responding, magnitude of the treatment effect (portrayed interms of number needed to treat [NNT] and standardized effectsize estimates), and general comments by the authors.

The NNT is a measure of the average response, presented as theprobability of response in single patient units. Arithmetically, theNNT is the inverse of the absolute risk reduction (1/ARR), definedas the percentage of response in the experimental group minus thepercentage of response in the control condition. In practice, NNTrepresents the number of patients who need to be treated with theactive treatment to produce one additional positive outcome be-yond that obtainable with the control or comparison condition. Forexample, an NNT of 10 describes the number of patients whom aclinician would need to treat with the active treatment rather thanthe control treatment to see one additional positive outcome. A verysmall NNT (that is, an NNT that approaches 1) suggests that a

favorable outcome occurs in nearly every patient who receives thetreatment and in relatively few patients in the comparison group.An NNT of 2 or 3 indicates that a treatment is quite effective.

Standardized effect size estimates were calculated with the assis-tance of ES (Shadish et al., 1999), a computer software programdesigned to calculate effect size estimates from published studies. EScalculates the standardized mean difference statistic, commonly re-ferred to as Cohens d and computed as d= (M

t M

c)/SD, where

Mt

is the mean of the treatment group, Mc

is the mean of thecomparison group, and SD is the pooled within-group standarddeviation. All effect size estimates are reported such that positivescores indicate that the treatment group improved more than thecomparison group.

TREATMENT OF ANXIETY DISORDERS

To their advantage, cognitive-behavioral therapistshave a robust literature validating the effectiveness ofspecific psychological techniques for anxiety disordersand a steadily growing literature supporting the use ofprescriptive treatment protocols for these disorders.

Types of Investigations

Twenty-one RCTs evaluating a variety of cognitive-behavioral interventions for the treatment of child andadolescent anxiety disorders were identified (Table 1).

As a group, these studies are noteworthy for their meth-

odological rigor and the systematic way in which theyhave advanced the understanding of childhood anxietydisorders and how best to treat this important popula-tion. With respect to methodological rigor, all studiesused contrasting group designs in which active treat-ments were compared with either a wait-list or no-treatment control condition (Cornwall et al., 1996;Hayward et al., 2000; Kendall, 1994; Kendall et al.,1997; King et al., 1998; Shortt et al., 2001; Silvermanet al., 1999a) or an attention placebo-controlled con-dition (Beidel et al., 2000; Last et al., 1998; Muris etal., 2002). Moreover, several studies compared more

than one active treatment condition (Barrett, 1998;Barrett et al., 1996; Beidel et al., 2000; Cobham et al.,1998; Flannery-Schroeder and Kendall, 2000; Mend-lowitz et al., 1999; Menzies and Clarke, 1993; Muris etal., 2001; Nauta et al., 2003; Silverman et al., 1999b;Spence et al., 2000).

Investigators in this area have also systematicallyevaluated a variety of clinically relevant questions: forinstance, whether group CBT is more effective thanindividual CBT (Flannery-Schroeder and Kendall,2000; Manassis et al., 2002; Muris et al., 2001), wheth-er adding parental participation enhances treatmentoutcomes (Barrett, 1998; Barrett et al., 1996; Cobhamet al., 1998; Mendlowitz et al., 1999; Nauta et al.,2003; Shortt et al., 2001; Spence et al., 2000), whetherconcurrent treatment of parental anxiety enhancestreatment outcomes (Cobham et al., 1998), and

whether two active treatment components, which are

C O M P TO N E T A L .



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TABLE

1

Ran

dom

ized

Clinic

alT

rials

ofC

BT

for

Child

and

Adole

scen

tA

nxiety

Diso

rders:

Eff

ects

atP

ost-trea

tmen

t

Aut

hor

(s)

Des

ign

Sample

Informat

ion

Target

Diagnos

is

Treatment

Informat

ion

Primary

Depen

dent

Measures

SampleSi

ze

(Initial/

C

ompleted

)

Proportion

Responding

Posttreatm

ent

EBMNN

T

EffectSize

Comments

Barrett,

1998

RCT

,al

ternative

treatmentand

WL

control,

blind

assessment,

completer

analys

is

N=607

14

years,53

%

male

Ethnicity

unspec

ified

OAD(n=30

)

SAD(n=26

)

SOP

(n=4)

12se

ssions,gr

oup

CBT-C

12se

ssions,gr

oup

family

CBT-C

P

WL

(12

wee

ks,

thenof

fered

treatment)

FSSC-R

CBCL

Noan

xietydx

23/19

17/15

20/16

11/19

11/15

4/16

4 2 FSSC-R

GCBT

=1.

58

GCBT+=

2.53

CBCL-I(mo

ther

)

GCBT

=3.

37

GCBT+=

3.98

Bot

htr

eatments

associatedw

ith

sign

ificant

improvements;

GCBT+

associatedw

ith

marginal

ly

betterou

tcomes

Barrett,

Dad

ds,&

Rapee,

1996

RCT

,W

Lco

ntrol,

blind

assessment,

completer

analys

is

N=79

9.3

years

57%male

Ethnicity

unspec

ified

OAD(n=30

)

SAP

(n=30

)

SOP

(n=19

)

12se

ssions,

indivi

dualC

BT

12se

ssions,

indivi

dual

CBT-C

P

WL

(12

wee

ks,

thenof

fered

treatment)

RCMAS

FSSC-R

CBCL

Noan

xietydx

28/28

25/25

26/23

16/28

21/25

6/23

3 2 RCMAS

CBT

=0.40

CBT+=0

.94

FSSC-R

CBT

=0.49

CBT+=0

.73

CBCL-I(mo

ther

)

CBT

=0.96

CBT+=1

.19

Bot

hac

tive

treatments

showedpo

sitive

benef

it,C

BT+

wassu

perioron

several

outcomes

Bei

del,

Turner,&

Morris,

2000

RCT;n

onspeci

fic

treatment

control,bli

nd

assessment,

completer

analys

is

N=67

10.5ye

ars;

40%male,

70%w

hite

SOP

(n=67

)

12in

divi

dualan

d

12gr

oup

sess

ions,C

BT

12in

divi

dualan

d

12gr

oup

sess

ions,

Nonspec

ific

treatment

control

SPAI-C

,

C-G

AS,

ADIS-C

CSR

,

Noan

xietydx

36/30

31/20

20/30

1/20

2 SPAI-C=0.

91

C-G

AS

=1.4

6

ADIS-C

CSR

=

2.04

Act

ivetr

eatment

wasas

sociated

with

sign

ificant

improvements

acrossm

ultiple

domains

cont

inue

d




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TABLE

1

cont

inue

d

Aut

hor

(s)

Des

ign

Sample

Informat

ion

Target

Diagnos

is

Treatment

Informat

ion

Primary

Depen

dent

Measures

SampleSi

ze

(Initial/

C

ompleted

)

Proportion

Responding

Posttreatm

ent

EBMNN

T

EffectSize

Comments

Cob

ham,

Dad

ds,&

Spence,

1998

RCT

,al

ternative

treatment

control,bli

nd

assessment,

ITT

analys

is

N=67

9.6

years

51%male

Ethnicity

unspec

ified

SAD(n=8)

OAD(n=3)

GAD(n=40

)

SIP

(n=12

)

SOP

(n=3)

AGP

(n=1)

10se

ssions,

child-focused

group

CBT

(parents

participated

)

10se

ssionspl

us4

parent

anxiety

management

sess

ions,gr

oup

CBT+P

AM

(parents

participated

);

outcomesw

ere

alsocr

osse

don

parental

anxiety

(nonanxious

parent

vs.

anxiouspa

rent)

RCMAS

STAIC

Noan

xietydx

(usingA

DIS-P

CSR)

