cognitive-behavioral therapies with youth: guiding theory, current

Jour1993

nal of Consulting and Clinical Psychologyi. Vol. 61. No. 2. 235-247

Copyright 1993 by the American Psychological Association, Inc.0022-006X/93/$3.00

Cognitive-Behavioral Therapies With Youth: Guiding Theory,Current Status, and Emerging Developments

Philip C. Kendall

This article begins with a brief description of the guiding theory behind cognitive-behavioralinterventions with youth, such as a therapeutic posture, an important cognitive distinction, and aspecific treatment goal. Next, on the basis of a review of the literature, the nature of cognitivefunctioning, the treatments, and the outcome of treatment studies are described and examined for(a) aggression, (b) anxiety, (c) depression, and (d) attention-deficit hyperactivity. Conclusions andemerging developments are provided.

Central to a successful completion of childhood is the child'sdevelopment of a confident sense of mastery, of appropriatesocial behavior, and of an ability to engage in self-control. Aschildren enter and pass through school and become more inde-pendently involved in social relationships, there is a new empha-sis toward carrying through on activities and accomplishinggoals. The child must work to strike a balance between compli-ance with adult rules and the assertion of independent compe-tence. Industrious work in school and social interactions are thetesting ground for children to compare themselves with others,to gain a sense of self, and to acquire the skills needed to adjustto the demands of the environment.

Adjusting and coping with these developmental challengescan be a struggle for children, and not all manage the tasksuccessfully. Indeed, current estimates of the amount of psycho-pathology in children in the United States are alarming. Recentepidemiological data suggest that between 15% and 22% of thenation's approximately 63 million youth have mental healthproblems severe enough to warrant treatment (Costello, 1990;National Advisory Mental Health Council, 1990). Yet, as Tuma(1989) noted, of those in need of mental health care, less than20% received the appropriate services. These data are probablyrepresentative of a concern that is worldwide. Indeed, psycho-logical maladjustment in youth is a major problem confrontingtoday's society.

All children face developmental challenges, yet not all ofthese children are prepared, and not all of the challenges aremet. Thus, the issue facing clinical child psychology is how tobest intervene to reduce or remediate the cognitive, behavioral,and emotional difficulties in childhood that are associatedwith present psychological distress and later psychopathology.

Guiding Theory

Those involved in designing interventions for youth have ap-proached their task from various perspectives. Some have

Preparation of this article was facilitated by National Institute ofMental Health Grant 44042.

Correspondence concerning this article should be addressed toPhilip C. Kendall, Weiss Hall, Department of Psychology, Temple Uni-versity, Philadelphia, Pennsylvania 19122.

sought to have a preventive influence, intervening to reduceproblems in youth at risk for later maladjustment (e.g., Weiss-berg, Caplan, & Harwood, 1991), whereas others have taken atherapeutic approach, providing therapy for youth with identi-fied psychopathology (e.g., Kendall, 199la). Some applicationshave followed more behavioral guidelines (see Barkley, 1990);others have been influenced by rational-emotive therapy (Ber-nard & Joyce, 1984). Some have sought to intervene at the levelof the family (e.g., Robin & Foster, 1989), the school (e.g., Elias,1989), or the community (e.g., Glenwick & Jason, 1984),whereas others work directly with youth (e.g., Kendall & Bras-well, 1985).

