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):930–959.

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 andWells, 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 criticalreview 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 a“how-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 précis, 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. Weersingis with the Yale Child Study Center, New Haven, CT.

Correspondence to Dr. Compton, Duke University Medical Center, Box3527, Durham, NC 27710; e-mail: scompton@duke.edu.

0890-8567/04/4308–0930©2004 by the American Academy of Childand Adolescent Psychiatry.

DOI: 10.1097/01.chi.0000127589.57468.bf

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004930

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 thatperson–environment 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 presentingwith 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 scientist–clinicianmodel, 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 andO’Brien [1990]); (3) an emphasis on psychoeducation;(4) problem-specific treatment interventions designedto 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 usuallyavailable 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 specificcompetencies, 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 importance—in diabetes, insulin,and in the anxiety or affective disorders, a serotoninreuptake inhibitor—the 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). Indiabetes, 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-

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 931

cally akin to the scientist–practitioner 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 clinicalpractice 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 stressdisorder, 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 afavorable 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 Cohen’s d and computed as d = (Mt − Mc)/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 morethan 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), andwhether two active treatment components, which are

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004932

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RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 933

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COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004934

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dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

479–

13ye

ars

60%

mal

es76

%w

hite

OA

D(n

=30

)SA

D(n

=8 )

AV

D(n

=9 )

16se

ssio

ns,

indi

vidu

alC

BT

WL

(8w

eeks

,th

enof

fere

dtr

eatm

ent)

RC

MA

SFS

SC-R

CB

CL-

I

No

prim

ary

anxi

ety

dx(u

sing

AD

IS-P

)

27/N

R20

/NR

(Not

e:13

subj

ects

drop

ped,

not

repo

rted

bygr

oup)

17/2

71/

202 R

CM

AS

=0.

87FS

SC-R

=0.

38C

BC

L-I

=1.

22

Indi

vidu

alC

BT

was

asso

ciat

edw

ith

low

erra

tes

ofan

xiet

ydi

sord

ers

and

enha

nced

copi

ngab

iliti

esK

enda

ll,Fl

anne

y-Sc

hroe

der,

Pani

chel

li-M

inde

l,So

utha

m-

Ger

owet

al.,

1997

RC

T,

WL

conr

ol,

blin

dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

9 49–

13ye

ars

62%

mal

e85

%w

hite

OA

D(n

=55

)SA

D(n

=22

)A

VD

(n=

17)

16se

ssio

ns,

indi

vidu

alC

BT

WL

(8w

eeks

,th

enof

fere

dtr

eatm

ent)

RC

MA

SST

AIC

No

anxi

ety

dxby

AD

IS-P

75/6

043

/34

32/6

02/

342 R

CM

AS

-0.

59ST

AIC

-TA

=0.

72ST

AIC

-SA

=0.

40

Ove

rall,

resu

ltsw

ere

very

sim

ilar

toea

rlie

rst

udy

ofin

divi

dual

CB

T

Kin

get

al.,

1998

RC

T,

WL

cont

rol,

blin

dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

3 411

.03

year

s53

%m

ale

Eth

nici

tyun

spec

ified

SR(n

=34

)6

sess

ions

(ove

r4

wee

ks;

plus

5pa

rent

sess

ions

and

1te

ache

rm

eeti

ng),

indi

vidu

alC

BT

WL

(4w

eeks

,th

enof

fere

dtr

eatm

ent)

Scho

olat

tend

ance

(%da

yspr

esen

t)FT G

AF

CB

CL-

I

17/1

717

/17

No.

who

achi

eved

90%

scho

olat

tend

ance

15/1

75/

17

2 FT=

1.38

GA

F=

1.50

CB

CL-

I=

0.59

Act

ive

trea

tmen

tw

asas

soci

ated

wit

hsi

gnifi

cant

impr

ovem

ents

onal

lou

tcom

esex

cept

teac

her

repo

rts

—co

ntin

ued

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 935

TA

BL

E1

cont

inue

d

Aut

hor(

s)D

esig

nSa

mpl

eIn

form

atio

nT

arge

tD

iagn

osis

Tre

atm

ent

Info

rmat

ion

Prim

ary

Dep

ende

ntM

easu

res

Sam

ple

Size

(Ini

tial

/C

ompl

eted

)Pr

opor

tion

Res

pond

ing

Post

trea

tmen

tE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Last

,H

anse

n,&

Fran

co,

1998

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

indn

ess

uncl

ear,

com

plet

eran

alys

is

N=

5612

.04

year

s,40

%m

ale

89%

whi

te

ASR

(n=

56)

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

alE

S

Scho

olat

tend

ance

GIS

FSSC

-RST

AIC

-MN

oan

xiet

ydx

32/2

024

/21

No.

who

atta

ined

95%

atte

ndan

ce13

/20

10/2

1

6 95%

atte

ndan

ce=

0.39

Clin

icia

nG

IS=

0.20

FSSC

-R=

0.49

STA

IC-M

=0.

31N

odx

=0.

39

Bot

htr

eatm

ents

wer

eeq

ually

effe

ctiv

ein

retu

rnin

gch

ildre

nto

scho

ol

Man

assi

set

al.,

2002

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

indn

ess

uncl

ear,

com

plet

eran

alys

is

N=

789.

98ye

ars

54%

mal

e85

%w

hite

GA

D(n

=47

)SA

D(n

=20

)SI

P(n

=5)

SOP

(n=

5)PA

D(n

=1)

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

grou

pC

BT

(Not

e:pa

rent

spa

rtic

ipat

edin

both

trea

tmen

ts)

MA

SCC

GA

S41

/NR

37/N

RC

ateg

oric

alou

tcom

esw

ere

not

prov

ided

NA

Rel

ativ

eto

indi

vidu

alC

BT

MA

SC=

−0.3

1C

GA

S=

−0.6

4

Bot

htr

eatm

ents

wer

eas

soci

ated

wit

him

prov

emen

tson

child

and

pare

ntra

ting

s;cl

inic

ian

CG

AS

rati

ngs

favo

red

indi

vidu

alC

BT

;in

divi

dual

CB

Tw

asm

ore

effe

ctiv

efo

rch

ildre

nre

port

ing

high

rate

sof

soci

alan

xiet

yM

endl

owit

zet

al.,

1999

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

indn

ess

uncl

ear,

com

plet

eran

alys

is

N=

6 89.

8ye

ars

43%

mal

eE

thni

city

unsp

ecifi

ed

Chi

ldre

nw

ith

DSM

-IV

anxi

ety

dx(u

sing

DIC

A-R

-P)

12se

ssio

ns,

grou

pC

BT

(chi

ldon

ly)

12se

ssio

ns,

grou

pC

BT

-P12

sess

ions

,gr

oup

CB

T-C

PW

L(2

to6

mon

ths,

then

offe

red

trea

tmen

t)

RC

MA

SC

CSC

GIS

23/2

321

/21

18/1

8

Cat

egor

ical

outc

omes

wer

eno

tpr

ovid

ed

NA

RC

MA

SC

BT

-C=

0.18

CB

T-P

=0.

18C

BT

-CP

=0.

35C

CSC

(Act

ive

Cop

ing)

CB

T-C

=0.

26C

BT

-P=

−0.6

5C

BT

-CP

=0.

57C

CSC

(Avo

idan

tC

opin

g)C

BT

-C=

0.33

CB

T-P

=−0

.39

CB

T-C

P=

0.39

All

thre

etr

eatm

ents

wer

eas

soci

ated

wit

hsi

gnifi

cant

impr

ovem

ents

insy

mpt

oms

ofan

xiet

yan

dde

pres

sion

;ch

ildre

nin

CB

T(c

hild

+pa

rent

)co

ndit

ion

repo

rted

usin

gm

ore

adap

tive

copi

ngsk

ills

than

the

othe

rtw

otr

eatm

ent

cond

itio

ns

—co

ntin

ued

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004936

TA

BL

E1

cont

inue

d

Aut

hor(

s)D

esig

nSa

mpl

eIn

form

atio

nT

arge

tD

iagn

osis

Tre

atm

ent

Info

rmat

ion

Prim

ary

Dep

ende

ntM

easu

res

Sam

ple

Size

(Ini

tial

/C

ompl

eted

)Pr

opor

tion

Res

pond

ing

Post

trea

tmen

tE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Men

zies

&C

lark

e,19

93

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

ind

asse

ssm

ent,

com

plet

eran

alys

is

N=

485.

5ye

ars

65%

mal

eE

thni

city

unsp

ecifi

ed

SIP

(wat

erph

obia

,n

=48

)

3se

ssio

ns,

IVV

E3

sess

ions

,V

E3

sess

ions

,IV

EN

o-tr

eatm

ent

cont

rol

BR

SPC

WP

CW

PO

R

13/1

213

/12

12/1

2

Cat

egor

ical

outc

omes

wer

eno

tpr

ovid

ed

NA

Una

ble

toca

lcul

ate

due

toin

suff

icie

ntda

ta

Bot

hIV

VE

and

IVE

wer

eeq

ually

effe

ctiv

ean

dm

ore

effe

ctiv

eth

anW

Lin

redu

cing

wat

erph

obia

;IV

Ere

sulte

din

grea

ter

gene

raliz

atio

nto

nove

lsi

tuat

ions

;V

Esh

owed

nobe

nefit

over

no-t

reat

men

tco

ntro

lM

uris

,M

ayer

,B

arte

lds,

Tie

rney

,&

Bog

ie,

2001

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

indn

ess

uncl

ear,

com

-pl

eter

anal

ysis

N=

3 69.

9ye

ars

25%

mal

e97

%w

hite

GA

D(n

=14

)SA

D(n

=14

)SO

P(n

=7 )

OC

D(n

=1 )

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

grou

pC

BT

SCA

RE

D-R

STA

IC17

/not

repo

rted

19/n

otre

port

ed

Cat

egor

ical

outc

omes

wer

eno

tpr

ovid

ed

NA

Rel

ativ

eto

indi

vidu

alC

BT

SCA

RE

D-R

(tot

al)

=−0

.32

STA

IC(t

rait

anxi

ety)

=0.

14

Bot

htr

eatm

ents

wer

eas

soci

ated

wit

heq

ual

impr

ovem

ents

insy

mpt

oms

ofan

xiet

y

Mur

is,

Mee

ster

s,&

van

Mel

ick

2002

RC

T,

psyc

holo

gica

lPB

Oan

dno

-tre

atm

ent

cont

rol,

blin

dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

3 010

.2ye

ars

33%

mal

e90

%w

hite

SAD

(n=

10)

GA

D(n

=7 )

SOP

(n=

3 )D

iagn

osti

cst

atus

ofno

-tre

at-

men

tco

ntro

lsno

tas

sess

ed

12se

ssio

ns,

grou

pC

BT

12se

ssio

ns,

grou

pE

DN

o-tr

eatm

ent

cont

rol

RC

AD

SST

AIC

10/1

010

/10

10/1

0

Cat

egor

ical

outc

omes

wer

eno

tpr

ovid

ed

NA

Com

bine

dac

tive

trea

tmen

tre

lati

veto

no-t

reat

men

tco

ntro

lR

CA

DS

(tot

alan

xiet

y)C

BT

=1.

48E

D=

−0.1

7ST

AIC

(tra

itan

xiet

y)C

BT

=0.

83E

D=

−0.4

6

CB

Tre

lati

veto

ED

RC

AD

S(t

otal

anxi

ety)

=0.