35/35

32/32

(no

te:3

fam

iliesin

eac

hco

ndition

com

pletedle

ss

tha

n50

%of

the

sess

ions)

CBT

NAP

=

14/17

CBT

AP

=

7/18

CBT+P

AM

NAP

=12

/15

CBT+P

AM

AP

=13

/17

(Calcu

lations

madeusin

g

CBT

APas

control

condition)

CBT

NAP=

2

CBT+P

AM

NAP

=2

CBT+P

AM

AP

=3

ESs

wereno

t

calculated

on

self-report

measures

dueto

lowco

mpletion

rate

ofthe

assessment

instruments

(n=29

)

Children

with

anxious

parent(s)

respon

ded

less

favorablyto

child-focuse

d

CBT

at

post-treatment;

thead

ditionof

PAMimproved

outcomesfo

r

children

with

anxious

parent(s)bu

t

notfo

rch

ildren

with

nonanxious

parents

Cornwal

l,

Spence,&

Schotte,

1996

RCT

,W

Lco

ntrol,

blindness

unclear,

completer

analys

is

N=24

8.25

years

Gen

der

unspeci

fied

Ethnicity

unspeci

fied

SIP

(dar

kness

phob

ia,n=

24)

6se

ssions,em

otive

imagery

WL

(3m

onthsin

duration

)

FSSC-R

RCMAS

FT

DFBQ

12/12

12/?

Dataun

avai

lable

Datau

navailab

le

toca

lculate

NNT

FSSC-R=

0.53

RCMAS=

0.52

DFBQ=1.

59

Act

ivetr

eatment

associatedw

ith

sign

ificant

improvement

in

all

outcomes

Flannery-

Schroe

der

& Ken

dall,

2000

RCT

,W

Lco

ntrol,

blind

assessment,

ITT

and

comple

ter

analys

is

N=45

814

years

46%males

89%w

hite

GAD(n

=21

)

SAD(n=11

)

SOP

(n=5)

18se

ssions,

indivi

dualC

BT

18se

ssions,gr

oup

CBT

WL

(9w

eeks

,

thenof

fered

treatment)

RCMAS

CBCL-I

Noan

xietydx

(usingA

DIS-P

)

18/13

13/12

14/12

Noan

xiety

dx(I

TT)

8/18

6/13

0/14

2 2 RCMAS

ICBT

=0.7

9

GCBT

=1.

11

CBCL-I

ICBT

=1.5

2

GCBT

=0.

84

Bot

hin

divi

dual

and

group

CBT

wereas

sociated

with

lowerra

tes

ofan

xiety

disordersan

d

enhance

d

copingab

ilities;

outcomesfo

r

ICBT

and

GCBT

were

comparable

cont

inue

d




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TABLE

1

cont

inue

d

Aut

hor

(s)

Des

ign

Sample

Informat

ion

Target

Diagnos

is

Treatment

Informat

ion

Primary

Depen

dent

Measures

Sam

pleSi

ze

(Initial/

Com

pleted

)

Proportion

Responding

Posttreatment

EBMNNT

Effect

Size

Comments

Haywar

det

al.,20

00

RCT

,no-treatment

control,bl

ind

assessment,

completer

analys

is

N=35

15.8ye

ars10

0%

females

Ethnicity

unspec

ified

SOP

(n=35

)

16

sess

ions,gr

oup

CBT

N

o-treatment

control

ADIS

CSR

,

SPAI-C

Noan

xietydx

12/11

23/22

6/11

1/22

2 ADIS-C=1.23

ADIS-P=0.

67

SPAI-C=0.

29

Act

ivetr

eatment

wasas

sociated

with

sign

ificant

improvement;

55%ofsu

bjects

continue

dto

meet

diagnostic

criter

iafo

rdx

Ken

dall,

1994

RCT

,W

Lco

ntrol,

blindness

unclear,

completer

analys

is

N=47

913

years

60%males

76%w

hite

OAD(n=30

)

SAD(n=8)

AVD(n=9)

16

sess

ions,

indivi

dualC

BT

W

L(8w

eeks

,

thenof

fered

treatment)

RCMAS

FSSC-R

CBCL-I

Nopr

imary

anxietydx

(usingA

DIS-P

)

27/NR

20/NR

(Note:13

sub

jects

dro

pped,

not

reported

bygr

oup)

17/27

1/20

2 RCMAS

=0.87

FSSC-R=0.

38

CBCL-I=1.22

Indivi

dualC

BT

wasas

sociated

with

lowerra

tes

ofan

xiety

disordersan

d

enhance

d

copingab

ilities

Ken

dall,

Flanney-

Schroe

der,

Pan

ichelli-

Mindel,

Sout

ham-

Gerowet

al.,19

97

RCT

,W

Lco

nro

l,

blindness

unclear,

completer

analys

is

N=94

913

years

62%male

85%w

hite

OAD(n

=55

)

SAD(n=22

)

AVD(n=17

)

16

sess

ions,

indivi

dualC

BT

W

L(8w

eeks

,

thenof

fered

treatment)

RCMAS

STAIC

Noan

xietydx

byA

DIS-P

75/60

43/34

32/60

2/34

2 RCMAS

-0.

59

STAIC-T

A=0.7

2

STAIC-S

A=0.

40

Overall,

resu

lts

wereve

ry

similar

toea

rlier

studyof

indivi

dualC

BT

Kingetal.,

1998

RCT

,W

Lco

ntrol,

blindness

unclear,

completer

analys

is

N=34

11.0

3ye

ars

53%male

Ethnicity

unspec

ified

SR(n=34

)

6

sess

ions(o

ver

4

wee

ks;pl

us5

parent

sess

ions

and

1te

acher

meeting),

indivi

dualC

BT

W

L(4w

eeks

,

thenof

fered

treatment)

Schoolat

tendance

(%days

present)

FT

GAF

CBCL-I

17/17

17/17

No.w

ho

achieved90

%

school

attendance

15/17

5/17

2 FT

=1.

38

GAF

=1.

50

CBCL-I=0.59

Act

ivetr

eatment

wasas

sociated

with

sign

ificant

improvements

onal

lou

tcomes

except

teac

her

reports

cont

inue

d




7/30

TABLE

1

continued

Aut

hor

(s)

Des

ign

Sample

Informat

ion

Target

Diagnos

is

Treatment

Informat

ion

Primary

Depen

dent

Measures

Sam

pleSi

ze

(Initial/

Com

pleted

)

Proportion

Responding

Posttreatment

EBMNNT

Effect

Size

Comments

Last, H

ansen,

&Franco,

1998

RCT

,al

ternat

ive

treatment

control,

blindness

unclear,

completer

analys

is

N=56

12.0

4ye

ars,

40%male

89%w

hite

ASR

(n=56

)

12

sess

ions,

indivi

dualC

BT

12

sess

ions,

indivi

dualE

S

Schoolat

tendance

GIS

FSSC-R

STAIC-M

Noan

xietydx

32/20

24/21

No.w

ho

attained95

%

attendance

13/20

10/21

6 95%attendance=

0.39

Clinician

GIS=

0.20

FSSC-R=0.

49

STAIC-M=0.

31

Nodx=0.