Cognitive-behavioral approaches can be defined as a ratio-nal amalgam: a purposeful attempt to preserve the demon-strated positive effects of behavioral therapy within a less doc-trinaire context and to incorporate the cognitive activities of theclient into the efforts to produce therapeutic change. Accord-ingly, cognitive-behavioral strategies with children and adoles-cents use enactive, performance-based procedures as well ascognitive interventions to produce changes in thinking, feeling,and behavior (Kendall, 199 Ib). The cognitive-behavioral analy-ses of child and adolescent disorders and adjustment problems,as well as related analyses of treatment-produced gains, includeconsiderations of the child's internal and external environment,and represent an integratoonist perspective (Meichenbaum,1977). The model places the greatest emphasis on the learningprocess and the influence of the contingencies and models inthe environment while underscoring the centrality of the indi-vidual's mediating-information-processing style in the develop-ment and remediation of psychological distress (Kendall,1985). Cognitive-behavioral therapies do not insult the role ofaffect and the social context. Rather, they integrate cognitive,behavioral, affective, social, and contextual strategies forchange. The cognitive-behavioral model includes the relation-ships of cognition and behavior to the affective state of theorganism and the functioning of the organism in the largersocial context.

Therapy With Youth: The Cognitive-Behavioral Posture

The "posture" (used here to refer to one's mental attitude) ofthe cognitive-behavioral therapist working with youth can be

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236 PHILIP C. KENDALL

described using the terms consultant, diagnostician, and educa-tor. As a consultant, the therapist is a person who does not haveall the answers but has some ideas worthy of trying out andsome ways to examine whether or not the ideas have value forthe individual youth. The consultant therapist helps create be-havioral experiments to test some of the dysfunctional beliefs ofthe client. Telling a child or adolescent exactly what to do is notthe idea; rather, the therapist should give the client an opportu-nity to try something and help him or her to make sense of theexperience. The therapist as consultant-collaborator strives todevelop skills in the client that include thinking on his or herown and moving toward independent, mature problem solving.The youngster and therapist interact in a collaborative, prob-lem-solving manner. When the client asks, "Well, what am Isupposed to do?" the therapist might reply, "Let's see, what doyou want to accomplish here?" and then "What are our op-tions?" or "What's another way we could look at this problem?"The consultative exchange is intended to facilitate the processof problem solving.

As a diagnostician, the therapist integrates data and, judgingagainst a background of knowledge of psychopathology, nor-mal development, and psychologically healthy environments,makes meaningful decisions. Mental health professionals can-not let others tell them what is wrong and what needs to befixed (e.g., it is not sufficient that a parent or teacher says that achild is "hyperactive"). The fact that a parent or teacher sus-pects hyperactivity is one piece of useful information, but thereare rival hypotheses that must be considered. For example, thechild's behavior may be within normal limits but appear astroubled when judged against inappropriate parental (orteacher) expectations. There is also the possibility of alternativedisorders; hyperactivity may be the term used by the referringadult, but aggressive noncompliance may be a better descriptionin terms of mental health professionals' communications. Adysfunctional family interaction pattern may need the greatestattention, not the child per se. The cognitive-behavioral thera-pist serves as a diagnostician by taking into account the varioussources of information and, judging against a background ofknowledge, describes the nature of the problem and an optimalstrategy for its intervention.

As an educator, the therapist is involved in interventions forlearning behavior control, cognitive ̂ kills, and emotional devel-opment and in determining optimal ways to communicate tohelp young people to learn. A good educator stimulates youthto think for themselves. A good therapist is an active and in-volved educator. A good educator observes the student, helps tomaximize strengths and reduce hindrances, and accepts thatindividuals can and should do things differently. A good educa-tor pays attention to what the learner is saying to himself orherself, because this internal dialogue influences performance.An effective therapist, just as an effective teacher, is involved inthe process. A high-quality intervention is one that alters howthe child makes sense of experiences and the way the child willbehave in the future.