98ST

AID

(tra

itan

xiet

y)=

1.05

CB

Tw

assu

peri

orto

ED

and

no-t

reat

men

tco

ntro

l;E

Dsh

owed

nobe

nefit

over

no-t

reat

men

tco

ntro

l

—co

ntin

ued

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 937

TA

BL

E1

cont

inue

d

Aut

hor(

s)D

esig

nSa

mpl

eIn

form

atio

nT

arge

tD

iagn

osis

Tre

atm

ent

Info

rmat

ion

Prim

ary

Dep

ende

ntM

easu

res

Sam

ple

Size

(Ini

tial

/C

ompl

eted

)Pr

opor

tion

Res

pond

ing

Post

trea

tmen

tE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Nau

ta,

Scho

ling,

Em

mel

kam

p,& M

inde

raa,

2003

RC

T,

WL

cont

rol,

blin

das

sess

men

t,IT

Tan

alys

is

N=

7911

.0ye

ars

49%

mal

eE

thni

city

unsp

ecifi

ed

SAD

(n=

26)

SOP

(n=

31)

GA

D(n

=15

)PA

D(n

=7)

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

alC

BT

plus

7se

ssio

nsC

PTW

L(d

urat

ion

not

spec

ified

,th

enof

fere

dtr

eatm

ent)

SCA

S-c/

pFS

SC-R

CB

CL

No

anxi

ety

dx(A

DIS

-Can

dP)

29/2

630

/30

20/1

7

Com

bine

dvs

.W

L32

/59

2/18

CB

Tvs

.C

BT

+20

/37

23/3

9

Act

ive

trea

tmen

tre

lati

veto

WL

2 Una

ble

toca

lcul

ate

due

toin

suff

icie

ntda

ta

CB

Tre

lati

veto

CB

T+

20

SCA

S-c

=−0

.20

SCA

S-p

=−0

.33

FSSC

-R=

−0.1

2

Rel

ativ

eto

WL,

acti

vetr

eatm

ent

show

edlo

wer

scor

eson

pare

ntre

port

san

dm

ore

child

ren

diag

nost

icfr

ee;

nodi

ffer

ence

betw

een

WL

and

acti

vetr

eatm

ent

onch

ildre

port

s;th

ead

diti

onof

CPT

show

edno

addi

tion

albe

nefit

acro

ssal

lou

tcom

esSh

ortt

,B

arre

tt,

&Fo

x,20

01

RC

T,

WL

cont

rol,

blin

das

sess

men

t,co

mpl

eter

anal

ysis

N=

7 17.

85ye

ars

41%

mal

e92

%A

ustr

alia

n

GA

D(n

=42

)SA

D(n

=19

)SO

P(n

=10

)

10se

ssio

ns(p

lus

2bo

oste

rse

ssio

ns),

grou

pC

BT

WL

(10

wee

ks,

then

offe

red

trea

tmen

t)

RC

MA

SC

BC

LN

oan

xiet

ydx

54/4

817

/16

33/4

81/

162 R

CM

AS

=0.

99M

othe

rC

BC

L-I

=5.

08Fa

ther

CB

CL-

I=

1.91

Act

ive

trea

tmen

tw

asas

soci

ated

wit

hsi

gnifi

cant

impr

ovem

ents

acro

ssal

lou

tcom

es

Silv

erm

anet

al.,

1999

aR

CT

,W

Lco

ntro

l,bl

ind

asse

ssm

ent,

com

plet

eran

alys

is

N=

569.

66ye

ars

61%

mal

es45

%w

hite

GA

D(n

=12

)SO

P(n

=15

)O

AD

(n=

29)

12se

ssio

ns,

grou

pC

BT

(con

curr

ent

child

and

pare

ntgr

oups

wit

h15

min

.co

njoi

ntm

eeti

ng)

WL

(8to

10w

eeks

,th

enof

fere

dtr

eatm

ent)

RC

MA

SFS

SC-R

CB

CL-

IPG

RS

No

anxi

ety

dx(A

DIS

-C/P

)

37/2

519

/16

16/2

52/

162 R

CM

AS

=0.

58FS

SC-R

=0.

65C

BC

L-I

=1.

25PG

RS

=1.

78

Gro

upC

BT

was

asso

ciat

edw

ith

sign

ifica

ntim

prov

emen

tsac

ross

all

prim

ary

outc

ome

dom

ains

s

—co

ntin

ued

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004938

TA

BL

E1

cont

inue

d

Aut

hor(

s)D

esig

nSa

mpl

eIn

form

atio

nT

arge

tD

iagn

osis

Tre

atm

ent

Info

rmat

ion

Prim

ary

Dep

ende

ntM

easu

res

Sam

ple

Size

(Ini

tial

/C

ompl

eted

)Pr

opor

tion

Res

pond

ing

Post

trea

tmen

tE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Silv

erm

anet

al.,

1999

bR

CT

,al

tern

ativ

etr

eatm

ent

cont

rol,

blin

das

sess

men

t,co

mpl

eter

anal

ysis

N=

104

9.83

year

s52

%m

ales

62%

whi

te

SIP

(n=

87)

SOP

(n=

10)

AG

P(n

=7)

10se

ssio

ns,

indi

vidu

alch

ildan

dpa

rent

SC10

sess

ions

,in

divi

dual

child

and

pare

ntC

M10

sess

ions

,in

divi

dual

child

and

pare

ntE

S

RC

MA

SFS

SC-R

PGR

SN

oan

xiet

ydx

40/3

341

/32

23/1

6

29/3

318

/32

9/16

3 NA

RC

MA

SSC

=0.

72C

M=

0.13

FSSC

-RSC

=1.

07C

M=

0.18

PGR

SSC

=0.

47C

M=

0.40

All

thre

etr

eatm

ent

cond

itio

nssh

owed

com

para

ble

impr

ovem

ent

Spen

ceet

al.,

2000

RC

T,

WL,

blin

das

sess

men

t,co

mpl

eter

anal

ysis

N=

5 010

.7ye

ars

62%

mal

eE

thni

city

unsp

ecifi

ed

SOP

(n=

50)

12se

ssio

ns,

child

and

pare

ntgr

oup

CB

T12

sess

ions

,ch

ildon

lygr

oup

CB

TN

o-tr

eatm

ent

WL

AD

IS-P

CSR

RC

MA

SN

oan

xiet

ydx

(AD

IS-P

)

17/1

619

/15

14/9

14/1

69/

151/

9

1 2 AD

IS-P

CSR

CB

T-C

P=

1.88

CB

T=

1.01

RC

MA

SC

BT

-CP

=0.

45C

BT

=0.

46

Bot

htr

eatm

ents

wer

eas

soci

ated

wit

hsi

gnifi

cant

impr

ovem

ents

;no

sign

ifica

ntdi

ffer

ence

betw

een

acti

vetr

eatm

ents

note

d

Not

e:A

DIS

CSR

=A

nxie

tyD

isor

ders

Inte

rvie

wSc

hedu

lefo

rC

hild

ren,

clin

icia

nse

veri

tyra

ting

(sum

mar

ysc

ore)

;A

DIS

-C=

Anx

iety

Dis

orde

rsIn

terv

iew

Sche

dule

for

Chi

ldre

n;A

DIS

-CC

SR=

Anx

iety

Dis

orde

rsIn

terv

iew

Sche

dule

for

Chi

ldre

n,cl

inic

ian

seve

rity

rati

ngch

ildba

sed;

AD

IS-P

=A

nxie

tyD

isor

ders

Inte

rvie

wSc

hedu

lefo

rC

hild

ren,

Pare

ntV

ersi

on;

AD

IS-P

CSR

=A

nxie

tyD

isor

ders

Inte

rvie

wSc

hedu

lefo

rChi

ldre

n,cl

inic

ian

seve

rity

rati

ngpa

rent

base

d;A

GP

=ag

orap

hobi

a;A

SR=

anxi

ety-

base

dsc

hool

refu

sal;

AT

cont

rol=

alte

rnat

ive

trea

tmen

tco

ntro

l;A

VD

=av

oida

ntdi

sord

er;

BR

S=

Beh

avio

urR

atin

gSc

ale;

CB

CL

=C

hild

Beh

avio

rC

heck

list;

CB

CL-

I=

Chi

ldB

ehav

ior

Che

cklis

t-In

tern

aliz

ing

Subs

cale

;C

BT

=co

gnit

ive-

beha

vior

alth

erap

y;C

BT

AP

=C

BT

wit

han

xiou

spa

rent

; CB

TN

AP

=C

BT

wit

hno

nanx

ious

pare

nt;C

BT

+PA

M=

CB

Tpl

uspa

rent

alan

xiet

ym

anag

emen

t;C

BT

+PA

MA

P=

CB

Tpl

uspa

rent

alan

xiet

ym

anag

emen

twit

han

xiou

spa

rent

;CB

T+P

AM

NA

P=

CB

Tpl

uspa

rent

alan

xiet

ym

anag

emen

twit

hno

nanx

ious

pare

nt;C

BT

-C=

CB

Tch

ildon

ly;C

BT

-CP

=C

BT

child

and

pare

nt;

CB

T-P

=C

BT

pare

nton

ly;

CC

SC=

Chi

ldre

n’s

Cop

ing

Stra

tegi

esC

heck

list;

CG

AS

=C

hild

ren’

sG

loba

lA

sses

smen

tSc

ale;

CM

=co

ntin

genc

y-m

anag

emen

tth

erap

y;C

WP

=W

ater

Phob

iaSu

rvey

Sche

dule

,ch

ildve

rsio

n;D

FBQ

=D

arkn

ess

Fear

Beh

avio

urQ

uest

ionn

aire

;D

ICA

-R-P

=D

iagn

osti

cIn

vent

ory

for

Chi

ldre

nan

dA

dole

scen

ts-

Rev

ised

,Pa

rent

Ver

sion

;dx

=di

agno

sis;

ED

=em

otio

nald

iscl

osur

e;E

Ss=

effe

ctsi

zees

tim

ates

;FS

SC-R

=Fe

arSu

rvey

Sche

dule

for

Chi

ldre

n-R

evis

ed;

FT=

fear

ther

mom

eter

;G

AD

=ge

nera

lized

anxi

ety

diso

rder

;G

AF

=G

loba

lA

sses

smen

tof

Func

tion

ing;

GC

BT

=gr

oup

cogn

itiv

e-be

havi

oral

ther

apy;

GIS

=G

loba

lIm

prov

emen

tSc

ale;

ICB

T=

indi

vidu

alco

gnit

ive

beha

vior

ther

apy;

ITT

=in

tent

totr

eat;

IVE

=in

vivo

expo

sure

;IV

VE

=in

vivo

expo

sure

plus

vica

riou

sex

posu

re;

MA

SC=

Mul

tidi

men

sion

alA

nxie

tySc

ale

for

Chi

ldre

n;N

A=

not

avai

labl

e;N

R=

not

repo

rted

;N

Tco

ntro

l=no

-tre

atm

ent

cont

rol;

OA

D=

over

anxi

ous

diso

rder

;O

R=

over

all

reac

tion

toph

obic

situ

atio

n;PA

D=

pani

cdi

sord

erw

ith

orw

itho

utag

orap

hobi

a;PA

M=

pare

ntal

anxi

ety

man

agem

ent;

PBO

=pl

aceb

o;PC

WP

=W

ater

Phob

iaSu

rvey

Sche

dule

,Par

entV

ersi

on;P

GR

S=

pare

ntgl

obal

rati

ngof

seve

rity

;RC

AD

S=

Rev

ised

Chi

ldre

n’s

Anx

iety

and

Dep

ress

ion

Scal

e;R

CM

AS

=R

evis

edC

hild

ren’

sM

anife

stA

nxie

tySc

ales

;RC

T=

rand

omiz

edcl

inic

altr

ial;

SAD

=se

para

tion

anxi

ety

diso

rder

;SC

=se

lf-co

ntro

lth

erap

y;SC

AR

ED

-R=

Scre

enfo

rC

hild

Anx

iety

Rel

ated

Em

otio

nal D

isor

ders

-Rev

ised

;SC

AS-

c/p

=Sp

ence

Chi

ldA

nxie

tySc

ale,

Chi

ldan

dPa

rent

Ver

sion

;SIP

=si

mpl

eph

obia

;SO

P=

soci

alph

obia

;SPA

I-C

=So

cial

Phob

iaan

dA

nxie

tyIn

vent

ory

for

Chi

ldre

n;SR

=sc

hool

-ref

usin

gch

ildre

n;ST

AIC

=St

ate-

Tra

itA

nxie

tyIn

vent

ory

for

Chi

ldre

n;ST

AIC

-M=

Mod

ified

Stat

e-T

rait

Anx

iety

Inve

ntor

yfo

rC

hild

ren;

STA

IC-S

A=

Stat

e-T

rait

Anx

iety

Inve

ntor

yfo

rC

hild

ren

stat

ean

xiet

y;ST

AIC

-TA

=St

ate-

Tra

itA

nxie

tyIn

vent

ory

for

Chi

ldre

ntr

ait

anxi

ety;

VE

=vi

cari

ous

expo

sure

;W

L=

wai

t-lis

tco

ntro

l.