39

Bot

htr

eatments

wereeq

ually

effect

ivein

returning

children

to

schoo

l

Manassiset

al.,20

02

RCT

,al

ternat

ive

treatment

control,

blindness

unclear,

completer

analys

is

N=78

9.98

years

54%male

85%w

hite

GAD(n=47

)

SAD(n=20

)

SIP

(n=5)

SOP

(n=5)

PAD(n=1)

12

sess

ions,

indivi

dualC

BT

12

sess

ions,gr

oup

CBT

(Note:

parents

participatedin

both

treatments)

MASC

CGAS

41/NR

37/NR

Categor

ical

outcomes

weren

ot

prov

ided

NA

Relat

iveto

indivi

dualC

BT

MASC=

0.31

CGAS

=

0.64

Bot

htr

eatments

wereas

sociated

with

improvements

onch

ildan

d

parent

ratings;

clinician

CGAS

ratingsfa

vored

indivi

dualC

BT;

indivi

dualC

BT

wasm

ore

effect

ivefo

r

children

reportingh

igh

ratesofso

cial

anxiety

Men

dlow

itz

etal.,

1999

RCT

,al

ternat

ive

treatment

control,

blindness

unclear,

completer

analys

is

N=68

9.8

years

43%male

Ethnicity

unspec

ified

Children

with

DSM-I

V

anxietydx

(using

DICA-R-P

)

12

sess

ions,gr

oup

CBT

(child

only)

12

sess

ions,gr

oup

CBT-P

12

sess

ions,gr

oup

CBT-C

P

W

L(2to6

months,th

en

offered

treatment)

RCMAS

CCSC

GIS

23/23

21/21

18/18

Categor

ical

outcomes

weren

ot

prov

ided

NA

RCMAS

CBT-C=0.1

8

CBT-P=0.1

8

CBT-C

P=0

.35

CCSC(Act

ive

Cop

ing)

CBT-C=0.2

6

CBT-P=

0.6

5

CBT-C

P=0

.57

CCSC(Avo

idant

Cop

ing)

CBT-C=0.3

3

CBT-P=0.3

9

CBT-C

P=0

.39

All

three

treatments

were

associatedw

ith

sign

ificant

improvements

insy

mptomsof

anxietyan

d

depression;

children

in

CBT

(child

+

parent)

condition

reportedu

sing

moread

aptive

copingsk

ills

thanth

eot

her

twotr

eatment

conditions

continued




8/30

TABLE

1

continued

Aut

hor

(s)

Des

ign

Sample

Informat

ion

Target

Diagnos

is

Treatment

Informat

ion

Primary

Depen

dent

Measures

SampleSi

ze

(Initial/

C

ompleted

)

Proportion

Responding

Posttreatm

ent

EBMNN

T

EffectSize

Comments

Menzies&

Clarke,

1993

RCT

,al

ternative

treatment

control,bli

nd

assessment,

completer

analys

is

N=48

5.5

years

65%male

Ethnicity

unspec

ified

SIP

(water

phob

ia,

n=48

)

3se

ssions,IV

VE

3se

ssions,V

E

3se

ssions,IV

E

No-treatment

control

BRS

PCWP

CWP

OR

13/12

13/12

12/12

Categor

ical

outcomes

weren

ot

prov

ided

NA

Unab

leto

calculated

ueto

insu

fficient

data

Bot

hIV

VE

and

IVE

were

equa

llyef

fect

ive

and

more

effect

iveth

an

WL

inre

ducing

waterph

obia;

IVE

resu

ltedin

greater

generalizat

ion

to

novelsi

tuat

ions;

VE

showedn

o

benef

itov

er

no-treatment

control

Mur

is,

Mayer,

Bartelds,

Tierney,

&Bog

ie,

2001

RCT

,al

ternative

treatment

control,

blindness

unclear,

com-

pleteran

aly

sis

N=36

9.9

years

25%male

97%w

hite

GAD(n

=14

)

SAD(n=14

)

SOP

(n=7)

OCD(n=1)

12se

ssions,

indivi

dualC

BT

12se

ssions,gr

oup

CBT

SCARED-R

STAIC

17/not

reported

19/not

reported

Categor

ical

outcomes

weren

ot

prov

ided

NA

Relat

iveto

indivi

dual

CBT

SCARED-R

(total

)=

0.32

STAIC(trait

anxiety)=

0.14

Bot

htr

eatments

wereas

sociated

with

equal

improvements

insy

mptomsof

anxiety

Mur

is,

Meesters,

&van

Mel

ick

2002

RCT

,psyc

hological

PBOan

d

no-treatment

control,

blindness

unclear,

completer

analys

is

N=30

10.2ye

ars

33%male

90%w

hite

SAD(n

=10

)

GAD(n=7)

SOP

(n=3)

Diagnosticst

atus

ofn

o-treat-

ment

controls

notas

sessed

12se

ssions,gr

oup

CBT

12se

ssions,gr

oup

ED

No-treatment

control

RCADS

STAIC

10/10

10/10

10/10

Categor

ical

outcomes

weren

ot

prov

ided

NA

Com

binedact

ive

treatment

relativeto

no-treatment

control

RCADS

(total

anxiety)

CBT

=1.48

ED=0.1

7

STAIC(trait

anxiety)

CBT

=0.83

ED=0.4

6

CBT

relative

to

ED

RCADS

(total

anxiety)=

0.98

STAID(trait

anxiety)=

1.05

CBT

wassu

perior

toE

Dan

d

no-treatment

control;E

D

showedno

benef

itov

er

no-treatment

control

continued




9/30

TABLE

1

continued

Aut

hor

(s)

Des

ign

Sample

Informat

ion

Target

Diagnos

is

Treatment

Informat

ion

Primary

Depen

dent

Measures

SampleSi

ze

(Initial/

C

ompleted

)

Proportion

Responding

Posttreatm

ent

EBMNN

T

EffectSize

Comments

Nauta,

Scholing,

Emmel

kamp,

& Minderaa,

2003

RCT

,W

Lco

ntrol,

blind

assessment,

ITT

analys

is

N=79

11.0ye

ars

49%male

Ethnicity

unspec

ified

SAD(n=26

)

SOP

(n=31

)

GAD(n=15

)

PAD(n

=7)

12se

ssions,

indivi

dualC

BT

12se

ssions,

indivi

dualC

BT

plus7se

ssions

CPT

WL

(durat

ion

not

spec

ified,

then

offered

treatment)

SCAS-c/p

FSSC-R

CBCL

Noan

xietydx

(ADIS-Can

d

P)

29/26

30/30

20/17

Com

binedvs.

WL

32/59

2/18

CBT

vs.C

BT+

20/37

23/39

Act

ivetr

eatm

ent

relativeto

WL

2 Unab

leto

calculated

ueto

insu

fficient

data

CBT

relative

to

CBT+20

SCAS-c=

0

.20

SCAS-p

=0

.33

FSSC-R=

0.12

Relat

ivetoW

L,

activetr

eatment

showedlo

wer

scoresonpa

rent

reportsan

d

morech

ildren

diagnosticfr

ee;

nodi

fference

between

WL

and

active

treatment

on

child

reports;

thead

ditionof

CPT

showedn

o

additional

benef

itac

rossal

l

outcomes

Shortt,

Barrett,&

Fox,20

01

RCT

,W

Lco

ntrol,

blind

assessment,

completer

analys

is

N=71

7.85

years

41%male

92%

Austral

ian

GAD(n=42

)

SAD(n=19

)

SOP

(n=10

)

10se

ssions(p

lus2

booster

sess

ions),gr

oup

CBT

WL

(10

wee

ks,

thenof

fered

treatment)

RCMAS

CBCL

Noan

xietydx

54/48

17/16

33/48

1/16

2 RCMAS

=0.9

9

Mot

her

CBC

L-I=

5.08

Fat

her

CBCL-I=

1.91

Act

ivetr

eatment

wasas

sociated

with

sign

ificant

improvements

acrossal

l

outcomes

Silvermanet

al.,19

99a

RCT

,W

Lco

ntrol,

blind

assessment,

completer

analys

is

N=56

9.66

years

61%males

45%w

hite

GAD(n=12

)

SOP

(n=15

)

OAD(n=29

)

12se

ssions,gr

oup

CBT

(concurrent

child

and

parent

groups

with

15

min

.co

njoint

meeting)

WL

(8to10

wee

ks,th

en

offered

treatment)

RCMAS

FSSC-R

CBCL-I

PGRS

Noan

xietydx

(ADIS-C

/P)

37/25

19/16

16/25

2/16

2 RCMAS

=0.5

8

FSSC-R=0.6

5

CBCL-I=1.2

5

PGRS

=1.7

8

GroupC

BT

was

associatedw

ith

sign

ificant

improvements

acrossal

l

primary

outcome

domainss

continued




10/30


11/30

often combined in traditional cognitive-behavioral pro-tocols (e.g., behavioral contingency management versuscognitive self-control), are differentially effective (Sil-verman et al., 1999b). Moreover, several of the studiescited were replications and extensions of existing pro-tocols by independent researchers (Barrett, 1998; Bar-

rett et al., 1996; Manassis et al., 2002; Mendlowitz etal., 1999; Muris et al., 2001, 2002).