A Treatment Goal: Building a Coping Template

Cognitive-behavioral theorists have promoted the notionthat individuals perceive and make sense of the world through

their cognitive structures, also referred to as schemata (Beck,1976). Such a template has an influence on what is perceivedand how it is processed and understood. Children and adoles-cents are in the process of developing ways to view their world,and cognitive-behavioral treatments provide educational expe-riences and therapist-coached reconceptualizations of prob-lems to build a new "coping" template. That is, the treatmentgoal is for the child to develop a new cognitive structure, or amodified existing structure, through which he or she can lookat formerly distressing situations. Therapy helps in reducing thesupport for dysfunctional schemata and in constructing a newschema through which the child can identify and solve prob-lems. An effective intervention capitalizes on creating behav-ioral experiences with emotional involvement while paying at-tention to the cognitive activities of the participant. The thera-pist guides both the youngster's attributions about priorbehavior and his or her expectations for future behavior. Thus,the youngster can acquire a cognitive structure for future eventsthat includes the adaptive skills and appropriate cognition asso-ciated with adaptive functioning. The child's acquisition anduse of a coping template is a major goal of the treatment, a goalthat requires the therapist's use of several treatment strategies.

A Cognitive Differentiation: Distortion Versus Deficiency

With cognitive dysfunction emerging as a target for therapy, itis important to recognize that all cognitive dysfunction is notthe same and that an understanding of the nature of the cogni-tive dysfunction associated with specific psychological dis-orders has important implications for treatment. With refer-ence to children and adolescents, I have made the distinctionbetween cognitive distortions and cognitive deficiencies (Ken-dall, 1985,1991b). Deficiencies in cognitive functioning refer toan absence of thinking. Youth with cognitive deficiencies lackcareful information processing in situations in which thinkingwould be beneficial. In contrast, cognitive distortions are evi-dent in youth who engage in information processing but do soin a dysfunctional or biased fashion. Acting without thinking isin marked contrast to action that follows misguided thinking,and treatment strategies must be modified accordingly. Target-ing cognitive deficiencies requires stopping nonthoughtful ac-tivity and developing and deploying skills in thoughtful prob-lem solving. Cognitive distortions require that the faulty think-ing first be identified and that the distorted processing then becorrected.

Anxiety and depression in youth have been linked to dis-torted thinking, such as misconstruals and misperceptions ofthe social situation and the demands in the environment, aswell as harsh and critical views of the self. For example, a recentstudy showed that depressed youngsters viewed themselves asless capable than nondepressed youth, even though teachersperceived the groups as indistinct (Kendall, Stark, & Adam,1990). Impulsive children are often found to act without think-ing and to perform poorly because of a lack of forethought andplanning (deficiencies in information processing; e.g., Douglas,1972). In aggression, there is evidence of both cognitive defi-ciency and cognitive distortion (e.g., Lochman, White, & Way-land, 1991). As will become evident as cognitive-behavioralinterventions are reviewed, interventions often consider and

SPECIAL SECTION: THERAPIES WITH YOUTH 237

target the nature of the cognitive dysfunction in the specificHicnrHprdisorder.

Areas of Application: Current Status

Cognitive-behavioral approaches to interventions for chil-dren and adolescents have been applied to a wide variety oftopics (see Kendall, 199 la; Meyers & Craighead, 1984), includ-ing anger (e.g., Lochman et al., 1991), attention-deficit hyperac-tivity disorder (ADHD; e.g., Braswell & Bloomquist, 1991; Hin-shaw & Erhardt, 1991), anxiety disorders (Kendall et al., 1992),medical and dental stress (Melamed, Klingman, & Siegel,1984), depression (Stark, Rouse, & Livingston, 1991), and im-pulsivity (Kendall & Braswell, 1985). Cognitive-behavioral ap-proaches have also been used with children with chronic illness(e.g., Walco & Varni, 1991) and with learning disabilities (e.g.,Keogh & Hall, 1984; Wong, Harris, & Graham, 1991). Inclusionof the parents (e.g., Braswell, 1991; Braswell & Bloomquist,1991; Kendall et al., 1992) and the families (e.g., Turkewitz,1984) of youth has also been undertaken from the cognitive-be-havioral perspective. In the present discussion,11 provide a se-lective review of applications and their outcomes across severalareas: (a) aggression, (b) anxiety, (c) depression, and (d) ADHD.In each, I describe the nature of the disorder, the components ofthe intervention, and illustrative outcomes.