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 939

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 awhole. 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 mostwidely 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 clinician’s 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 etal., 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 severeenough 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 towithin 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 tostudy, 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

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004940

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 gainswere 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 conditionedresponses 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 “I’ll 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 awide 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, stimuluspresentation 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-

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 941

TA

BL

E2

Ran

dom

ized

Clin

ical

Tri

als

ofC

BT

for

Chi

ldan

dA

dole

scen

tA

nxie

tyD

isor

ders

:E

ffec

tsat

Follo

w-u

p

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Sam

ple

Size

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(Ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

FUE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Bar

rett

etal

.,19

96In

orig

inal

arti

cle

12-m

oFU

(act

ive

trea

tmen

tson

ly)

EN

=79

FUN

=53

RC

MA

S,FS

SC-R

,C

BC

L,in

depe

nden

tcl

inic

ian

rati

ngs;

noan

xiet

ydx

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

alch

ildan

dpa

rent

CB

T

28/2

725

/23

19/2

722

/23

NA

NA

CB

T+

had

sign

ifica

ntly

mor

ech

ildre

ndi

agno

sis

free

,lo

wer

FSSC

-Rsc

ores

,an

dhi

gher

clin

icia

nra

ting

sof

impr

ovem

ent;

nosi

gnifi

cant

diff

eren

ceon

CB

CL;

youn

ger

child

ren

and

fem

ales

resp

onde

dbe

tter

toC

BT

+B

arre

ttet

al.,

1996

Bar

rett

etal

.,20

016-

yrFU

EN

=79

FUN

=52

RC

MA

S,FS

SC-R

,no

anxi

ety

dx12

sess

ions

,in

divi

dual

CB

T12

sess

ions

,in

divi

dual

child

and

pare

ntC

BT

28/3

1,18

/21

(inc

lude

son

lysu

bjec

tsw

hom

etdx

stat

usat

pret

reat

men

tby

child

inte

rvie

w)

24/2

818

/21

NA

NA

12-m

otr

eatm

ent

gain

sw

ere

larg

ely

mai

ntai

ned

at6-

yrFU

;co

ntra

ryto

auth

ors’

pred

icti

ons,

CB

T+

was

not

mor

eef

fect

ive

than

CB

T

Bar

rett

,19

98In

orig

inal

arti

cle

12-m

oFU

(act

ive

trea

tmen

tson

ly)

EN

=60

FUN

=di

ffic

ult

tode

term

ine

FSSC

-R,

CB

CL,

inde

pend

ent

clin

icia

nra

ting

s,no

anxi

ety

dx

12se

ssio

ns,

grou

pC

BT

(chi

ldon

ly)

12se

ssio

ns,

grou

pfa

mily

CB

T(c

hild

and

pare

nt)

Diff

icul

tto

dete

rmin

eG

CB

T=

64.5

%,

GC

BT

+=

84.8

%

NA

NA

Bot

hac

tive

trea

tmen

tgr

oups

cont

inue

dto

show

impr

ovem

ent;

nosi

gnifi

cant

diff

eren

cebe

twee

n2

acti

vetr

eatm

ents

ondi

agno

stic

stat

us;

GC

BT

+gr

oup

repo

rted

sign

ifica

ntly

low

erFS

SC-R

scor

esan

dC

BC

Lsc

ores

;G

CB

T+

rece

ived

sign

ifica

ntly

high

ercl

inic

ian

rati

ngs

ofim

prov

emen

t —co

ntin

ued

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004942

TA

BL

E2

cont

inue

d

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Sam

ple

Size

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(Ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

FUE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Bar

rett

etal

.,19

96In

orig

inal

arti

cle

6-m

oFU

(act

ive

trea

tmen

tson

ly)

EN

=79

FUN

=53

RC

MA

S,FS

SC-R

,C

BC

L,in

depe

nden

tcl

inic

ian

rati

ngs,

noan

xiet

ydx

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

alch

ildan

dpa

rent

CB

T

28/2

825

/25

20/2

821

/25

NA

NA

Bot

hac

tive

trea

tmen

tgr

oups

cont

inue

dto

show

impr

ovem

ent;

nosi

gnifi

cant

diff

eren

cebe

twee

n2

acti

vetr

eatm

ents

ondi

agno

stic

stat

us,

RC

MA

S,FS

SC-R

,or

CB

CL

scor

es;

CB

T+

rece

ived

sign

ifica

ntly

high

ercl

inic

ian

rati

ngs

ofim

prov

emen

tB

eide

let

al.,

2000

Inor

igin

alar

ticl

e6-

mo

FUE

N=

67FU

N=

22(c

hild

ren

inth

eno

nspe

cific

trea

tmen

tco

ndit

ion

wer

eN

Afo

rFU

anal

ysis

SPA

I-C

,C

GA

S,A

DIS

-CC

SR,

noan

xiet

ydx

12in

divi

dual

and

12gr

oup

sess

ions

,C

BT

12in

divi

dual

and

12gr

oup

sess

ions

,no

nspe

cific

trea

tmen

tco

ntro

l

36/2

219

/22

NA

NA

Tre

atm

ent

gain

sw

ere

mai

ntai

ned

at6-

mo

FU

Cob

ham

etal

.,19

98In

orig

inal

arti

cle

12-m

oFU

EN

=67

FUN

=65

No

anxi

ety

dx10

sess

ions

,ch

ild-f

ocus

edgr

oup

CB

T(p

aren

tspa

rtic

ipat

ed)

10se

ssio

ns+

4pa

rent

anxi

ety

man

agem

ent

sess

ions

,gr

oup

CB

T=P

AM

(par

ents

part

icip

ated

);gr

oups

wer

eal

socr

osse

don

pare

ntal

anxi

ety

NA

Pvs

.A

P

33/3

532

/32

CB

TN

AP

=12

/16

CB

TA

P=

10/1

7C

BT

+PA

MN

AP

=12

/15

CB

T+P

AM

AP

=12

/17

NA

NA

Ove

rall,

trea

tmen

tef

fect

sw

eake

ned

by12

-mo

FU;

nosi

gnifi

cant

mai

nef

fect

for

anxi

ety

cond

itio

n(a

nxio

uspa

rent

vs.

nona

nxio

uspa

rent

);no

sign

ifica

ntm

ain

effe

ctfo

rtr

eatm

ent

cond

itio

n(C

BT

vs.

CB

T+P

AM

);no

sign

ifica

ntin

tera

ctio

nsbe

twee

npa

rent

anxi

ous

stat

usan

dtr

eatm

ent

cond

itio

n

—co

ntin

ued

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 943

TA

BL

E2

cont

inue

d

Cob

ham

etal

.,19

98In

orig

inal

arti

cle

6-m

oFU

EN

=67

FUN

=66

No

anxi

ety

dx10

sess

ions

,ch

ild-f

ocus

edgr

oup

CB

T(p

aren

tspa

rtic

ipat

ed)

10se

ssio

ns+

4pa

rent

anxi

ety

man

agem

ent

sess

ions

,gr

oup

CB

T+P

AM

(par

ents

part

icip

ated

);gr

oups

wer

eal

socr

osse

don

pare

ntal

anxi

ety

NA

Pvs

.A

P

34/3

532

/32

CB

T NA

P=

14/1

6C

BT

AP

=8/

18C

BT

+PA

MN

AP

=12

/15

CB

T+P

AM

AP

=12

/17

NA

NA

Chi

ldre

nw

ith

anxi

ous

pare

nt(s

)co

ntin

ued

tore

spon

dle

ssfa

vora

bly

toch

ild-f

ocus

edC

BT

;ov

eral

l,ch

ildre

nw

ith

nona

nxio

uspa

rent

sre

spon

ded

mor

efa

vora

bly

totr

eatm

ent

rega

rdle

ssof

trea

tmen

tco

ndit

ion

Cor

nwal

let

al.,

1996

Inor

igin

alar

ticl

e3-

mo

FUE

N=

24FU

N=

24FS

SC-R

,R

CM

AS,

FT,

DFB

Q6

sess

ions

,em

otiv

eim

ager

yW

L(3

mo

indu

rati

on)

12/1

212

/12

NR

NA

FSSC

-R=

0.90

RC

MA

S=

0.79

DFB

Q=

1.82

Tre

atm

ent

gain

sin

the

acti

vetr

eatm

ent

cond

itio

nw

ere

mai

ntai

ned

at3-

mo

FU

Flan

nery

-Sc

hroe

der

& Ken

dall,

2000

Inor

igin

alar

ticl

e3-

mo

FUE

N=

45F U

N=

2 9(i

nclu

des

subj

ects

trea

ted

afte

rW

L)

RC

MA

S,C

BC

L-I,

noan

xiet

ydx

18se

ssio

ns,

indi

vidu

alC

BT

18se

ssio

ns,

grou

pC

BT

WL

(9w

k,th

enof

fere

dtr

eatm

ent)

18/1

418

/15

Prim

ary

dx:

11/1

48/

15

Any

Anx

dx:

7/14

8/15

NA

NA

Tre

atm

ent

gain

sw

ere

mai

ntai

ned

at3-

mo

FU;

nosi

gnifi

cant

diff

eren

ces

betw

een

the

two

acti

vetr

eatm

ents

onse

lf-re

port

and

pare

ntre

port

mea

sure

sH

ayw

ard

etal

.,20

00

Inor

igin

alar

ticl

e12

-mo

FUE

N=

35F U

N=

2 8A

DIS

CSR

,SP

AI

No

anxi

ety

dx16

sess

ions

,gr

oup

CB

TN

otr

eatm

ent

cont

rol

12/1

023

/18

4/10

10/1

8−6 SP

AI

=0.

07

No

sign

ifica

ntbe

twee

n-gr

oup

diff

eren

cein

rate

sof

soci

alph

obia

orSP

AI

mea

nsc

ores

at12

-mo

FU;

addi

tion

alan

alys

esco

mbi

ning

soci

alph

obia

and

depr

essi

ondi

agno

ses

prod

uced

mor

ero

bust

betw

een

grou

ptr

eatm

ent

chan

ges

Ken

dall,

1994

Inor

igin

alar

ticl

e12

-mo

FUE

N=

47F U

N=

3 8(i

nclu

des

Sstr

eate

daf

ter

WL

peri

od)

RC

MA

SFS

SC-R

CB

CL-

I

No

prim

ary

anxi

ety

dx(A

DIS

-P)

16se

ssio

ns,

indi

vidu

alC

BT

WL

(8w

k,th

enof

fere

dtr

eatm

ent)

47/3

8Pe

rcen

tdx

-fre

eno

tre

port

edN

A

NA

Tre

atm

ent

gain

sw

ere

mai

ntai

ned

at12

-mo

FUon

self-

repo

rtan

dpa

rent

repo

rtm

easu

res

—co

ntin

ued

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004944

TA

BL

E2

cont

inue

d

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Sam

ple

Size

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(Ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

FUE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Ken

dall,

1994

Ken

dall

&So

utha

m-

Ger

ow,

1996

2–5

yrFU

EN

=47

FUN

=36

(inc

lude

sSs

trea

ted

afte

rW

Lpe

riod

)

RC

MA

SFS

SC-R

CB

CL-

I

No

prim

ary

anxi

ety

dx(A

DIS

-C)

Indi

vidu

alC

BT

47/3

6Pe

rcen

tdx

-fre

eno

tre

port

edN

A

NA

Tre

atm

ent

gain

sw

ere

larg

ely

mai

ntai

ned

atlo

ng-t

erm

FUon

self-

repo

rtan

dpa

rent

repo

rtm

easu

res

Ken

dall

etal

.,19

97In

orig

inal

arti

cle

12-m

oFU

EN

=94

FUN

=85

(inc

lude

sSs

trea

ted

afte

rW

Lpe

riod

)

RC

MA

SST

AIC

No

anxi

ety

dxby

AD

IS-P

16se

ssio

ns,

indi

vidu

alC

BT

WL

(8w

k,th

enof

fere

dtr

eatm

ent)

85/9

4Pe

rcen

tdx

free

not

repo

rted

NA

NA

Post

trea

tmen

tre

duct

ions

wer

em

aint

aine

dat

12-m

oFU

wit

hth

eex

cept

ion

that

CB

CL-

I(m

othe

r)ra

ting

sw

ere

sign

ifica

ntly

low

erK

ing

etal

.,19

98In

orig

inal

arti

cle

3-m

oFU

EN

=34

FUN

=17

(WL

not

asse

ssed

)

Scho

olat

tend

ance

(1%

days

pres

ent)

FT GA

FC

BC

L-I

6se

ssio

ns(o

ver

4w

k;pl

us5

pare

ntse

ssio

nsan

d1

teac

her

mee

ting

),in

divi

dual

CB

TW

L(4

wk,

then

offe

red

trea

tmen

t)

17/1

7N

o.w

hoac

hiev

ed90

%sc

hool

atte

ndan

ce14

/17

NA

NA

Tre

atm

ent

gain

sac

ross

all

prim

ary

outc

omes

wer

em

aint

aine

dat

3-m

oFU

Last

etal

.,19

98In

orig

inal

arti

cle

2w

kin

toth

esu

bseq

uent

scho

olye

ar

EN

=56

F UN

=4 1

%re

port

ing:

(1)

nodi

ffic

ulty

retu

rnin

gto

scho

olin

new

year

(2)

mild

diff

icul

ty(3

)m

oder

ate

diff

icul

ty(4

)ex

trem

edi

ffic

ulty

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

aled

ucat

iona

lsu

ppor

t

32/2

024

/21

CB

Tvs

.E

S(1

)40

%vs

.52

%(2

)30

%vs

.19

%(3

)10

%vs

.5%

(4)

20%

vs.