Assessment Issues

Diagnosis and Symptom Profile. Valid and reliableassessment is essential to the skillful application andevaluation of cognitive-behavioral treatments (Thyer,1991) and is a strength of the cited studies taken as a

whole. All but 2 of the 21 studies cited in Table 1(Cornwall et al., 1996; Menzies and Clarke, 1993) usedsemistructured clinical interviews to identify subjects ashaving an anxiety disorder as well as documenting di-

agnostic comorbidities and assessing treatment out-comes. By a significant margin (13 of 21), the most

widely used semistructured clinical interview was theAnxiety Disorders Interview Schedule, Child and Par-ents Versions (ADIS-C/P) (Silverman, 1987; Silver-man and Albano, 1996a,b; Silverman and Nelles,1988). This interview is most commonly administeredseparately to children and parents, and then data arecombined from both sources to derive a final com-posite diagnosis; however, several studies deviatedfrom this standard practice and relied solely on infor-mation obtained from parents to determine diagnosticstatus (Shortt et al., 2001; Spence et al., 2000) andtreatment outcome (Cobham et al., 1998; Flannery-Schroeder and Kendall, 2000; Kendall, 1994; Kendallet al., 1997; Shortt et al., 2001; Spence et al., 2000). Inaddition to providing a diagnosis, the ADIS requiresthe clinician to provide a clinician severity rating(CSR). The CSR is the clinicians estimate of the de-gree of functional impairment and distress engenderedby the disorder (Albano and Silverman, 1996). Unfor-tunately, only two studies characterized the sample interms of the CSR (Hayward et al., 2000; Silverman et

al., 1999a). Because the CSR may predict the natureand outcome of treatment, the failure of researchers toadequately characterize the baseline characteristics oftheir sample along this dimension is a notable defi-ciency.

Demographics and Severity. Both genders are largelyrepresented in the treated population, with only one

study containing a sample that was limited to females(Hayward et al., 2000). Although the majority of stud-ies attempted to recruit children and adolescents, theaverage age of subjects across all studies was approxi-mately 9.85 years. This leaves open the question ofgeneralizability of the research findings, as well as pro-

tocol-driven interventions, to older adolescent popula-tions. Other demographic variables, such as ethnicityor socioeconomic status, were generally well docu-mented. However, with the exception of two trials (Sil-verman et al., 1999a,b), most studies had extremelylow rates of ethnic minority participation (see Pina etal. [2003] who examined the differential treatment re-sponse of Hispanic/Latino youth and European-

American youth). A noted strength of the citedinvestigations was the clinical severity of the researchsample. All studies focused on subjects who soughtclinical services and whose impairment was severe

enough to warrant a psychiatric diagnosis. No studyincluded children who were simply endorsing symp-toms of anxiety on a self-report measure.

Outcome Measures. To their credit, the majority ofcited investigations relied on a multimethod (e.g., clini-cal interview, self-report measures), multiinformant(e.g., child, parent, clinician) approach to documenttreatment outcomes. Both scalar and dichotomousmeasures that sampled specific symptom domains wereregularly reported. Another strength of many of thecited investigations was that outcomes were not re-stricted to the simple reporting of statistically signifi-cant symptom improvement or symptom change.More clinically informative outcomes were commonlyreported, such as clinically significant improvement(defined as changes that return deviant subjects to

within nondeviant limits [Kendall and Grove, 1988])and posttreatment diagnostic status (defined as the per-centage of children who no longer meet criteria for acurrent anxiety disorder). For instance, 14 of the 21investigations reported the posttreatment diagnosticstatus of subjects. However, the methods used to quan-tify diagnostic status varied moderately from study to

study, which made it difficult to compare outcomesacross trials. For instance, some studies combined in-formation obtained from separate child and parentclinical interviews to determine posttreatment diagnos-tic status (Barrett, 1998; Barrett et al., 1996; Beidel etal., 2000; Last et al., 1998; Nauta et al., 2003; Silver-man et al., 1999a,b), whereas others relied solely on




12/30

information obtained from the parent (Cobham et al.,1998; Flannery-Schroeder and Kendall, 2000; Kendall,1994; Kendall et al., 1997; Shortt et al., 2001; Spenceet al., 2000). Moreover, some studies defined a subjectas diagnosis free if criteria for his or her primary anxietydiagnosis were no longer met (Last et al., 1998),

whereas others used a more restrictive definition anddefined a subject as diagnosis free if criteria for both hisor her primary and secondary (if present) anxiety di-agnoses were no longer met (e.g., Barrett, 1998).

Moderators of Outcome. Ten of the 21 cited investi-gations reported results of secondary analyses that at-tempted to determine whether basic demographic andclinical variables moderated treatment outcome (e.g.,age, sex, ethnicity, clinical severity, pretreatment diag-nosis, comorbidities). The most frequent finding is thatnone of the variables analyzed moderate treatment out-come (for a notable exception, see Barrett et al.

[1996]). However, the strength of this conclusion mustbe tempered because few studies were sufficiently pow-ered to adequately address this important question.

Long-Term Follow-up. Although the follow-up pe-riod varied widely across the cited investigations (from3 months to 6 years, with a modal length of 12months), the general conclusion that can be reached isthat CBT for anxiety disorders in children and adoles-cents is a durable intervention (Table 2). With fewexceptions (Cobham et al., 1998), posttreatment gains

were largely maintained at follow-up and showed littledeterioration. Interestingly, several studies that foundsignificant differences between two active treatmentspost-treatment reported that, at follow-up, the twotreatments were equally effective. However, because allcited studies lacked an adequate control group duringthe follow-up period, competing explanations for thepositive results reported cannot be dismissed.

Treatments

The behavioral treatment of fear and anxiety in chil-dren builds on early studies indicating that anxiety isreadily conceptualized as a set of classically conditioned

responses that can be unlearned or counterconditionedthrough associative pairing with anxiety-incompatiblestimuli and responses. For example, in systematic de-sensitization (SD), anxiety-arousing stimuli are system-atically and gradually paired (imaginally or in vivo)

with competing stimuli such as food, praise, imagery,or cues generated from muscular relaxation. SD with

children consists of three basic steps: (1) training inprogressive muscle relaxation, (2) rank ordering of fear-ful situations from lowest to highest, and (3) hierarchi-cal presentation of fear stimuli via imagery while thechild is in a relaxed state (Eisen and Kearney, 1995).SD appears to work well with older children and ado-

lescents. Younger children, however, often have diffi-culty with both obtaining vivid imagery and acquiringthe incompatible muscular relaxation. Strategies suchas using developmentally appropriate imagery and ad-

junctive use of workbooks may boost the effectivenessof these procedures with younger children.