Aggression in Youth

Although common in mild forms during early childhood,aggression becomes clinically significant when it occurs withhigh frequency or intensity or across multiple settings (e.g.,home and school; e.g., Loeber & Dishion, 1983). Five percent to10% of children display clinically significant aggressive behav-ior, with boys outnumbering girls by about three to one (Kaz-din, 1987; Quay, 1986). Clinical concern has been focused onaggressive children because of the substantial stability of ag-gressive behavior over time (Huesmann, Eron, Lefkowitz, &Walker, 1984; Olweus, 1979) and because childhood aggressivebehavior has emerged as a significant risk marker for subse-quent substance abuse, delinquency, and school failure (Coie,Lochman, Terry, & Hyman, 1991; see also Pepler & Rubin,1991).

What is the nature of cognitive functioning in aggressiveyouth? Aggressive children can be said to surfer from bothdistortions and deficiencies in their cognitive processing (Ken-dall, Ronan, & Epps, 1991). Cognitive distortions involve dys-functional thinking processes, whereas cognitive deficienciesinvolve an insufficient amount of cognitive activity in situationsin which greater forethought prior to action is needed.

Several factors have been identified in the cognitive distor-tions of aggressive children. Aggressive children have beenfound to use fewer environmental cues to mediate their behav-ior. Dodge and Newman (1981) found that in a "detective" gamein which children were to determine whether a fictitious peerhad committed a hostile act, aggressive kindergarten children(identified by teacher ratings) used 30% fewer bits of informa-tion than did nonaggressive children. Likewise, when allowedto listen to an audiotape about another child's intentions, non-aggressive boys listened to 40% more statements than did ag-

gressive boys (Dodge & Newman, 1981). In addition, aggressivechildren have been found to pay greater attention to aggressiveenvironmental cues than do nonaggressive children and havebeen found to recall high rates of hostile cues present in socialstimuli (Dodge, 1985; Dodge, Pettit, McClaskey, & Brown,1986; Milich & Dodge, 1984), to attribute others' behavior inambiguous situations to their hostile intentions (Dodge et al.,1986), to underperceive their own level of aggressiveness andtheir responsibility for early stages of dyadic conflict, and togenerate fewer verbal assertion solutions and more action-ori-ented and aggressive solutions to social problems (Asarnow &Callan, 1985; Lochman & Lampron, 1986; Richard & Dodge,1982). It appears, then, that aggressive children are hypervigi-lant in scanning their social environment for hostile cues, andthat their tendencies to perceive hostile intentions in others'behavior lead them to respond in a nonverbal, action-orientedmanner (Kendall & Lochman, in press).

Other cognitive processes have been investigated. Aggressivechildren have shown an unusual pattern of affect labeling(Garrison & Stolberg, 1983) in that they anticipate that they willhave fewer feelings of fear or sadness in difficult social situa-tions. When they suddenly experience these states, aggressivechildren are likely to be ill prepared to cope, and they are apt tolabel the generalized arousal as anger. Aggressive children'sproblem solving has been found to be limited; however, whenaggressive children respond to social conflicts in a more delib-erate (rather than automatic) manner, they generate higher ratesof competent, assertive solutions (Lochman, Lampron, & Ra-biner, 1990; Rabiner, Lenhart, & Lochman, 1990). Aggressivechildren think of nonverbal, action-oriented solutions whenthey use quick, automatic processing of social events ratherthan using deliberate, memory-retrieval strategies. Aggressivechildren expect that an aggressive solution will reduce aversivereactions from others and allow them to acquire tangible posi-tive outcomes (Perry, Perry, & Rasmussen, 1986), and aggres-sive adolescents believe that aggressive behavior will enhanceself-esteem, will avoid a negative image, and will not causevictims to suffer (Slaby & Guerra, 1988). Boldizar, Perry, andPerry (1989) found that aggressive children placed more valueon controlling the victim and less value on victim suffering,victim retaliation, peer rejection, and negative self-evaluation.Similarly, Lochman et al. (1991) have found that aggressive boysvalue social goals of dominance and revenge more, and a socialgoal of affiliation less, than do nonaggressive boys.