24%

NA

NA

Rou

ghly

30%

oftr

eatm

ent

com

plet

ers

inbo

thgr

oups

repo

rted

mod

erat

eto

seve

redi

ffic

ulty

retu

rnin

gto

scho

olth

efo

llow

ing

scho

olye

ar

Last

etal

.,19

98In

orig

inal

arti

cle

4-w

kFU

EN

=56

F UN

=2 9

%re

port

ing:

(1)

mai

ntai

ned

impr

ovem

ent

(2)

show

edfu

rthe

rim

prov

emen

t(3

)re

laps

ed(4

)ne

ver

impr

oved

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

aled

ucat

iona

lsu

ppor

t

32/1

424

/15

CB

Tvs

.E

S(1

)65

%vs

.40

%(2

)14

%vs

.13

%(3

)7%

vs.

7%(4

)14

%vs

.40

%

4 NA

The

maj

orit

yof

Ssco

ntin

ued

tosh

owim

prov

emen

t,w

ith

nosi

gnifi

cant

betw

een

grou

pdi

ffer

ence

sat

4-w

kFU

Men

zies

&C

lark

e,19

93

Inor

igin

alar

ticl

e12

-wk

FUE

N=

51F U

N=

3 6(W

Lno

tas

sess

ed)

BR

SPC

WP

CW

PO

R

3se

ssio

ns,

IVV

E3

sess

ions

,V

E3

sess

ions

,IV

EN

otr

eatm

ent

cont

rol

13/1

213

/12

13/1

2

NA

NA

NA

Non

sign

ifica

ntde

teri

orat

ion

intr

eatm

ent

gain

sno

ted,

IVV

Egr

oup

perf

orm

edbe

tter

than

IVE

grou

pat

FU

—co

ntin

ued

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 945

TA

BL

E2

cont

inue

d

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Sam

ple

Size

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(Ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

FUE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Nau

taet

al.,

2003

Inor

igin

alar

ticl

e3-

mo

FUE

N=

79FU

N=

73SC

AS-

c/p

FSSC

-RC

BC

LN

oan

xiet

ydx

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

alC

BT

plus

7se

ssio

nsC

PTW

L(d

urat

ion

not

spec

ified

,th

enof

fere

dtr

eatm

ent)

37/3

439

/39

23/3

427

/39

0 Rel

ativ

eto

CB

TSC

AS-

c=

−0.3

1SC

AS-

p=

−0.2

4FS

SC-R

=−0

.24

Bot

hac

tive

trea

tmen

tgr

oups

cont

inue

dto

show

impr

ovem

ent

acro

ssal

lpr

imar

you

tcom

esdu

ring

FUpe

riod

;th

ead

diti

onof

CPT

conf

erre

dno

addi

tion

albe

nefit

acro

ssal

lou

tcom

esSh

ortt

etal

.,20

01In

orig

inal

arti

cle

12-m

oFU

EN

=71

FUN

=63

(inc

lude

sSs

trea

ted

afte

rW

Lpe

riod

)

RC

MA

SC

BC

LN

oan

xiet

ydx

10se

ssio

ns(p

lus

2bo

oste

rse

ssio

ns),

grou

pC

BT

WL

(10

wk,

then

offe

red

trea

tmen

t)

47/6

332

/47

NA

NA

Clin

icia

nra

ting

sw

ere

mai

ntai

ned

atFU

,R

CM

AS

scor

esw

ere

sign

ifica

ntly

low

erth

anat

post

-tre

atm

ent

Silv

erm

anet

al.,

1999

a

Inor

igin

alar

ticl

e3-

,6-

,12

-mo

FU(r

esul

tsfr

omea

chFU

asse

ssm

ent

peri

odpr

esen

ted

and

anal

yzed

toge

ther

)

EN

=5 6

F UN

=3 1

(inc

lude

spo

oled

GC

BT

and

WL

data

)

RC

MA

SFS

SC-R

CB

CL-

IPG

RS

No

anxi

ety

dx

12se

ssio

ns,

grou

pC

BT

(con

curr

ent

child

and

pare

ntgr

oups

wit

h15

min

.co

njoi

ntm

eeti

ng)

WL

(8to

10w

k,th

enof

fere

dtr

eatm

ent)

3-m

oFU

=41

/31

6-m

oFU

=41

/33

12-m

oFU

=41

/25

3-m

oFU

=24

/31

6-m

oFU

=26

/33

12-m

oFU

=19

/25

NA

NA

Ove

rall

patt

ern

ofre

sults

show

eda

larg

epr

e-to

post

trea

tmen

tch

ange

follo

wed

bygr

adua

lbu

tco

ntin

ued

impr

ovem

ent

acro

ssal

lpr

imar

you

tcom

esdu

ring

FUpe

riod

Silv

erm

anet

al.,

1999

b

Inor

igin

alar

ticl

e3-

,6-

,12

-mo

FU(r

esul

tsfr

omea

chFU

asse

ssm

ent

peri

odpr

esen

ted

and

anal

yzed

toge

ther

)

EN

=10

4FU

N=

15%

unav

aila

ble

for

FUas

sess

men

ts

RC

MA

SFS

SC-R

PGR

SN

oan

xiet

ydx

10se

ssio

ns,

indi

vidu

alch

ildan

dpa

rent

SC10

sess

ions

,in

divi

dual

child

and

pare

ntC

M10

sess

ions

,in

divi

dual

child

and

pare

ntE

S

NR

bytr

eatm

ent

grou

p

NR

NA

NA

Ove

rall

patt

ern

ofre

sults

show

eda

larg

epr

e-to

post

trea

tmen

tch

ange

follo

wed

bygr

adua

lbu

tco

ntin

ued

impr

ovem

ent

acro

ssal

lpr

imar

you

tcom

esdu

ring

FUpe

riod

Spen

ce,

Don

ovan

,& B

rech

man

-Tou

ssai

nt,

2000

Inor

igin

alar

ticl

e12

-mo

FUE

N=

50F U

N=

3 6(n

umbe

rof

drop

outs

,if

any,

wer

eno

tsp

ecifi

ed)

AD

IS-P

CSR

RC

MA

SN

oan

xiet

ydx

(AD

IS-P

)

12se

ssio

ns,

child

and

pare

ntgr

oup

CB

T12

sess

ions

,ch

ildon

lygr

oup

CB

TN

otr

eatm

ent

WL

16/1

717

/19

13/1

69/

17N

A

NA

Tre

atm

ent

gain

sw

ere

larg

ely

mai

ntai

ned

at12

-mo

FUac

ross

all

prim

ary

outc

omes

;in

vest

igat

ors

mod

ified

AD

ISto

fitD

SM-I

Vcr

iter

ia;

only

pare

nts

wer

ein

terv

iew

ed;

only

phon

ein

terv

iew

sco

nduc

ted

for

post

and

follo

w-u

pas

sess

men

ts.

Res

ults

for

self-

repo

rtan

dbe

havi

oral

mea

sure

sal

sore

port

ed

—co

ntin

ued

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004946

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 “template”of 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 child’s anxiety symptoms, it is crucial that they stopparticipating in or reinforcing the child’s 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 Kendall’s “Coping Cat”based 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 sessionwith the therapist. The crux of the program is to em-power parents and children by forming an “expertteam” to overcome and master anxiety. Parents aretrained 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

TA

BL

E2

cont

inue

d

Not

e:A

DIS

=A

nxie

tyD

isor

ders

Inte

rvie

wSc

hedu

le;

AD

ISC

SR=

Anx

iety

Dis

orde

rsIn

terv

iew

Sche

dule

for

Chi

ldre

n,cl

inic

ian

seve

rity

rati

ng(s

umm

ary

scor

e);

AD

IS-C

=A

nxie

tyD

isor

ders

Inte

rvie

wSc

hedu

lefo

rC

hild

ren;

AD

IS-C

CSR

=A

nxie

tyD

isor

ders

Inte

rvie

wSc

hedu

lefo

rC

hild

ren,

clin

icia

nse

veri

tyra

ting

child

base

d;A

DIS

-P=

Anx

iety

Dis

orde

rsIn

terv

iew

Sche

dule

for

Chi

ldre

n,Pa

rent

Ver

sion

;AD

IS-P

CSR

=A

nxie

tyD

isor

ders

Inte

rvie

wSc

hedu

lefo

rC

hild

ren,

clin

icia

nse

veri

tyra

ting

pare

ntba

sed;

BR

S=

Beh

avio

urR

atin

gSc

ale;

CB

CL

=C

hild

Beh

avio

rC

heck

list;

CB

CL-

I=

Chi

ldB

ehav

ior

Che

cklis

t-In

tern

aliz

ing

Subs

cale

;CB

T=

cogn

itiv

e-be

havi

oral

ther

apy;

CB

TA

P=

CB

Tw

ith

anxi

ous

pare

nt;C

BT

NA

P=

CB

Tw

ith

nona

nxio

uspa

rent

;CB

T+P

AM

=C

BT

plus

pare

ntal

anxi

ety

man

agem

ent;

CB

T+P

AM

AP

=C

BT

plus

pare

ntal

anxi

ety

man

agem

entw

ith

anxi

ous

pare

nt;C

BT

+PA

MN

AP

=C

BT

plus

pare

ntal

anxi

ety

man

agem

ent

wit

hno

nanx

ious

pare

nt;

CM

=co

ntin

genc

y-m

anag

emen

tth

erap

y;C

WP

=W

ater

Phob

iaSu

rvey

Sche

dule

,C

hild

Ver

sion

;D

FBQ

=D

arkn

ess

Fear

Beh

avio

urQ

uest

ionn

aire

;E

N=

entr

ynu

mbe

r;E

S=

educ

atio

nsu

ppor

t;FS

SC-R

=Fe

arSu

rvey

Sche

dule

for

Chi

ldre

n-R

evis

ed;

FT=

fear

ther

mom

eter

;FU

=fo

llow

-up;

FUN

=fo

llow

-up

num

ber;

GA

F=

Glo

bal

Ass

essm

ent

ofFu

ncti

onin

g;G

CB

T=

grou

pco

gnit

ive-

beha

vior

alth

erap

y;IV

E=

invi

voex

posu

re;

IVV

E=

invi

voex

posu

repl

usvi

cari

ous

expo

sure

;C

GA

S=

Chi

ldre

n’s

Glo

balA

sses

smen

tSca

le;N

A=

nota

vaila

ble;

NR

=no

trep

orte

d;O

R=

over

allr

eact

ion

toph

obic

situ

atio

n;PC

WP

=W

ater

Phob

iaSu

rvey

Sche

dule

,Par

entV

ersi

on;

PGR

S=

pare

ntgl

obal

rati

ngof

seve

rity

;RC

MA

S=

Rev

ised

Chi

ldre

n’s

Man

ifest

Anx

iety

Scal

es;S

C=

self-

cont

rolt

hera

py;S

PAI

=So

cial

Phob

iaan

dA

nxie

tyIn

vent

ory;

SPA

I-C

=So

cial

Phob

iaan

dA

nxie

tyIn

vent

ory

for

Chi

ldre

n;V

E=

vica

riou

sex

posu

re;

WL

=w

ait-

list

cont

rol.

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 947

for managing the child’s 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 usualcare 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 etal., 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.