Without encouragement, anxious children and ado-lescents often find it difficult to remain in the presenceof anxiety-arousing stimuli for a sufficient length oftime to allow habituation to occur in the natural en-vironment. In fact, in some cases, the process of nega-tive reinforcement maintains the anxiety response.

That is, when an individual initially confronts an anxi-ety-provoking situation (e.g., the assignment of an oralreport for the socially anxious youth), there is an in-crease in discomforting sensations and anxiousthoughts (e.g., rapid heart rate, sweating, thoughts suchas Ill look stupid to others). By escaping or avoidingthe situation, such as through complaints of feeling illand needing to leave class or the behavior of schoolavoidance/refusal, the individual feels immediate relieffrom the anxiety. This is the process of negative rein-forcement. The escape behavior is reinforced by therelief and sets the stage for cycles of anxiety arousalfollowed by escape or avoidance and relief.

After the adult treatment literature, the identifica-tion of the negative reinforcement paradigm led to thedevelopment of exposure-based interventions for a

wide range of pediatric anxiety disorders. Because es-cape and avoidance behaviors are negatively reinforcedby the cessation of anxiety, exposure-based proceduresrequire extended presentation of fear stimuli with con-current prevention of escape and avoidance behaviorsin order for the extinction of the conditioned responsesto occur. Unlike systematic desensitization, stimulus

presentation is not accompanied by progressive musclerelaxation. Rather, graduated imaginal and/or in vivoexposure to hierarchically presented fear stimuli is usedto attenuate anxiety to phobic stimuli. Gradual expo-sure, with the consent of the child, is generally consid-ered to produce less stress for the client (and therapist)and thus is often preferred over the use of more pre-




13/30

TABLE

2

Ran

dom

ized

Clinic

alT

rialsof

CBT

for

Child

and

Adole

scen

tA

nxietyD

isor

ders:

Eff

ects

atF

ollo

w-u

p

Aut

hor

(s)

Fol

low-up

Citat

ion

Fol

low-up

Des

ign

Sample

Size

Prim

ary

Dependent

Measures

Treatment

Con

ditions

SampleS

ize

(Initial/F

U)

Proportion

Responding

FU

EBMNNT

Effect

Size

Comments

Barrett

et

al.,19

96

Inor

iginal

article

12-moF

U

(act

ive

treatments

only)

EN=79

FUN=53

RCMAS,

FSSC-R,

CBCL

,

independent

clinician

ratings;

noanx

iety

dx

12se

ssions,in

divi

dual

CBT

12se

ssions,in

divi

dual

child

and

parent

CBT

28/27

25/23

19/27

22/23

NA

NA

CBT+ha

dsi

gnificantly

morech

ildren

diagnosis

free,lo

werF

SSC-R

scores,an

dhi

gher

clinician

ratingsof

improvement;

no

sign

ificant

differenceon

CBCL;yo

unger

children

and

femalesre

spon

ded

bettertoC

BT+

Barrett

et

al.,19

96

Barrett

et

al.,20

016-yr

FU

EN=79

FUN=52

RCMAS,

FSSC-R,

noanx

iety

dx

12se

ssions,in

divi

dual

CBT

12se

ssions,in

divi

dual

child

and

parent

CBT

28/31,

18/21

(includes

only

subjects

who

me

tdx

statusa

t

pretreatment

bych

ild

interview

)

24/28

18/21

NA

NA

12-motr

eatment

gainsw

ere

largelym

aintainedat6-

yr

FU;co

ntrarytoau

thors

pred

ictions,C

BT+w

as

notm

oreef

fect

iveth

an

CBT

Barrett,

1998

Inor

iginal

article

12-moF

U

(act

ive

treatments

only)

EN=60

FUN=di

fficult

tode

termine

FSSC-R,C

BCL

,

independent

clinician

ratings,

noanx

iety

dx

12se

ssions,gr

oup

CBT

(child

only)

12se

ssions,gr

oup

family

CBT

(child

and

parent)

Difficu

ltto

determine

GCBT

=64.5

%,

GCBT+=

84.8

%

NA

NA

Bot

hac

tivetr

eatment

groups

continuedto

showim

provement;

no

sign

ificant

difference

between

2ac

tive

treatments

ondi

agnostic

status;G

CBT+gr

oup

reportedsi

gnificantly

lowerF

SSC-Rsc

oresan

d

CBCL

scores;G

CBT+

rece

ivedsi

gnificantly

higher

clinician

ratingsof

improvement

continued




14/30

TABLE

2

continued

Aut

hor

(s)

Fol

low-up

Citat

ion

Fol

low-up

Des

ign

Sample

Size

Prim

ary

Dependent

Measures

Treatment

Con

ditions

SampleS

ize

(Initial/F

U)

Proportion

Responding

FU

EBMNNT

Effect

Size

Comments

Barrett

et

al.,19

96

Inor

iginal

article

6-moF

U(act

ive

treatments

only)

EN=79

FUN=53

RCMAS,

FSSC-R,

CBCL

,

independent

clinician

ratings,

noanx

iety

dx

12se

ssions,in

divi

dual

CBT

12se

ssions,in

divi

dual

child

and

parent

CBT

28/28

25/25

20/28

21/25

NA

NA

Bot

hac

tivetr

eatment

groups

continuedto

showim

provement;

no

sign

ificant

difference

between

2ac

tive

treatments

ondi

agnostic

status,R

CMAS,

FSSC-R,

orC

BCL

scores;C

BT+

rece

ivedsi

gnificantly

higher

clinician

ratingsof

improvement

Bei

del

et

al.,20

00

Inor

iginal

article

6-moF

U

EN=67

FUN=22

(children

in

then

onspec

ific

treatment

condition

were

NA

for

FU

analys

is

SPAI-C,

CGAS,

ADIS-CCSR

,

noanx

iety

dx

12in

divi

dualan

d12

group

sess

ions,

CBT

12in

divi

dualan

d12

group

sess

ions,

nonspec

ific

treatment

control

36/22

19/22

NA

NA

Treatment

gainsw

ere

maintainedat6-

moF

U

Cob

hamet

al.,19

98

Inor

iginal

article

12-moF

U

EN=67

FUN=65

Noan

xiety

dx

10se

ssions,

child-focusedgr

oup

CBT

(parents

participated

)

10se

ssions+4pa

rent

anxiety

management

sess

ions,gr

oup

CBT=P

AM(parents

participated

);

groups

wereal

so

crosse

donpa

rental

anxietyN

AP

vs.A

P

33/35

32/32

CBT

NAP

=

12/16

CBT

AP

=

10/17

CBT+P

AM

NAP

=12

/15

CBT+P

AM

AP

=12

/17

NA

NA

Overall,

treatment

effects

wea

kenedby12

-moF

U;

nosi

gnificant

main

effect

for

anxietyco

ndition

(anxiouspa

rent

vs.

nonanxiouspa

rent);n

o

sign

ificant

main

effectfo

r

treatment

condition

(CBT

vs.C

BT+P

AM);

nosi

gnificant

interact

ions

between

parent

anxious

statusan

dtr

eatment

condition

continued




15/30

TABLE

2

continued

Cob

hamet

al.,19

98

Inor

iginal

article

6-moF

U

EN=67

FUN=66

Noanx

iety

dx

10se

ssions,

child-focusedgr

oup

CBT

(parents

participated

)

10se

ssions

+4pa

rent

anxiety

management

sess

ions,gr

oup

CBT+P

AM(parents

participated

);

groups

wereal

so

crosse

donpa

rental

anxietyN

AP

vs.A

P

34/35

32/32

CBT N

AP

=14

/16

CBT

AP

=8/

18

CBT+P

AM

NAP

=12

/15

CBT+P

AM

AP

=12

/17

NA

NA

Children

with

anxious

parent(s)co

ntinue

dto

respon

dle

ssfa

vorably

toch

ild-focusedC

BT;

overal

l,ch

ildren

with

nonanxiouspa

rents

respon

ded

more

favorablytotr

eatment

regardlessoftr

eatment

condition

Cornwal

l

etal.,

1996

Inor

iginal

article

3-moF

U

EN=24

FUN=24

FSSC-R

,R

CMAS,

FT,D

FBQ

6se

ssions,em

otive

imagery

WL

(3m

oin

duration

)

12/12

12/12

NR

NA

FSSC-R=0.