Aggressive children also demonstrate deficiencies in thefinal stages of Dodge's (1985, 1986) information-processingmodel: (a) generation of alternative solutions, (b) a decision con-cerning which solution is most appropriate, and (c) behavioralimplementation of the solution (Kendall et al., 1991; Lochmanet al., 1991). In generating alternative solutions, aggressive chil-dren have been shown to demonstrate both quantitative andqualitative deficiencies (Lochman et al., 1991). For instance,Richard and Dodge (1982) found that in response to a conflict

' Some portions of this section appear in an expanded form in Ken-dall and Lochman (in press), Kendall and Braswell (1993), and Ken-dall, Chansky, and Kortlander (in press). I wish to acknowledge andthank my coauthors for their valuable input.


situation, poorly adjusted children (including aggressive chil-dren) produced fewer solutions and a proportionally highernumber of hostile, ineffective responses than did cooperativechildren. Deluty (1981) found that in comparison with assertiveand submissive children, aggressive children generated moreaggressive solutions to interpersonal conflict situations.

Cognitive-behavioral treatment addresses the various distor-tions and deficiencies that characterize aggressive children'sthinking. To address distortions in the appraisal of situations aswell as deficiencies in the generation, selection, and implemen-tation of effective solutions, the treatment relies on the activeinvolvement of the therapist. For instance, through modeling,the therapist overtly verbalizes his or her appraisal of the situa-tion, various solutions to the situation, and possible conse-quences of the different solutions. Role plays provide the ag-gressive child not only with a chance to practice interpersonalsocial-cognitive skills, but also with the opportunity to increaseskills in perspective taking. In role plays, which may involve thetherapist or a group of other children, aggressive children aregiven the opportunity to hear the other person's perspective onthe situation and thereby increase their abilities to make moreaccurate attributions about the intent of others as well as todevelop greater empathy for the feelings of others.

Self-monitoring and self-instruction components assist chil-dren in accurately monitoring their arousal state, labeling thearousal as coexisting with an appropriate emotional state, recog-nizing situations that typically provide intense feelings of angerand frustration, and using inhibitory self-directives (e.g., "Stop!Think! What can I do?") to slow down the automaticity of theirresponse. Social perspective-taking components focus on help-ing children to be more aware of nonhostile cues in social situa-tions and to become aware of the variety of intentions thatpeers and adults might have in ambiguous social situations.Social problem-solving training is a core element in most cogni-tive-behavioral interventions and involves assisting children tothink of a wider array of possible solutions to perceived socialprovocations, with particular emphasis on verbal assertion,bargaining and compromise solutions, and competent enact-ment of selected solutions.

What are the effects of cognitive-behavioral therapy for aggres-sive youth? Research has indicated that cognitive-behavioraltherapy is a promising form of treatment and secondary pre-vention of conduct and oppositional disorders (Kazdin, 1987).Using a 20-session problem-solving skills training program(combining the Kendall & Braswell [1985] and Spivack & Shure[1974] programs) with aggressive psychiatric inpatient chil-dren, Kazdin, Esveldt-Dawson, French, and Unis (1987) re-ported that problem-solving skills training produced signifi-cant reductions in parents' and teachers' ratings of aggressivebehavior at posttest and at a 1 -year follow-up. These results havebeen replicated in a study combining problem-solving skillstraining with parent behavioral management training with in-patient children (Kazdin et al., 1987) and in a study with antiso-cial children treated in outpatient and inpatient settings (Kaz-din, Bass, Siegel, & Thomas, 1989). Some treatment effects forcognitive-behavioral therapy have also been found withday-hospital conduct-disordered children (Kendall, Reber,McLeer, Epps, & Ronan, 1990) and with hospitalized aggres-sive adolescents (Feindler, Ecton, Kingsley, & Dubey, 1986).