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004948

TA

BL

E3

Ran

dom

ized

Clin

ical

Tri

als

ofC

BT

for

Chi

ldan

dA

dole

scen

tD

epre

ssiv

eD

isor

ders

:E

ffec

tsat

Post

-tre

atm

ent

Aut

hor(

s)D

esig

nSa

mpl

eIn

form

atio

nT

arge

tD

iagn

osis

Tre

atm

ent

Info

rmat

ion

Prim

ary

Dep

ende

ntM

easu

res

Sam

ple

Size

(Ini

tial

/Com

plet

ed)

Prop

orti

onR

espo

ndin

g

Post

trea

tmen

tE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Ack

erso

net

al.,

1998

RC

T,

WL

cont

rol,

unbl

inde

das

sess

men

t,co

mpl

eter

anal

ysis

N=

3015

.9yr

36%

mal

e65

%w

hite

Ado

lesc

ents

wit

hm

ildto

mod

erat

esy

mpt

oms

ofde

pres

sion

4w

kto

com

plet

ese

lf-gu

ided

CB

Tbi

blio

ther

apy

WL

(4w

k,th

enof

fere

dtr

eatm

ent)

CD

IH

AM

-DN

orm

alC

DI

Nor

mal

HA

M-D

15/1

215

/10

Cat

egor

ical

outc

omes

not

repo

rted

NA

CD

I=

1.05

HA

M-D

21=

2.57

CB

Tbi

blio

ther

apy

supe

rior

toW

Lac

ross

mul

tipl

em

easu

res;

pare

ntm

easu

reof

depr

essi

onsh

owed

nosi

gnifi

cant

betw

een-

grou

pdi

ffer

ence

sA

sarn

owet

al.,

2002

RC

T,

WL

cont

rol,

blin

dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

234t

hto

6th

grad

ers

35%

mal

e57

%w

hite

Chi

ldre

nw

ith

elev

ated

sym

ptom

sof

depr

essi

on

9se

ssio

ns,

child

+gr

oup

CB

T,

+1se

ssio

nfa

mily

grou

pC

BT

and

psyc

hoed

ucat

ion

5w

kW

L

CD

IN

otre

port

ed(1

child

had

mis

sing

data

,no

tre

port

edby

grou

p)

Cat

egor

ical

outc

omes

not

repo

rted

NA

CD

I=

0.92

Whe

nou

tlier

rem

oved

,C

BT

show

edsu

peri

oref

ficac

yto

WL

onm

ulti

ple

mea

sure

s(d

epre

ssio

n,ne

gati

veth

ough

ts,

copi

ng)

Bre

ntet

al.,

1997

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

ind

asse

ssm

ent,

ITT

anal

ysis

N=

107

15.6

yr24

%m

ale

83%

whi

te

DSM

-III

RM

DD

12–1

6se

ssio

ns,

indi

vidu

alC

BT

12–1

6se

ssio

ns,

SBFT

12–1

6se

ssio

ns,

NST

BD

IN

om

ood

dxan

dno

rmal

BD

I

37/3

035

/24

35/2

4

22/3

710

/35

13/3

5

4 −12

BD

I CB

T=

0.41

SBFT

=0.

07

CB

Tsh

owed

supe

rior

effic

acy

rela

tive

toSB

FTan

dN

ST;

nosi

gnifi

cant

betw

een-

grou

pdi

ffer

ence

sw

ere

foun

don

suic

idal

orfu

ncti

onal

stat

usou

tcom

esC

lark

eet

al.,

2002

RC

T,

TA

Uco

ntro

l,bl

ind

asse

ssm

ent,

ITT

anal

ysis

N=

8 815

.3yr

17%

mal

e96

%w

hite

DSM

-III

RM

DD

ordy

sthy

mia

16se

ssio

ns,

grou

pC

BT

TA

U

CE

S-D

,H

AM

-D14

No

moo

ddx

41/N

R47

/NR

(2su

bjec

tsdr

oppe

d,no

tre

port

edby

grou

p)

24/4

125

/47

19 CE

S-D

=0.

20H

AM

-D14

=0.

10

Bot

htr

eatm

ents

show

edpo

siti

vebe

nefit

;no

sign

ifica

ntbe

twee

n;gr

oup

diff

eren

ces

onan

ypr

imar

you

tcom

em

easu

re

Cla

rke

etal

.,19

99R

CT

,W

Lco

ntro

l,bl

ind

asse

ssm

ent,

com

plet

eran

alys

is

N=

123

16.2

yr29

%m

ale

Eth

nici

tyun

spec

ified

DSM

-III

RM

DD

ordy

sthy

mia

16se

ssio

ns,

grou

pC

BT

16se

ssio

ns,

child

grou

pC

BT

+8

sess

ions

,pa

rent

grou

pC

BT

(inc

lude

d2

join

tse

ssio

ns)

8-w

kW

L

BD

IN

om

ood

dx45

/37

42/3

236

/27

24/3

722

/32

13/2

7

3 5 BD

I CB

T=

0.58

CB

T+

=0.

24

Bot

hac

tive

trea

tmen

tgr

oups

show

edsi

gnifi

cant

impr

ovem

ent

acro

ssm

ulti

ple

outc

omes

rela

tive

toW

L;ho

wev

er,

ther

ew

ere

nosi

gnifi

cant

diff

eren

ces

inou

tcom

esbe

twee

nac

tive

trea

tmen

tgr

oups

—co

ntin

ued

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 949

TA

BL

E3

cont

inue

d

Aut

hor(

s)D

esig

nSa

mpl

eIn

form

atio

nT

arge

tD

iagn

osis

Tre

atm

ent

Info

rmat

ion

Prim

ary

Dep

ende

ntM

easu

res

Sam

ple

Size

(Ini

tial

/Com

plet

ed)

Prop

orti

onR

espo

ndin

g

Post

trea

tmen

tE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Kah

net

al.,

1990

RC

T,

WL

cont

rol,

blin

dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

6812

.1yr

49%

mal

eE

thni

city

unsp

ecifi

ed

Chi

ldre

nw

ith

mod

erat

eto

seve

resy

mpt

oms

ofde

pres

sion

12se

ssio

ns,

grou

pC

BT

12se

ssio

ns,

indi

vidu

alR

T12

sess

ions

,in

divi

dual

SM10

-wk

WL

CD

IN

orm

alC

DI

17/1

717

/17

17/1

717

/17

15/1

713

/17

10/1

72/

17

1 2 2 CD

I CB

T=

1.68

RT

=1.

06SM

=1.

11

All

trea

tmen

tsre

lati

veto

WL

show

edsi

gnifi

cant

decr

ease

insy

mpt

oms

ofde

pres

sion

;ve

rysm

all

sam

ple

size

s

Lew

inso

hnet

al.,

1990

RC

T,

WL

cont

rol,

blin

dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

6916

.2yr

39%

mal

eE

thni

city

unsp

ecifi

ed

DSM

-III

MD

D,

min

orde

pres

sion

,or

inte

rmit

tent

depr

essi

on

14se

ssio

ns,

grou

pC

BT

14se

ssio

ns,

child

grou

pC

BT

+8

sess

ions

,pa

rent

grou

pC

BT

(inc

lude

d2

join

tse

ssio

ns)

7to

8-w

kW

L

BD

IN

om

ood

dx24

/21

21/1

924

/19

9/21

9/19

1/19

3 1 BD

I CB

T=

0.94

CB

T+

=1.

48

Bot

hac

tive

trea

tmen

tgr

oups

show

edsi

gnifi

cant

impr

ovem

ent

acro

ssm

ulti

ple

outc

omes

rela

tive

toW

L;ho

wev

er,

ther

ew

ere

nosi

gnifi

cant

diff

eren

ces

inou

tcom

esbe

twee

nac

tive

trea

tmen

tgr

oups

Lidd

le&

Spen

ce,

1990

RC

T,

notr

eatm

ent

cont

rol

and

atte

ntio

npl

aceb

oco

ntro

l,co

mpl

eter

anal

ysis

N=

3 19.

2yr

68%

mal

eE

thni

city

unsp

ecifi

ed

Chi

ldre

nw

ith

mild

tom

oder

ate

sym

ptom

sof

depr

essi

on

8se

ssio

ns,

grou

pC

BT

8se

ssio

ns,

grou

pA

PCN

TC

CD

I11

/11

10/1

010

/10

Cat

egor

ical

outc

omes

not

repo

rted

NA

CD

I CB

Tvs

.A

PC=

0.71

CB

Tvs

.N

TC

=0.

36

All

trea

tmen

tsas

soci

ated

wit

ha

sign

ifica

ntde

clin

ein

sym

ptom

sof

depr

essi

on;

very

smal

lsa

mpl

esi

zes

Ros

sello

&B

erna

l,19

99

RC

T,

WL

cont

rol,

blin

dnes

sun

clea

r,co

mpl

eter

anal

ysis

N=

7 114

.7yr

46%

mal

e10

0%La

tino

DSM

-III

RM

DD

ordy

sthy

mia

12se

ssio

ns,

indi

vidu

alC

BT

12se

ssio

ns,

indi

vidu

alIP

T12

-wk

WL

(the

nof

fere

dtr

eatm

ent)

CD

I25

/21

23/1

912

/18

15/2

117

/19

12/1

8(b

ased

onC

DI

cuto

ffpo

ints

)

10 4 CD

I CB

T=

0.35

IPT

=0.

76

Bot

hac

tive

trea

tmen

tgr

oups

show

edpo

siti

vebe

nefit

rela

tive

toW

L;no

sign

ifica

ntdi

ffer

ence

sin

outc

omes

betw

een

acti

vetr

eatm

ent

grou

psV

osta

nis,

Feeh

an,

Gra

ttan

,& B

icke

rton

,19

96

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

indn

ess

uncl

ear,

com

plet

eran

alys

is

N=

5 712

.7yr

44%

mal

e88

%w

hite

DSM

-III

RM

DD

9se

ssio

ns,

indi

vidu

alC

BT

9se

ssio

ns,

indi

vidu

alN

FI

MFQ

-CN

om

ood

dx29

/29

28/2

825

/29

21/2

89 M

FQ=

0.05

Bot

hgr

oups

show

edsi

gnifi

cant

impr

ovem

ent;

alth

ough

MFQ

show

eda

tren

dfa

vori

ngth

eC

BT

cond

itio

n,no

sign

ifica

ntbe

twee

n-gr

oup

diff

eren

ces

wer

efo

und

oncl

inic

alou

tcom

es

—co

ntin

ued

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004950

TA

BL

E3

cont

inue

d

Aut

hor(

s)D

esig

nSa

mpl

eIn

form

atio

nT

arge

tD

iagn

osis

Tre

atm

ent

Info

rmat

ion

Prim

ary

Dep

ende

ntM

easu

res

Sam

ple

Size

(Ini

tial

/Com

plet

ed)

Prop

orti

onR

espo

ndin

g

Post

trea

tmen

tE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Wei

sz,

Thu

rber

,Sw

eene

y,Pr

offit

t,& Le

Gag

noux

,19

97

RC

T,

notr

eatm

ent

cont

rol,

blin

das

sess

men

t,co

mpl

eter

anal

ysis

N=

489.

6yr

old

51%

mal

e38

%w

hite

Chi

ldre

nw

ith

mild

tom

oder

ate

sym

ptom

sof

depr

essi

on

8se

ssio

ns,

grou

pC

BT

NT

C

CD

IC

DR

S-R

16/1

632

/32

8/16

5/32

3 CD

I=

0.48

CD

RS-

R=

0.16

Chi

ldre

nin

the

acti

vetr

eatm

ent

grou

pre

port

edsi

gnifi

cant

lyfe

wer

sym

ptom

sof

depr

essi

on

Woo

d,H

arri

ngto

n,& M

oore

,19

96

RC

T,

alte

rnat

ive

trea

tmen

tco

ntro

l,bl

ind

asse

ssm

ent,

ITT

anal

ysis

N=

5 314

.2yr

31%

mal

eE

thni

city

unsp

ecifi

ed

DSM

-III

RM

DD

5–8

sess

ions

indi

vidu

alC

BT

5–8

sess

ions

RT

MFQ

-CM

FQ-P

No

moo

ddx

26/2

427

/24

13/2

45/

243 M

FQ-P

=0.