90

RCMAS

=0.

79

DFBQ=1.

82

Treatment

gainsinth

e

activetr

eatment

condition

were

maintainedat3-

moF

U

Flannery-

Schroe

der

& Ken

dall,

2000

Inor

iginal

article

3-moF

U

EN=45

FUN=29

(includes

subjects

treated

after

WL)

RCMAS

,C

BCL-I,

noan

xietydx

18se

ssions,in

divi

dual

CBT

18se

ssions,gr

oup

CBT

WL

(9w

k,

thenof

fered

treatment)

18/14

18/15

Primarydx

:

11/14

8/15

Any

Anxdx

:

7/14

8/15

NA

NA

Treatment

gainsw

ere

maintainedat3-

mo

FU;n

osi

gnificant

differencesbe

tween

the

twoac

tivetr

eatments

onse

lf-report

and

parent

report

measures

Haywar

d

etal.,

2000

Inor

iginal

article

12-moF

U

EN=35

FUN=28

ADISC

SR,SP

AI

Noanxietydx

16se

ssions,gr

oup

CBT

Notr

eatment

control

12/10

23/18

4/10

10/18

6 SP

AI

=0.

07

Nosi

gnificant

between-group

differenceinra

tesof

socialph

obia

orSP

AI

mean

scoresat12

-mo

FU;ad

ditionalan

alyses

combiningso

cial

phob

iaan

dde

pression

diagnosespr

oduced

morero

bustbe

tween

group

treatment

changes

Ken

dall,

1994

Inor

iginal

article

12-moF

U

EN=47

FUN=38

(includesSs

treated

after

WL

period

)

RCMAS

FSSC

-R

CBCL-I

Noprimary

anxiety

dx

(ADIS-P)

16se

ssions,in

divi

dual

CBT

WL

(8w

k,th

en

offered

treatment)

47/38

Percent

dx-free

notre

ported

NA

NA

Treatment

gainsw

ere

maintainedat12

-mo

FUonse

lf-report

and

parent

report

measures

continued




16/30

TABLE

2

continued

Aut

hor

(s)

Fol

low-up

Citat

ion

Fol

low-up

Des

ign

Sample

Size

Primary

Dep

endent

Me

asures

Treatment

Con

ditions

Sample

Size

(Initial/

FU)

Proportion

Responding

FU

EBMNNT

Effect

Size

Comments

Ken

dall,

1994

Ken

dall

&

Sout

ham-

Gerow,

1996

25

yrF

U

EN=47

FUN=36

(includesSs

treated

after

WL

period

)

RCMAS

FSSC-R

CBCL-I

Noprim

ary

anxiety

dx

(ADIS-C)

Indivi

dualC

BT

47/36

Percent

dx-free

notre

ported

NA

NA

Treatment

gainsw

ere

largelym

aintainedat

long-termFUon

self-report

and

parent

report

measures

Ken

dall

et

al.,19

97

Inor

iginal

article

12-moF

U

EN=94

FUN=85

(includesSs

treated

after

WL

period

)

RCMAS

STAIC

Noanx

iety

dxby

ADIS

-P

16se

ssions,in

divi

dual

CBT

WL

(8w

k,th

en

offered

treatment)

85/94

Percent

dxfr

ee

notre

ported

NA

NA

Posttreatment

reduct

ions

werem

aintainedat

12-moF

Uw

ith

the

exception

thatC

BCL-I

(mot

her)

ratingsw

ere

sign

ificantlylo

wer

Kingetal.,

1998

Inor

iginal

article

3-moF

U

EN=34

FUN=17

(WL

not

assessed

)

Schoolat

tendance

(1%days

present)

FT

GAF

CBCL-I

6se

ssions(o

ver

4w

k;

plus5pa

rent

sess

ionsan

d1

teac

her

meeting),

indivi

dualC

BT

WL

(4w

k,th

en

offered

treatment)

17/17

No.w

ho

achieved90

%

schoo

l

attendance

14/17

NA

NA

Treatment

gainsac

rossal

l

primaryou

tcomesw

ere

maintainedat3-

moF

U

Last

etal.,

1998

Inor

iginal

article

2w

kin

toth

e

subsequent

schoolye

ar

EN=56

FUN=41

%repor

ting:

(1)

nod

ifficu

lty

returningto

schoolinne

w

year

(2)

mild

difficulty

(3)

mod

erate

difficu

lty

(4)

extreme

difficu

lty

12se

ssions,in

divi

dual

CBT

12se

ssions,in

divi

dual

educat

ionalsu

pport

32/20

24/21

CBT

vs.E

S

(1)

40%vs.

52%

(2)

30%vs.

19%

(3)

10%vs.5%

(4)

20%vs.

24%

NA

NA

Rough

ly30

%of

treatment

completersin

both

groups

reported

moderatetose

vere

difficulty

returningto

schoolth

efo

llow

ing

schoolye

ar

Last

etal.,

1998

Inor

iginal

article

4-w

kF

U

EN=56

FUN=29

%repor

ting:

(1)

main

tained

improvement

(2)

show

edfu

rther

improvement

(3)

relap

sed

(4)

neve

r

improve

d

12se

ssions,in

divi

dual

CBT

12se

ssions,in

divi

dual

educat

ionalsu

pport

32/14

24/15

CBT

vs.E

S

(1)

65%vs.

40%

(2)

14%vs.

13%

(3)

7%vs.7%

(4)

14%vs.

40%

4 NA

Them

ajor

ityofSs

continuedtosh

ow

improvement,

with

no

sign

ificant

between

group

differencesat

4-w

kF

U

Menzies&

Clarke,

1993

Inor

iginal

article

12-w

kF

U

EN=51

FUN=36

(WL

not

assessed

)

BRS

PCWP

CWP

OR

3se

ssions,IV

VE

3se

ssions,V

E

3se

ssions,IV

E

Notr

eatment

control

13/12

13/12

13/12

NA

NA

NA

Nonsign

ificant

deteriorat

ion

in

treatment

gainsn

oted,

IVVE

group

performed

betterth

anIV

Egr

oup

atF

U

continued




17/30

TABLE

2

continued

Aut

hor(s)

Fol

low-up

Citat

ion

Fol

low-up

Des

ign

Sample

Size

Primary

Depen

dent

Measures

Treatment

Con

ditions

Sample

Size

(Initial/FU)

Proportion

Responding

FU

EBMNNT

Effect

Size

Comments

Nauta

et

al.,20

03

Inor

iginal

article

3

-moF

U

EN=79

FUN=73

SCAS-c/p

FSSC-R

CBCL

Noan

xietydx

12se

ssions,in

divi

dual

CBT

12se

ssions,in

divi

dual

CBT

plus7

sess

ionsC

PT

WL

(durat

ion

not

spec

ified,

then

offered

treatment)