Treatment and client characteristics predictive of outcomehave been examined by Lochman and his colleagues in a seriesof studies using a 12- to 18-session school-based anger copingprogram. Reductions were found in independently observeddisruptive classroom behavior and in parents' ratings of aggres-sive behavior, and improvements in self-esteem were enhanced,when the cognitive-behavioral anger coping program was aug-mented with a behavioral goal-setting component (Lochman,Burch, Curry, & Lampron, 1984) and when the program waslengthened to include 18 weekly group sessions (Lochman,1985). Aggressive boys who initially had the poorest problem-solving skills were found to have the greatest behavioral im-provement after the anger coping program (Lochman, Lam-pron, Burch, & Curry, 1985). In a 3-year follow-up study, aggres-sive boys treated in the anger coping program maintainedsignificant improvements in self-esteem and social problem-solving skills and had a markedly lower substance use rate(Lochman, 1991) than did untreated aggressive boys.

Anxiety Disorder in Youth

Anxiety can be a normal and adaptive response to a varietyof situations. The ability to recognize and avoid harm andthreat is a necessary component of a child's repertoire. Mostchildhood fears are transitory, emerge in the course of en-counters with new challenges, and are resolved by facing thesedemands. In contrast to normal anxious reactions, fears or anxi-eties that are excessive, occur beyond the developmental timeta-ble, or disrupt the child's life are considered maladaptive.Whereas fear is a discrete response to a circumscribed threatand phobias are severe fears involving persistent behavioralavoidance (Barrios & Hartmann, 1988; Miller, Barrett, &Hampe, 1974; Morris & Kratochwill, 1983), anxiety is morediffuse both in stimulus and response and is more long-stand-ing and disruptive than an isolated fear or phobia (Kendall etal., 1992; Morris & Kratochwill, 1991).

Separation anxiety provides a clear illustration of the con-trast between normal and pathological forms of anxiety. Anxi-ety about separation involves a child's being distressed whenapart from caregivers: School and social activities are oftenavoided to maintain contact with caregivers (see also Campbell,1986). Separation anxiety appears naturally and recedes in earlychildhood, and it is characterized by the child's protests attimes of separation or in anticipation of separation. In contrast,when separation anxiety disorder occurs in a 9- or 10-year-old,this signals a maladaptive anxiety past the developmental time-table and, although it may spring from achild'ssomewhat realis-tic concerns about a parent (e.g., in cases of parent conflict),signals the need for intervention in the child's world to rectifythe anxiety provocation.

Clinicians and researchers view childhood anxiety as a mul-tidimensional construct manifested at physiological, behav-ioral, and cognitive levels. Common beliefs hold that the mo-toric components of anxiety responses include, most promi-nently, avoidance, as well as shaky voice, rigid posture, crying,nail biting, and thumb sucking (Barrios & Hartmann, 1988).Physiological reactions are said to include an increase in auto-matic nervous activity, perspiration, diffuse abdominal pain("butterflies in the stomach"), flushed face, urgent need to uri-


nate, trembling, and gastrointestinal distress (see also Barrios &Hartmann, 1988). The physiological assessment of anxiety inadults has received wide attention (see Himadi, Boice, & Bar-low, 1985), yet little empirical data on these indicators in chil-dren exist (Barrios & Hartmann, 1988; Beidel, 1988), eventhough such indicators may be a promising area of research. Anexception is a recent study by Beidel (1988) in which significantdifferences in autonomic activity were found in anxious chil-dren, compared with nonanxious controls, during a test-takingtask. Overall, test-anxious children had significantly higherheart rates than did nonanxious controls; however, no differ-ences were found in systolic or diastolic blood pressure. Suchresults confirm cautions by some (e.g., Haynes, 1978) who advo-cate monitoring more than one physiological indicator becauseconcurrent indicators may not correlate.