41C

BT

was

asso

ciat

edw

ith

sign

ifica

ntly

mor

eim

prov

emen

tac

ross

mul

tipl

eou

tcom

es

Not

e:A

PC=

atte

ntio

npl

aceb

oco

ntro

l;B

DI

=B

eck

Dep

ress

ion

Inve

ntor

y;C

BT

=co

gnit

ive-

beha

vior

alth

erap

y;C

DI

=C

hild

ren’

sD

epre

ssio

nIn

vent

ory;

CD

RS-

R=

Chi

ldre

n’s

Dep

ress

ion

Rat

ing

Scal

e-R

evis

ed;

CE

S-D

=C

ente

rfo

rE

pide

mio

logi

cSt

udie

s-D

epre

ssio

nSc

ale;

HA

M-D

14=

14-I

tem

Ham

ilton

Dep

ress

ion

Rat

ing

Scal

e;H

AM

-D21

=21

-Ite

mH

amilt

onD

epre

ssio

nR

atin

gSc

ale;

IPT

=in

terp

erso

nalp

sych

othe

rapy

; IT

T=

inte

ntto

trea

t;M

DD

=m

ajor

depr

essi

vedi

sord

er;M

FQ=

Moo

dan

dFe

elin

gsQ

uest

ionn

aire

;MFQ

-C=

Moo

dan

dFe

elin

gsQ

uest

ionn

aire

,Chi

ldV

ersi

on;M

FQ-P

=M

ood

and

Feel

ings

Que

stio

nnai

re,P

aren

tVer

sion

;NA

=no

tava

ilabl

e;N

FI=

nonf

ocus

edin

terv

enti

on;N

R=

notr

epor

ted;

NST

=no

ndir

ecti

vesu

ppor

tive

ther

apy;

NT

C=

no-t

reat

men

tco

ntro

l;R

CT

=ra

ndom

ized

clin

ical

tria

l;R

T=

rela

xati

ontr

aini

ng;

SBFT

=sy

stem

icbe

havi

orfa

mily

ther

apy;

SM=

self-

mod

elin

g;T

AU

=tr

eatm

ent

asus

ual;

WL

=w

ait-

list

cont

rol.

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 951

Demographics. Although both males and females arerepresented in the treated populations, other basic de-mographic variables, such as ethnicity, were generallynot well documented. Only 7 of the 12 cited investi-gations provided the ethnic breakdown of the sample.Moreover, the majority of children who have partici-pated in research studies to date have been overwhelm-ingly white, suggesting that future studies will beneeded to evaluate the exportability of protocol-drivenCBT treatment packages to divergent patient popula-tions.

Outcome Measures. All the cited investigations reliedon psychometrically sound measures to documenttreatment results and changes in specific symptom do-mains. One-half of the studies reported the percentageof subjects who no longer met criteria for a depressivedisorder after treatment (Brent et al., 1997; Clarke etal., 1999, 2002; Lewinsohn et al., 1990; Vostanis et al.,1996; Wood et al., 1996), and several studies reportedthe percentage of subjects who returned to the nonde-viant ranges on the primary outcome measures. Onlythree investigations provided quantitative measures ofchange in functional status (Brent et al., 1997; Clarkeet al., 1999, 2002). Because little is currently knownabout how treatments affect academic, social, and fam-ily domains, future studies would benefit from includ-ing a more diverse range of outcomes (Compton et al.,2002).

Long-Term Follow-up. The data addressing the du-rability of CBT for adolescent depression are mixed(Table 4). In general, studies characterized by a rela-tively short follow-up period (from 1 to 9 months)report that posttreatment gains are largely maintained,with several studies showing continued improvement.However, studies with longer follow-up periods (from9 months to 2 years) and low attrition rates at follow-up found that a sizable percentage of subjects contin-ued to report significant depressive symptoms or arecurrence of their depressive illness (Birmaher et al.,2000; Vostanis et al., 1996, 1998; Wood et al., 1996).Factors found to predict a lack of recovery or relapseinclude low self-esteem (Vostanis et al., 1996, 1998),comorbidity at post-treatment (Vostanis et al., 1998),severity of depression or high level of functional im-pairment at baseline (Birmaher et al., 2000), the pres-ence of subsyndromal depression (Brent et al., 2001),parental depression (Brent et al., 1998; Clarke et al.,2002), parent–child conflict (Birmaher et al., 2000),

and the source of treatment referral (Birmaher et al.,2000). These studies suggest that depression in adoles-cence is associated with a high risk of recurrence. Theyalso underscore the importance of developing interven-tions that specifically target adolescents at risk of re-lapse and investigate the impact of continuationtreatment on long-term outcomes.

Treatments

Like other cognitive-behavioral treatment packages,CBT for depression in youths is a present-oriented,skills-based treatment that, in this case, is based on theassumption that depression is either caused or main-tained by the way one perceives situations and events(e.g., cognitions about the world and self) and the pres-ence of skill deficits (both emotional and behavioral)that prevent the patient from interacting effectivelywith the world. Because personality is an interactivemultidirectional system of cognitions, behaviors, andemotions, depression is manifested in each of the threecomponents of the personality. However, CBT for de-pression assumes that symptom change is most likely tooccur through interventions that modify patterns ofbehavior through skills acquisition and patterns of cog-nition, with changes in depressed mood following inturn. Among the behavioral and cognitive skill deficitsthat may characterize a depressed youth are low levelsof involvement in pleasant activities, poor problem-solving and assertion skills, cognitive distortions thatnegatively bias perceptions, negative automaticthoughts, negative views of self and future, and failureto attribute positive outcomes to internal, stable, orglobal causes. The role of the therapist, therefore, is toestablish a collaborative working relationship with theadolescent and to help the adolescent learn new ways ofbehaving and thinking, which in turn reduces depres-sive severity and risk of relapse.

Current cognitive-behavioral treatment packagesfor depressed youths share two salient characteristics:(1) general and “required” skill building sessions andoptional “modular” sessions for specific problems and(2) the integration of parent and family sessions withindividual CBT (Treatment for Adolescents with De-pression Study, 2003). Treatment is generally designedto improve the teenager’s problem-solving abilitywhen faced with a stressful situation, for example,parent–child conflict, role transitions, grief reactions,or peer problems. Therefore, the required aspects of

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004952

TA

BL

E4

Ran

dom

ized

Clli

nica

lT

rial

sof

CB

Tfo

rC

hild

and

Ado

lesc

ent

Dep

ress

ive

Dis

orde

rs:

Eff

ects

atFo

llow

-up

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Tar

get

Dia

gnos

es

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(Ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

Follo

w-u

pE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Ack

erso

net

al.,

1998

Inor

igin

alar

ticl

e1-

mo

FUA

dole

scen

tsw

ith

mild

tom

oder

ate

sym

ptom

sof

depr

essi

on

CD

IH

AM

-D21

Nor

mal

CD

IN

orm

alH

AM

-D21

4w

kto

com

plet

ese

lf-gu

ided

CB

Tbi

blio

ther

apy

4-w

kW

L

15/1

215

/10

NA

NA

The

imm

edia

te-t

reat

men

tgr

oup

cont

inue

dto

show

impr

ovem

ent

inde

pres

sive

sym

ptom

son

the

HA

M-D

;tr

eatm

ent

gain

son

CD

Iw

ere

mai

ntai

ned

Bre

ntet

al.,

1997

Bir

mah

eret

al.,

2000

24-m

oFU

(mul

tipl

ein

terv

iew

s)

DSM

-III

RM

DD

BD

IN

om

ood

dxan

dno

rmal

BD

I

12–1

6se

ssio

ns,

indi

vidu

alC

BT

12–1

6se

ssio

ns,

SBFT

12–1

6se

ssio

ns,

NST

37/N

R35

/NR

35/N

R

97%

ofsa

mpl

eco

mpl

eted

atle

ast

3FU in

terv

iew

s

Not

sepa

rate

dby

grou

pIn

suff

icie

ntda

tapr

ovid

edO

ver

FUpe

riod

,th

e3

trea

tmen

tgr

oups

did

not

sign

ifica

ntly

diff

erin

term

sof

rem

issi

on,

reco

very

,re

laps

e,or

recu

rren

ce,

alth

ough

desc

ript

ive

data

favo

red

CB

T;

acro

ssgr

oups

,39

%of

pati

ents

had

pers

iste

ntre

cove

ryfr

omde

pres

sion

,40

%ha

din

term

itte

ntde

pres

sion

sym

ptom

s,an

d21

%w

ere

pers

iste

ntly

depr

esse

dC

lark

eet

al.,

2002

Inor

igin

alar

ticl

e12

-mo

FUD

SM-I

IIR

MD

Dor

dyst

hym

ia

CE

S-D

HA

M-D

14N

om

ood

dx

16se

ssio

ns,

grou

pC

BT

TA

U

41/N

R47

/NR

(6su

bjec

tsdr

oppe

d,no

tre

port

edby

grou

p)

71%

82%

Insu

ffic

ient

data

prov

ided

Bot

htr

eatm

ent

grou

psco

ntin

ued

tosh

owm

aint

enan

ceof

trea

tmen

tga

ins,

wit

hno

sign

ifica

ntbe

twee

n-gr

oup

diff

eren

ces

onm

ain

outc

omes

Cla

rke

etal

.,20

02In

orig

inal

arti

cle

24-m

oFU

DSM

-III

RM

DD

ordy

sthy

mia

CE

S-D

,H

AM

-D14

No

moo

ddx

16se

ssio

ns,

grou

pC

BT

TA

U

41/N

R47

/NR

(13

subj

ects

drop

ped,

not

repo

rted

bygr

oup)

89%

92%

Insu

ffic

ient

data

prov

ided

Bot

htr

eatm

ent

grou

psco

ntin

ued

tosh

owm

aint

enan

ceof

trea

tmen

tga

ins,

wit

hno

sign

ifica

ntbe

twee

n-gr

oup

diff

eren

ces

onm

ain

outc

omes

—co

ntin

ued

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 953

TA

BL

E4

cont

inue

d

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Tar

get

Dia

gnos

es

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

Follo

w-u

pE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Cla

rke,

Roh

de,

Lew

inso

hn,

Hop

s,&

Seel

ey,

1999

Inor

igin

alar

ticl

e12

-an

d24

-mo

FUto

addr

ess

ques

tion

ofre

cove

ryfr

oman

dre

curr

ence

ofde

pres

sion

epis

ode

DSM

-III

AR

MD

Dor

dyst

hym

ia

BD

IN

om

ood

dxSu

bjec

tsin

the

2ac

tive

trea

tmen

tco

ndit

ions

wer

era

ndom

lyas

sign

edto

:(1

)bo

oste

rse

ssio

nsev

ery

4m

o(2

)as

sess

men

ton

lyse

ssio

nsev

ery

4m

o(3

)as

sess

men

ton

lyse

ssio

nsev

ery

12m

o

24 16 24 (87

subj

ects

orig

inal

lyra

ndom

ized

toac

ute

trea

tmen

t,64

subj

ects

rand

omiz

eddu

ring

follo

w-u

pph

ase)

NA

NA

By

12-m

oFU

, 100

%of

subj

ects

who

wer

est

illde

pres

sed

atpo

st-t

reat

men

tan

das

signe

dto

the

boos

ter

cond

ition

had

reco

vere

dvs

.50%

ofth

ose

subj

ects

inth

e2

asse

ssm

ent-

only

cond

ition

s;ho

wev

er,a

t24

-mo

FU,r

ates

conv

erge

dw

ith10

0%of

subj

ects

inth

ebo

oste

rco

nditi

onre

cove

red

vs.

90%

inth

e2

asse

ssm

ent-

only

cond

ition

sB

y12

-mo

FU,r

ecur

renc

era

tes

wer

e14

%in

the

12-m

oas

sess

men

t-on

lyco

nditi

on,0

%in

the

4-m

oas

sess

men

t-on

lyco

nditi

on,a

nd27

%in

the

boos

ter

cond

ition

;at

24-m

oFU

,rec

urre

nce

rate

sw

ere

23%

inth

e12

-mo

asse

ssm

ent-

only

cond

ition

,0%

inth

e4-

mo

asse

ssm

ent-

only

cond

ition

,and

36%

inth

ebo

oste

rco

nditi

onLe

win

sohn

,C

lark

e,H

ops,

&A

ndre

ws,

1990

Inor

igin

alar

ticle

6-,1

2-,2

4-m

oFU

DSM

-III

MD

D,

min

orde

pres

sion,

orin

term

itten

tde

pres

sion

BD

I14

sess

ions

grou

pC

BT

14se

ssio

ns,c

hild

grou

pC

BT

plus

8se

ssio

ns,

pare

ntgr

oup

CB

T(in

clud

ed2

join

tse

ssio

ns)

(WL

subj

ects

wer

eof

fere

dtr

eatm

ent

imm

edia

tely

follo

win

gpo

st-t

reat

men

t)

At

24m

onth

s24

/10

21/1

3

NR

bytr

eatm

ent

cond

ition

NA

Bot

hac

tive

trea

tmen

tgr

oups

show

edco

ntin

ued

impr

ovem

ent

durin

gFU

resu

lting

ina

signi

fican

tdi

ffere

nce

betw

een

post

trea

tmen

tan

d6-

mo

FUsc

ores

;im

prov

emen

tsw

ere

mai

ntai

ned

atth

e12

-an

d24

-mo

asse

ssm

ents

—co

ntin

ued

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004954

TA

BL

E4

cont

inue

d

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Tar

get

Dia

gnos

es

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

Follo

w-u

pE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Lidd

le&

Spen

ce,

1990

Inor

igin

alar

ticl

e2-

mo

FUC

hild

ren

wit

hm

ildto

mod

erat

esy

mpt

oms

ofde

pres

sion

CD

I8

sess

ions

,gr

oup

CB

T8

sess

ions

,gr

oup

APC

NT

C

11/1

110

/10

10/1

0

Cat

egor

ical

outc

omes

not

repo

rted

NA

CD

I CB

Tvs

.A

PC=

0.41

CB

Tvs

.N

TC

=0.