37/34

39/39

23/34

27/39

0 Relat

ivetoC

BT

SCAS-c=

0.31

SCAS-p

=

0.24

FSSC-R=

0.24

Bot

hac

tivetr

eatment

groups

continue

dto

showim

provement

acrossal

lpr

imary

outcomesdu

ringF

U

period;th

ead

ditionof

CPT

conferredno

additionalbe

nef

it

acrossal

lou

tcomes

Shortt

et

al.,20

01

Inor

iginal

article

1

2-moF

U

EN=71

FUN=63

(includesSs

treated

after

WL

period

)

RCMAS

CBCL

Noan

xietydx

10se

ssions(p

lus2

booster

sess

ions),

group

CBT

WL

(10

wk,

then

offered

treatment)

47/63

32/47

NA

NA

Clinician

ratingsw

ere

maintainedatF

U,

RCMAS

scoresw

ere

sign

ificantlylo

werth

an

atpo

st-treatment

Silverman

etal.,

1999a

Inor

iginal

article

3

-,6-,12

-mo

FU(resu

lts

fromeachF

U

assessment

period

presented

and

analyzed

together

)

EN=56

FUN=31

(includes

pooledG

CBT

and

WL

data)

RCMAS

FSSC-R

CBCL-I

PGRS

Noan

xietydx

12se

ssions,gr

oup

CBT

(concurrent

child

and

parent

groups

with

15

min

.co

njoint

meeting)

WL

(8to10w

k,th

en

offered

treatment)

3-moFU

=

41/31

6-moFU

=

41/33

12-moFU

=

41/25

3-moF

U=

24/31

6-moF

U=

26/33

12-moF

U=

19/25

NA

NA

Overall

pattern

ofre

sults

showedala

rgepr

e-to

posttreatment

change

followedbygr

adua

lbu

t

continue

dim

provement

acrossal

lpr

imary

outcomesdu

ringF

U

period

Silverman

etal.,

1999b

Inor

iginal

article

3

-,6-,12

-mo

FU(resu

lts

fromeachF

U

assessment

period

presented

and

analyzed

together

)

EN=10

4

FUN=15

%

unava

ilablefo

r

FUassessments

RCMAS

FSSC-R

PGRS

Noan

xietydx

10se

ssions,in

divi

dual

child

and

parent

SC

10se

ssions,in

divi

dual

child

and

parent

CM

10se

ssions,in

divi

dual

child

and

parent

ES

NR

bytreatme

nt

group

NR

NA

NA

Overall

pattern

ofre

sults

showedala

rgepr

e-to

posttreatment

change

followedbygr

adua

lbu

t

continue

dim

provement

acrossal

lpr

imary

outcomesdu

ringF

U

period

Spence,

Donovan,

& Brechman-Toussaint,

2000

Inor

iginal

article

1

2-moF

U

EN=50

FUN=36

(num

ber

of

dropouts,if

any,w

eren

ot

spec

ified)

ADIS-PC

SR

RCMAS

Noan

xietydx

(ADIS

-P)

12se

ssions,ch

ildan

d

parent

group

CBT

12se

ssions,ch

ildon

ly

group

CBT

Notr

eatment

WL

16/17

17/19

13/16

9/17

NA

NA

Treatment

gainsw

ere

largelym

aintainedat

12-moF

Uacrossal

l

primaryou

tcomes;

invest

igatorsm

odified

ADIS

tofi

tDSM-I

V

criter

ia;on

lypa

rents

werein

terviewed;on

ly

phonein

terviews

conductedfo

rpo

stan

d

follow-up

assessments.

Results

for

self-report

and

behavioral

measuresal

sore

ported

continued




18/30

scriptive techniques, especially massed exposure orflooding.

Cognitive interventions, usually combined with ex-posure, also play a prominent role in CBT for anxiouschildren and adolescents. For example, Kendall andcolleagues developed a comprehensive cognitive-

behavioral protocol for anxious youth that focuses ontransmitting coping skills to children in need (Kendall,1994; Kendall et al., 1997). Based on the premise thatanxious children view the world through a templateof threat, automatic questioning (e.g., What if . . .),and behavioral avoidance, treatment is focused on pro-viding educational experiences to build a new copingtemplate for the child. Therapists assist the children toreconceptualize anxiety-provoking situations as prob-lems to be solved and situations with which to cope. Avariety of cognitive-behavioral components assist thetherapist and child in building the coping template:

relaxation training, imagery, correcting maladaptiveself-talk, problem-solving skills, and managing rein-forcers. Therapists use coping modeling, role-play re-hearsals, in vivo exposure, and a collaborativetherapeutic relationship with the child to facilitate thetreatment progress. As a rule, parents are actively in-volved in all facets of treatment as collaborators in thechange process.

For example, when significant others are trapped inthe childs anxiety symptoms, it is crucial that they stopparticipating in or reinforcing the childs avoidancestrategies or rituals. To test the hypothesis that addinga family anxiety management component would boosttreatment effectiveness, Barrett et al. (1996) developeda parallel family program to Kendalls Coping Catbased on behavioral family intervention strategiesfound effective for the treatment of externalizing dis-orders in youth. After the completion of each childsession with the therapist, the child and parents wouldparticipate in a family anxiety management session

with the therapist. The crux of the program is to em-power parents and children by forming an expertteam to overcome and master anxiety. Parents are

trained in reinforcement strategies, with an emphasison differential reinforcement and systematic ignoringof excessive complaining and anxious behavior. How-ever, unilateral extinction strategies, such as when aparent returns the school-phobic child to school byforce, have significant disadvantages relative to consen-sual child involvement: (1) lack of a workable strategy

TABLE

2

continued

Note:

ADIS

=A

nxiety

Dis

orders

Interv

iew

Schedule

;A

DIS

CSR

=A

nxiety

Dis

orders

Interv

iew

Schedule

forC

hildren

,cl

inician

seve

rity

rating

(sum

maryscore);

ADIS

-C=A

nxiety

Dis

orders

Interv

iew

Sched

ule

for

Children;

ADIS

-CCSR

=A

nxiety

Dis

orders

Interv

iew

Schedule

for

Children

,cl

inician

seve

rity

ratingch

ildba

sed;

ADIS

-P=A

nxiety

Dis

orders

Interv

iew

Sch

edule

for

Childr

en,P

aren

tV

ersion;A

DIS

-PC

SR=

Anxie

tyD

isor

ders

Interv

iew

Schedule

for

Children

,clinician

seve

rity

rating

parent

base

d;B

RS

=B

ehav

iour

Rat

ing

Scale;

CBCL

=C

hild

Behav

iorC

heck

list;

CBCL

-I=C

hild

Behav

ior

Che

cklist-

Internal

izin

gSu

bsca

le;

CBT

=co

gnitiv

e-behav

iora

lth

erapy;

CBT

AP

=C

BT

with

anx

ious

parent;

CBT

NAP

=

CBT

with

nonanxious

parent;C

BT

+PAM

=C

BT

plus

parenta

lanx

iety

managemen

t;C

BT

+PAMAP

=C

BT

plusp

aren

talanx

iety

managemen

tw

ithanxiousparen

t;C

BT

+PAMNAP

=

CBT

plus

parenta

lan

xiety

managemen

tw

ith

nonanxious

parent;

CM

=co

ntinge

ncy-

managemen

tth

erapy;

CWP

=W

ater

Phobi

aSu

rvey

Schedule

,Child

Ve

rsion;

DFBQ

=D

arkn

ess

Fea

rB

ehav

iour

Quest

ionna

ire;

EN

=en

try

num

ber;

ES

=ed

ucat

ionsu

ppor

t;F

SSC

-R=F

ear

Survey

Schedule

for

Children-Rev

ised;

FT

=fe

arther

mometer;

FU

=fo

llow-u

p;F

UN

=

follo

w-u

pnu

mber;

GAF=

Global

Assessmen

tofF

unct

ion

ing;

GCBT

=gr

oup

cogn

itiv

e-beh

aviora

lth

erapy;

IVE

=invi

voex

posu

re;

IVVE

=in

vivo

exposure

plus

vica

rious

exposu

re;

CGAS

=C

hildrens

Global

Assessmen

tSc

ale;

NA

=no

tav

ailabl

e;NR=

not

reported;O

R=ov

eral

lreact

ion

toph

ob

icsi

tuat

ion;

PCWP

=W

ater

Phobi

aSu

rvey

Schedule

,Paren

tV

ersion;

PGRS

=pa

rent

global

rating

ofse

verity;R

CMAS

=R

evis

edC

hildrens

Man

ifes

tA

nxiety

Scales;S

C=se

lf-con

trolt

herapy;S

PAI

=So

cial

Phobi

aan

dA

nxietyIn

ventory;S

PAI-C

=So

cial

Phobi

aan

dA

nxiety

Inventory

for

Children;

VE

=vi

carious

exposu

re;

WL

=w

ait-

list

control.