What is the nature of cognitive functioning in anxious youth?A variety of anxious children's thoughts have been described,including thoughts of being scared or hurt, self-criticalthoughts, and thoughts of danger (see Barrios & Hartmann,1988). However, until recently, little empirical work has exam-ined cognitions in clinically anxious children. Francis (1988), inher recent review of cognitions of anxious children, concludedthat "no definitive statements about the cognitions of anxiouschildren can be made" (p. 276). Studies on circumscribed fears,such as test anxiety (Prins, 1985), in nonclinical samples havefound that high anxiety is associated with negative self-referentcognitions (e.g., "I'm going to mess up" or "I'm going to get hurtagain").

In terms of information processing, anxious children do notappear to show deficiencies but do evidence a distortion orbias: The individual attends to social or environmental cues butdoes so in a distorted and dysfunctional manner. Anxious chil-dren, for example, seem preoccupied with concerns about evalu-ations by self and others and the likelihood of severe negativeconsequences. They seem to misperceive characteristically thedemands of the environment and routinely add stress to a vari-ety of situations.

Anxious children endorsed more threat-related self-state-ments than did nonanxious youth (Ronan, Kendall, & Rowe,1993) when responding to a self-statement questionnaire andprovided more coping self-talk when responding to a thought-listing task (Kendall & Chansky, 1991). Although they reporteda higher frequency of coping self-talk at pretreatment, it wasalso noted that the coping self-talk was excessive and nonfunc-tional.

What treatments are best for anxiety-disordered youth?Although the treatment of adult anxiety disorders has receivedmuch research attention (see Barlow, 1988; Beck & Emery, 1985;Kendall & Watson, 1989; Maser & Cloninger, 1990; Meichen-baum, 1986; Michelson & Ascher, 1987), the outcome literatureon treating child anxiety disorders is negligible. Strategies thathave proven useful for adults can serve as building blocks inchild interventions, with the addition of age-specific interven-tion materials (e.g., Coping Cat Workbook, Kendall, 1990). Abrief description of the components used in the treatment ofanxiety disorders in children is presented; however, there isincreasing recognition that a combination of strategies is mostefficacious (Kendall et al., 1992; King & Ollendick, 1989).Combining strategies is consistent with the multicomponent

conceptualization of anxiety: cognitive, behavioral, and physio-logical response pathways.

Physiological arousal accompanies anxious cognition; thus,methods that help identify children's physiological symptomsand teach them methods to reduce the arousal are often used.Relaxation training is useful in this regard, with scripts avail-able at the child's developmental level (see Koeppen, 1974; Ol-lendick & Cerny, 1981). Often, the combination of progressivemuscle relaxation, deep breathing, and cognitive imagery isused. There are several examples of use of relaxation trainingwith circumscribed anxiety, such as test anxiety (Richter, 1984).It remains unclear whether relaxation alone is helpful for anxi-ety-disordered children.

Relaxation training, along with the establishment of a fearhierarchy and the pairing of relaxation and fearful situations,composes systematic desensitization (Wolpe, 1973). The under-lying principle in systematic desensitization is the pairing oftwo incompatible emotional states: fear and relaxation. A criti-cal element of desensitization is the hierarchical presentation offeared situations. Beginning with the least threatening situationand building on success experiences allows the child to pro-gress to more frightening situations. Although there is a sub-stantial literature supporting the efficacy of systematic desensi-tization with children, most studies have used nonclinical sub-jects with circumscribed fears such as speech anxiety, testanxiety, or dog phobia (e.g., see Deffenbacher & Kemper, 1974);the efficacy of the treatment with more generalized, pervasivefears is not known.