20

All

trea

tmen

tgr

oups

show

edco

ntin

ued

impr

ovem

ent

at2-

mo

FU,

wit

hno

sign

ifica

ntbe

twee

n-gr

oup

diff

eren

ces

Ros

sello

&B

erna

l,19

99

Inor

igin

alar

ticl

e3-

mo

FUD

SM-I

IIR

MD

Dor

dyst

hym

ia

CD

I12

sess

ions

,in

divi

dual

CB

T12

sess

ions

,in

divi

dual

IPT

12-w

kW

L(t

hen

offe

red

trea

tmen

t)

25/1

423

/11

NR

NA

Tre

atm

ent

grai

nsw

ere

mai

ntai

ned

at3-

mo

FU;

nosi

gnifi

cant

betw

een-

grou

pdi

ffer

ence

sin

3-m

oou

tcom

esbe

twee

nth

e2

acti

vetr

eatm

ent

grou

psV

osta

nis,

Feeh

an,

Gra

ttan

,& B

icke

rton

,19

96b

Vos

tani

s,Fe

ehan

,G

ratt

an,

& Bic

kert

on,

1996

a

9-m

oFU

DSM

-III

RM

DD

MFQ

-CN

om

ood

dx9

sess

ions

,in

divi

dual

CB

T9

sess

ions

,in

divi

dual

NFI

29/2

828

/28

20/2

821

/28

−28

MFQ

-C=

−0.0

3

Tre

atm

ent

gain

sw

ere

mai

ntai

ned

inbo

thtr

eatm

ent

grou

psat

9-m

oFU

;ho

wev

er,

27%

ofth

esa

mpl

em

etcr

iter

iafo

rM

DD

and

45%

repo

rted

sign

ifica

ntde

pres

sive

sym

ptom

sdu

ring

the

prev

ious

9-m

ope

riod

;lo

wse

lf-es

teem

pred

icte

dlo

ng-t

erm

outc

ome

Vos

tani

set

al.,

1996

b

Vos

tani

s,Fe

ehan

,& G

ratt

an,

1998

2-yr

FUD

SM-I

IIR

MD

DM

FQ-C

No

moo

ddx

9se

ssio

ns,

indi

vidu

alC

BT

9se

ssio

ns,

indi

vidu

alN

FI

29/2

728

/27

20/2

723

/27

−9 MFQ

-C=

−0.3

6

Ove

rall,

trea

tmen

tga

ins

wer

em

aint

aine

din

both

trea

tmen

tgr

oups

at2-

yrFU

;ho

wev

er,

20%

ofsa

mpl

em

etcr

iter

iafo

rM

DD

and

39%

repo

rted

sign

ifica

ntde

pres

sive

sym

ptom

sdu

ring

the

prev

ious

year

;lo

wse

lf-es

teem

cont

inue

dto

pred

ict

long

-ter

mou

tcom

e

—co

ntin

ued

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 955

TA

BL

E4

cont

inue

d

Aut

hor(

s)Fo

llow

-up

Cit

atio

nFo

llow

-up

Des

ign

Tar

get

Dia

gnos

es

Prim

ary

Dep

ende

ntM

easu

res

Tre

atm

ent

Con

diti

ons

Sam

ple

Size

(ini

tial

/FU

)Pr

opor

tion

Res

pond

ing

Follo

w-u

pE

BM

NN

TE

ffec

tSi

zeC

omm

ents

Wei

szet

al.,

1997

Inor

igin

alar

ticl

e9-

mo

FUC

hild

ren

wit

hm

ildto

mod

erat

esy

mpt

oms

ofde

pres

sion

CD

IC

DR

S-R

8se

ssio

ns,

grou

pC

BT

NT

C

60.4

%of

the

orig

inal

sam

ple

avai

labl

efo

rFU

(not

repo

rted

bygr

oup)

NA

NA

Inge

nera

l,tr

eatm

ent

gain

sw

ere

mai

ntai

ned

over

the

9-m

oFU

;m

ore

child

ren

inth

etr

eatm

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COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004956

treatment include psychoeducation about depressionand its causes, goal setting with the adolescent, andgeneral problem-solving skills. Modules, chosen jointlyby the therapist and adolescent, then address thespecific skill deficits of the teenager. Because parent–child conflict is both a risk factor for depression andpredictive of poor treatment outcome and relapse, in-cluding a parent component in CBT is justified on anad hoc basis. Moreover, evidence is beginning toemerge that combined child and parent treatment maybe more effective than treatment directed at the teen-ager alone (Lewinsohn et al., 1990). In addition toteaching contingency management procedures, parentsare provided with alternative, effective methods for par-enting and creating a more positive family environ-ment. Furthermore, family interactions are targeteddirectly to shape and reinforce effective communica-tion and to increase pleasant activities and positive af-fect.

DISCUSSION

A substantial evidence base supports the efficacy ofproblem-specific cognitive-behavioral interventions fora variety of childhood and adolescent anxiety and de-pressive disorders. Unlike other psychotherapeutictechniques that have been applied to these disorders,CBT is consistent with an EBM perspective that valuesempirically supported problem-focused treatments.CBT presents a logical theoretical framework to guidepractitioners through an idiographic assessment of spe-cific problem domains, the delivery of problem-specifictreatment interventions, and well-specified outcomesto monitor treatment progress. However, CBT is notsimplistic. Helping children, adolescents, and parentsmake rapid and difficult behavior change over shorttime intervals requires considerable expertise and train-ing.

Future research in the areas of childhood and ado-lescent anxiety and depressive disorders will need tofocus on the following areas. First, controlled trialscomparing medications, CBT, and their combinationare needed to determine whether combined treatmentprovides an additive benefit in terms symptom reduc-tion. Second, treatment-dismantling studies are neededto identify the relative contributions of specific CBTcomponents to symptom reduction and treatment ac-ceptability. Third, mediational analyses (how a treat-

ment works) are needed to refine treatmentinterventions and better understand the mechanism(s)through which treatments achieve their therapeutic ef-fect. Fourth, follow-up studies with adequate controlgroups will be necessary to evaluate the long-term ben-efit of CBT, including examining whether boosterCBT sessions reduce relapse rates and whether inter-vening in childhood prevents the onset of adult psy-chiatric disorders. Finally, studies with diverse patientpopulations are needed to evaluate the exportabilityand generalizability of currently available protocol-driven treatments.

Disclosure: Dr. March receives consulting fees from Solvay, Pfizer,GSKI, Wyeth-Ayerst, and BMS and serves as Scientific Advisor forShire and Pfizer and DSMB Chair for the Organon Study. He hasfinancial relationships with MultiHealth Systems for the Multidimen-sional Anxiety Scale for Children.

REFERENCES

Ackerson J, Scogin F, McKendree-Smith N, Lyman RD (1998), Cognitivebibliotherapy for mild and moderate adolescent depressive symptom-atology. J Consult Clin Psychol 66:685–690

Albano AM, Silverman WK (1996), Clinician’s Guide to the Anxiety Disor-ders Interview Schedule for DSM-IV, Child Version. Boulder, CO: Gray-wind Publications

Andreason N (1997), Linking mind and brain in the study of mentalillnesses: a project for a scientific psychopathology. Science 275:1586–1598

Asarnow JR, Scott CV, Mintz J (2002), A combined cognitive-behavioralfamily education intervention for depression in children: a treatmentdevelopment study. Cognit Ther Res 26:221–229

Barlow DH (1993), On the relation of clinical research to clinical practice:current issues, new directions. In: Issues in Clinical Psychology: The Re-lationship Between the Scientist and the Practitioner, Mindell J, ed. Du-buque, IA: Wm. C. Brown, pp 11–35

Barrett PM (1998), Evaluation of cognitive-behavioral group treatments forchildhood anxiety disorders. J Clin Child Psychol 27:459–468

Barrett PM, Dadds MR, Rapee RM (1996), Family treatment of childhoodanxiety: a controlled trial. J Consult Clin Psychol 64:333–342

Barrett PM, Duffy AL, Dadds MR, Rapee RM (2001), Cognitive-behavioral treatment of anxiety disorders in children: long-term (6-year)follow-up. J Consult Clin Psychol 69:135–141

Beidel DC, Turner SM, Morris TL (2000), Behavioral treatment of child-hood social phobia. J Consult Clin Psychol 68:1072–1080

Bernstein GA, Shaw K (1997), Practice parameters for the assessment andtreatment of children and adolescents with anxiety disorders. J Am AcadChild Adolesc Psychiatry 36:69S–84S

Birmaher B, Brent DA, Kolko D et al. (2000), Clinical outcome aftershort-term psychotherapy for adolescents with major depressive disor-der. Arch Gen Psychiatry 57:29–36

Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J (1996a),Childhood and adolescent depression: a review of the past 10 years. PartII. J Am Acad Child Adolesc Psychiatry 35:1575–1583

Birmaher B, Ryan ND, Williamson DE et al. (1996b), Childhood andadolescent depression: a review of the past 10 years. Part I. J Am AcadChild Adolesc Psychiatry 35:1427–1439

Brent DA, Birmaher B, Kolko D, Baugher M, Bridge J (2001), Subsyn-

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 957

dromal depression in adolescents after a brief psychotherapy trial: courseand outcome. J Affect Disord 63:51–58

Brent DA, Holder D, Kolko D et al. (1997), A clinical psychotherapy trialfor adolescent depression comparing cognitive, family, and supportivetherapy. Arch Gen Psychiatry 54:877–885

Brent DA, Kolko DJ, Birmaher B et al. (1998), Predictors of treatmentefficacy in a clinical trial of three psychosocial treatments for adolescentdepression. J Am Acad Child Adolesc Psychiatry 37:906–914

Chambers WJ, Puig-Antich J, Hirsch M et al. (1985), The assessment ofaffective disorders in children and adolescents by semistructured inter-view. Test-retest reliability of the schedule for affective disorders andschizophrenia for school-age children, present episode version. Arch GenPsychiatry 42:696–702

Clarke G, Lewinsohn P, Hops H (1990), Instructor’s Manual for the Ado-lescent Coping With Depression Course, 4th ed. Eugene, OR: Castalia Press

Clarke GN, Hornbrook M, Lynch F et al. (2002), Group cognitive-behavioral treatment for depressed adolescent offspring of depressedparents in a health maintenance organization. J Am Acad Child AdolescPsychiatry 41:305–313

Clarke GN, Rohde P, Lewinsohn PM, Hops H, Seeley JR (1999), Cogni-tive-behavioral treatment of adolescent depression: efficacy of acutegroup treatment and booster sessions. J Am Acad Child Adolesc Psychiatry38:272–279

Cobham VE, Dadds MR, Spence SH (1998), The role of parental anxietyin the treatment of childhood anxiety. J Consult Clin Psychol 66:893–905

Cohen J, March J, Berliner L (2000), Treatment of PTSD in Children andAdolescents. In: Effective Treatments for PTSD, Foa E, Davidson J,Keane T, eds. New York: Guilford, pp 106–138

Compton SN, Burns BJ, Egger HL, Robertson E (2002), Review of theevidence base for treatment of childhood psychopathology: internalizingdisorders. J Consult Clin Psychol 70:1240–1266

Cornwall E, Spence SH, Schotte D (1996), The effectiveness of emotiveimagery in the treatment of darkness phobia in children. Behav Change13:223–229

Curry JF, Reinecke MA (2003), Modular therapy for adolescents withmajor depression. In: Cognitive Therapy With Children and Adolescents:A Casebook for Clinical Practice, 2nd ed., Reinecke MA, Dattilio FM etal., eds. New York: Guilford, pp 95–128