19/30

for managing the childs distress, (2) disruption of thetreatment relationship, (3) inability to target symptomsthat are out-of-sight for parents and teachers, and (4),most important, failure to help the child internalize amore skillful strategy for coping with current and po-tential future anxiety symptomatology.

MAJOR DEPRESSION

At any one time, approximately 1 in 20 children andadolescents suffers from major depressive disorder, withrates of depression rising dramatically in adolescents,especially in girls. Although the economic burden ofdepression in youth is uncertain, the human burden isconsiderable, especially with teenage suicide. Hence, itis of critical importance to note that the empirical lit-erature is more supportive for problem-specific psycho-therapies, especially CBT, than for medicationmanagement of pediatric depressive disorders (Birma-

her et al., 1996a; Hoberman et al., 1996). In particular,several controlled trials have demonstrated that indi-vidual or group administered cognitive-behavioral psy-chotherapy is an effective treatment for depressedyouth (Brent et al., 1997; Lewinsohn et al., 1994), andsome investigators now consider CBT to be the treat-ment of choice for this disorder (Reinecke et al., 1998).

Types of Investigations

Twelve articles describing a variety of cognitive-behavioral intervention packages for the treatment ofchild and adolescent depression were identified (Table3). Although these depression trials are equally meth-odologically rigorous when compared with child andadolescent anxiety trials (e.g., contrasting group designscomparing one or more active treatments with eitherno treatment, wait-list, or attention placebo controls),the number of studies is significantly fewer, and theresearch agenda to date has been less coherent andsystematic. Moreover, several of the studies with nullfindings likely had insufficient power to detect a be-tween-group treatment effect due to the small samplesize of each treatment condition. This is a notable de-

ficiency and contributes to the widely held notionamong practitioners that all treatments for depressionare equally effective. It also makes it difficult, if notimpossible, to reach strong conclusions regarding thedifferential efficacy of the treatments evaluated.

Two studies addressed the question of whether add-ing a separate treatment module for parents incremen-

tally improves outcomes (Clarke et al., 1999;Lewinsohn et al., 1990). One study compared indi-vidual CBT to systemic behavioral family therapy(Brent et al., 1997). Another study evaluated the rel-evant question of whether adding CBT to usual care ina health maintenance organization is better than usual

care alone (Clarke et al., 2002). Five studies evaluatedthe efficacy of one or more CBT interventions in de-signs that included either an attention placebo condi-tion (Kahn et al., 1990; Liddle and Spence, 1990;Vostanis et al., 1996; Wood et al., 1996) or a no-treatment control (Weisz et al., 1997). One studycompared individual CBT with interpersonal psycho-therapy (Rossello and Bernal, 1999). One investigationevaluated the effects of maintenance CBT for depressedadolescents (Clarke et al., 1999). One study evaluatedthe acceptability and efficacy of a combined cognitive-behavioral family education treatment (Asarnow et al.,

2002). Finally, one study evaluated the efficacy of cog-nitive bibliotherapy for adolescents with mild to mod-erate depressive symptoms (Ackerson et al., 1998). Nopublished investigations compared components oftreatments, and there were no systematic replicationstudies by independent investigators.

Assessment Issues

Diagnosis and Symptom Profile. Six of the 12 studiesused semistructured clinical interviews to identify sub-

jects as having DSM major depressive disorder or dys-thymia (Brent et al., 1997; Clarke et al., 1999, 2002;Lewinsohn et al., 1990; Vostanis et al., 1996; Wood etal., 1996). The most commonly used interview was theSchedule for Affective Disorders and Schizophrenia forSchool-Age Children (Chambers et al., 1985; Orvas-chel and Puig-Antich, 1986; Puig-Antich and Cham-bers, 1978). The remaining six studies either failed tomention the specific assessment procedures used to de-termine inclusion criteria (Rossello and Bernal, 1999)or enrolled subjects solely on the basis of mild to mod-erate levels of self-reported depressive symptomatology(Ackerson et al., 1998; Asarnow et al., 2002; Kahn et

al., 1990; Liddle and Spence, 1990; Weisz et al., 1997).The same six investigations that used semistructuredclinical interviews also assessed comorbidity but failedto analyze whether comorbidity status was related totreatment outcome. Thus, failure to systematically as-sess the impact of comorbidity on outcome is a criticaldeficiency in both the anxiety and depression literature.




20/30

TABLE

3

Ran

dom

ized

Clinic

alT

rials

ofCB

Tfo

rC

hild

and

Adole

scen

tD

epress

ive

Diso

rders:

Eff

ects

atP

ost-trea

tmen

t

Aut

hor

(s)

Des

ign

Sample

Informat

ion

Target

Diagnos

is

Treatment

Info

rmat

ion

Primary

Depen

dent

Measures

SampleS

ize

(Initial/Comple

ted)

Proportion

Responding

Posttreatment

EBMNNT

Effect

Size

Comments

Ackerson

etal.,

1998

RCT

,W

L

control,

unblinded

assessment,

completer

analys

is

N

=30

1

5.9

yr

3

6%male

6

5%w

hite

Adolescents

with

mild

to

moderate

symptomsof

depression

4w

kto

complete

self-g

uided

CBT

bibliot

herapy

WL

(4

wk,

then

offered

treatment)

CDI

HAM-D

NormalC

DI

NormalH

AM-D

15/12

15/10

Categor

ical

outcomesn

ot

reported

NA

CDI

=1.

05

HAM-D

21=2.

57

CBT

bibliotherapy

superiortoW

Lac

ross

multiplem

easures;

parent

measure

of

depressionsh

owedn

o

sign

ificant

between-group

differences

Asarnowet

al.,20

02

RCT

,W

L

control,

blindness

unclear,

completer

analys

is

N

=234t

hto

6th

graders

3

5%male

5

7%w

hite

Children

with

elevated

symptomsof

depression

9se

ssions,ch

ild+

group

CBT

,+1

sessio

nfa

mily

group

CBT

and

psych

oeducation

5w

kW

L

CDI

Notre

ported

(1ch

ildha

d

missing

data,no

t

reported

by

group)

Categor

ical

outcomesn

ot

reported

NA

CDI

=0.

92

When

outlier

removed,

CBT

showedsu

perior

efficacytoW

Lon

multiplem

easures

(depress

ion,n

egat

ive

thoughts,co

ping)

Brent

et

al.,19

97

RCT

,alternat

ive

treatment

control,

blind

assessment,

ITT

analys

is

N

=10

7

1

5.6

yr

2

4%male

8

3%w

hite

DSM-I

IIRMDD

12

16se

ssions,

indiv

idua

lC

BT

12

16se

ssions,

SBFT

12

16se

ssions,

NST

BDI

Nom

ood

dxan

d

norma

cognitive therapy, 2004.pdf

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