Eisen A, Kearney C (1995), Treating Fear and Anxiety in Children andAdolescents. Northvale, NJ: Jason Aronson

Flannery-Schroeder EC, Kendall PC (2000), Group and individual cogni-tive-behavioral treatments for youth with anxiety disorders: a random-ized clinical trial. Cognit Ther Res 24:251–278

Franklin ME, Rynn M, March JS, Foa EB (2002), Obsessive-compulsivedisorder. In: Clinical Behavior Therapy: Adults and Children, Hersen M,ed. New York: Wiley, pp 276–303

Geddes J, Reynolds S, Streiner D, Szatmari P (1997), Evidence basedpractice in mental health [editorial]. BMJ 315:1483–1484

Guyatt GH, Sackett DL, Cook DJ (1993), Users’ guides to the medicalliterature. II. How to use an article about therapy or prevention. A. Arethe results of the study valid? Evidence-Based Medicine WorkingGroup. JAMA 270:2598–2601

Guyatt GH, Sackett DL, Cook DJ (1994), Users’ guides to the medicalliterature. II. How to use an article about therapy or prevention. B.What were the results and will they help me in caring for my patients?Evidence-Based Medicine Working Group. JAMA 271:59–63

Guyatt GH, Sinclair J, Cook DJ, Glasziou P (1999), Users’ guides to themedical literature: XVI. How to use a treatment recommendation. Evi-dence-Based Medicine Working Group and the Cochrane ApplicabilityMethods Working Group. JAMA 281:1836–1843

Haynes SN, O’Brien WH (1990), Functional analysis in behavior therapy.Clin Psychol Rev 10:649–668

Hayward C, Varady S, Albano AM, Thienemann M, Henderson L,Schatzberg AF (2000), Cognitive-behavioral group therapy for socialphobia in female adolescents: results of a pilot study. J Am Acad ChildAdolesc Psychiatry 39:721–726

Hibbs E, Jensen P (1996), Psychosocial Treatments for Child and AdolescentDisorders Washington, DC: American Psychological Press

Hoberman HM, Clarke GN, Saunders SM (1996), Psychosocial interven-tions for adolescent depression: issues, evidence, and future directions.Prog Behav Modif 30:25–73

Hyman SE (2000), The millennium of mind, brain, and behavior. Arch GenPsychiatry 57:88–89

Kahn JS, Kehle TJ, Jenson WR, Clark E (1990), Comparison of cognitive-behavioral, relaxation, and self-modeling interventions for depressionamong middle-school students. School Psychol Rev 19:196–211

Kendall P (1993), Guiding theory for therapy with children and adoles-cents. In: Child and Adolescent Therapy, Kendall P, ed. New York:Guilford, pp 3–22

Kendall PC (1994), Treating anxiety disorders in children: results of arandomized clinical trial. J Consult Clin Psychol 62:100–110

Kendall PC, Aschenbrand SG, Hudson JL (2003), Child-focused treatmentof anxiety. In: Evidence-Based Psychotherapies for Children and Adoles-cents, Kazdin AE, ed. New York: Guilford, pp 81–100

Kendall PC, Chu BC, Pimentel SS, Choudhury M (2000), Treating anxietydisorders in youth. In: Child and Adolescent Therapy: Cognitive-Behavioral Procedures, 2nd ed. Kendall PC, ed. New York: Guilford, pp235–287

Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, Southam-Gerow M (1997), Therapy for youths with anxiety disorders: a secondrandomized clinical trial. J Consult Clin Psychol 65:366–380

Kendall PC, Grove WM (1988), Normative comparisons in therapy out-come. Behav Assess 10:147–158

Kendall PC, Krain A, Treadwell KR (1999), Generalized anxiety disorder.In: Handbook of Prescriptive Treatments for Children and Adolescents, 2nded. Ammerman RT, Hersen M, Last CG, eds. Boston: Allyn and Bacon,pp 155–171

Kendall PC, Panichelli-Mindel SM (1995), Cognitive-behavioral treat-ments. J Abnorm Child Psychol 23:107–124

Kendall PC, Southam-Gerow MA (1996), Long-term follow-up of a cog-nitive-behavioral therapy for anxiety-disordered youth. J Consult ClinPsychol 64:724–730

King NJ, Tonge BJ, Heyne D et al. (1998), Cognitive-behavioral treatmentof school-refusing children: a controlled evaluation. J Am Acad ChildAdolesc Psychiatry 37:395–403

Last CG, Hansen C, Franco N (1998), Cognitive-behavioral treatment ofschool phobia. J Am Acad Child Adolesc Psychiatry 37:404–411

Lewinsohn P, Clarke GN, Rohde P (1994), Psychological Approaches to theTreatment of Depression in Adolescents. New York: Plenum

Lewinsohn PM, Clarke GN, Hops H, Andrews JA (1990), Cognitive-behavioral treatment for depressed adolescents. Behav Ther 21:385–401

Liddle B, Spence SH (1990), Cognitive-behaviour therapy with depressedprimary school children: a cautionary note. Behav Psychother 18:85–102

Manassis K, Mendlowitz SL, Scapillato D et al. (2002), Group and indi-vidual cognitive-behavioral therapy for childhood anxiety disorders. Arandomized trial. J Am Acad Child Adolesc Psychiatry 41:1423–1430

March J, Mulle K (1998), OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. New York: Guilford

March J, Wells K (2003), Combining medication and psychotherapy. In:Pediatric Psychopharmacology: Principles and Practice, Martin A, ScahillL, Charney DS, Leckman JF, eds. London: Oxford University Press, pp426–446

March JS (1995), Cognitive-behavioral psychotherapy for children and ado-lescents with OCD: a review and recommendations for treatment. J AmAcad Child Adolesc Psychiatry 34:7–18

McClellan J, Werry J (1997), Practice parameters for the assessment andtreatment of children and adolescents with bipolar disorder. J Am AcadChild Adolesc Psychiatry 36:157S–176S

Mendlowitz SL, Manassis K, Bradley S, Scapillato D, Miezitis S, Shaw BF(1999), Cognitive-behavioral group treatments in childhood anxietydisorders: the role of parental involvement. J Am Acad Child AdolescPsychiatry 38:1223–1229

Menzies RG, Clarke J (1993), A comparison of in vivo and vicarious exposurein the treatment of childhood water phobia. Behav Res Ther 31:9–15

Muris P, Mayer B, Bartelds E, Tierney S, Bogie N (2001), The revised

COMPTON ET AL.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004958

version of the Screen for Child Anxiety Related Emotional Disorders(SCARED-R): treatment sensitivity in an early intervention trial forchildhood anxiety disorders. Br J Clin Psychol 40:323–336

Muris P, Meesters C, van Melick M (2002), Treatment of childhood anxi-ety disorders; A preliminary comparison between cognitive-behavioralgroup therapy and a psychological placebo intervention. J Behav TherExp Psychiatry 33:143–158

Nauta MH, Scholing A, Emmelkamp PM, Minderaa RB (2003), Cogni-tive-behavioral therapy for children with anxiety disorders in a clinicalsetting: no additional effect of a cognitive parent training. J Am AcadChild Adolesc Psychiatry 42:1270–1278

Orvaschel H, Puig-Antich J (1986), Schedule for Affective Disorders andSchizophrenia for School-Age Children, Epidemiologic Version. Pittsburgh:Western Psychiatric Institute and Clinic

Pina AA, Silverman WK, Fuentes RM, Kurtines WM, Weems CF (2003),Exposure-based cognitive-behavioral treatment for phobic and anxietydisorders: treatment effects and maintenance for Hispanic/Latino rela-tive to European-American youths. J Am Acad Child Adolesc Psychiatry42:1179–1187

Puig-Antich J, Chambers W (1978), The Schedule for Affective Disorders andSchizophrenia for School-Aged Children. New York: New York StatePsychiatric Institute

Rapee R, Spense S, Cobham V, Wignal A (2000), Helping Your AnxiousChild: A Step-By-Step Guide for Parents. San Francisco: New Harbinger

Reinecke MA, Dattilio FM, Freeman A (2003), What makes for an effectivetreatment? In: Cognitive Therapy With Children and Adolescents: A Case-book for Clinical Practice, 2nd ed. Reinecke MA, Dattilio FM, FreemanA, eds. New York: Guilford, pp 1–18

Reinecke MA, Ryan NE, DuBois DL (1998), Cognitive-behavioral therapyof depression and depressive symptoms during adolescence: a review andmeta-analysis. J Am Acad Child Adolesc Psychiatry 37:26–34

Rossello J, Bernal G (1999), The efficacy of cognitive-behavioral and in-terpersonal treatments for depression in Puerto Rican adolescents.J Consult Clin Psychol 67:734–745

Rutter M (1999), The Emanuel Miller Memorial Lecture 1998. Autism:two-way interplay between research and clinical work. J Child PsycholPsychiatry 40:169–188

Sackett D, Richardson W, Rosenberg W, Haynes B (1997), Evidence-BasedMedicine. London: Churchill Livingstone

Sackett D, Richardson W, Rosenberg W, Haynes B (2000), Evidence-BasedMedicine, 2nd ed. London: Churchill Livingstone

Shadish WR, Robinson L, Congxiao L (1999), ES: A Computer Program forEffect Size Calculation, 1.0 ed. St. Paul, MN: Assessment Systems

Shortt AL, Barrett PM, Fox TL (2001), Evaluating the FRIENDS Program:a cognitive-behavioral group treatment for anxious children and theirparents. J Clin Child Psychol 30:525–535

Silverman W, Kurtines W (1996), Anxiety and Phobic Disorders: A Prag-matic Approach. New York: Plenum

Silverman WK (1987), Anxiety Disorders Interview Schedule for Children.Boulder, CO: Graywind Publications

Silverman WK, Albano AM (1996a), The Anxiety Disorders InterviewSchedule for DSM-IV: Child Interview Schedule. Boulder, CO: Graywind

Silverman WK, Albano AM (1996b), The Anxiety Disorders InterviewSchedule for DSM-IV: Parent Interview Schedule. Boulder, CO: Gray-wind

Silverman WK, Kurtines WM, Ginsburg GS, Weems CF, Lumpkin PW,Carmichael DH (1999a), Treating anxiety disorders in children withgroup cognitive-behavioral therapy: a randomized clinical trial. J ConsultClin Psychol 67:995–1003

Silverman WK, Kurtines WM, Ginsburg GS, Weems CF, Rabian B, Se-rafini LT (1999b), Contingency management, self-control, and educa-tion support in the treatment of childhood phobic disorders: a random-ized clinical trial. J Consult Clin Psychol 67:675–687

Silverman WK, Nelles WB (1988), The Anxiety Disorders Interview Sched-ule for Children. J Am Acad Child Adolesc Psychiatry 27:772–778

Spence SH, Donovan C, Brechman-Toussaint M (2000), The treatment ofchildhood social phobia: the effectiveness of a social skills training-based, cognitive-behavioural intervention, with and without parentalinvolvement. J Child Psychol Psychiatry 41:713–726

Thyer BA (1991), Diagnosis and treatment of child and adolescent anxietydisorders. Behav Modif 15:310–325

Treatment for Adolescents with Depression Study (2003), Treatment forAdolescents with Depression Study (TADS): rationale, design, andmethods. J Am Acad Child Adolesc Psychiatry 42:531–542

Van Hasselt V, Hersen M (1993), Handbook of Behavior Therapy and Phar-macotherapy for Children. Boston: Longwood

Vostanis P, Feehan C, Grattan E (1998), Two-year outcome of childrentreated for depression. Eur Child Adolesc Psychiatry 7:12–18

Vostanis P, Feehan C, Grattan E, Bickerton W-L (1996b), Treatment forchildren and adolescents with depression: lessons from a controlled trial.Clin Child Psychol Psychiatry 1:199–212

Vostanis P, Feehan C, Grattan E, Bickerton W-L (1996a), A randomisedcontrolled out-patient trial of cognitive-behavioural treatment for chil-dren and adolescents with depression: 9-month follow-up. J Affect Dis-ord 40:105–116

Weisz JR, Thurber CA, Sweeney L, Proffitt VD, LeGagnoux GL (1997),Brief treatment of mild-to-moderate child depression using primary andsecondary control enhancement training. J Consult Clin Psychol 65:703–707

Wood A, Harrington R, Moore A (1996), Controlled trial of a brief cog-nitive-behavioural intervention in adolescent patients with depressivedisorders. J Child Psychol Psychiatry 37:737–746

RESEARCH UPDATE REVIEW: CBT

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004 959