Modeling involves the demonstration of the desired copingbehaviors in a feared or stressful situation such that they can besubsequently imitated by the child. Feedback and reinforce-ment can be used to maintain the desired behaviors (Ollendick& Francis, 1988). Modeling can be accomplished by having achild observe live or symbolic (videotaped) models or partici-pate with a live model. Ollendick (1979) suggested that not allmodeling experiences are equally powerful; he noted that themore involved the modeling, the more effective the outcome.Using opportunities for the therapist to serve as a coping modelfor the child has been found to be an effective and powerfultherapeutic tool when working with anxiety-disordered chil-dren (Kendall et al., 1992). As a coping model, the therapistself-discloses feared situations that are pertinent to the child'sdifficulties, describes his or her feelings about these situations,shares whether he or she would feel the same or different insimilar situations, and models a strategy for coping with un-wanted arousal.

Because practice is essential, role plays and in vivo experi-ences provide excellent opportunities to try out a variety ofcoping strategies. The therapist can be active in setting up thebehavioral experiments, providing the appropriate amount ofconcrete detail to engage the child and assist in creating thescene as authentically as possible. Particularly with youngerchildren who may be less able to identify the precipitatingevents in their anxious reactions, role plays can be used to helpthe therapist to notice when the child begins to become dis-tressed. In vivo exposure is essential, because it is in these realsituations that the newly developed coping skills can be bestpracticed.

Cognitive models of psychopathology highlight the impact of


maladaptive thinking (e.g., distortions) on maladaptive behav-ior and stress interventions that modify self-talk and addressfaulty cognitive processing. In an example of a controlled com-parative study, Kanfer, Karoly, and Newman (1975) taught chil-dren with nighttime fears positive self-talk (e.g., "I am a braveboy (girl); I can take care of myself in the dark") or encouragedthem to use stimulus-oriented self-talk (e.g., "There are manygood things in the dark; the dark is a fun place to be"). A thirdgroup repeated nursery rhymes as a control. In terms of theamount of time a child could stay in a dark room, the resultssuggested that both active treatments significantly increasedthe duration of staying alone as compared wiih the controlgroup children. Altering self-talk had a positive impact onanxiety.

The goal of cognitive interventions is to build a new (or elabo-rate on an existing) coping template. Building a coping tem-plate involves disputing or correcting the characteristic misin-terpretation and looking at the events through the alternativetemplate (based on coping). Problem-solving (e.g., D'Zurilla,1986; Kendall & Siqueland, 1989; Spivack & Shure, 1974) inter-ventions include problem identification and successive stagesof problem definition and formulation, generation of alterna-tive solutions, choice of desired strategy, and implementationand evaluation. Problem-solving skills provide the underlyingmodel for using available coping actions.

Cognitive-behavioral interventions have been applied tochildren facing stressful medical or dental procedures. Al-though a child facing a bone marrow transplant, chemotherapy,or painful dental procedures has a reality-based distress, effortsto increase the coping armamentarium of these children havebeen successful. Also, they provide guidelines as to what inter-ventions are most helpful to children in other stressful situa-tions. Peterson and her colleagues (Peterson &Shigetomi, 1981;Siegel & Peterson, 1980, 1981) demonstrated that childrenequipped with coping strategies, as compared with either educa-tional information or no preparation, were less anxious andmore cooperative and had lower pulse rates (Siegel & Peterson,1980). Children who received a combination of coping andmodeling were even better able to cope with their medical pro-cedure (tonsillectomy; Peterson & Shigetomi, 1981).

In one of the few investigations of an integrated cognitive-be-havioral treatment for children with diagnosed anxiety dis-orders, Kane and Kendall (1989) reported meaningful improve-ments. Specifically, using a multiple baseline design with 4 sub-jects diagnosed with overanxious disorder, they foundreductions in anxiety as reported by child, parents, and an inde-pendent diagnostician. These changes showed significant im-provements from pretreatment assessment and returned thechild to scores within the normal range, as expected from nor-mative data (see Kendall & Grove, 1988, for discussion of themethod of normative comparisons).

In a randomized clinical trial (Kendall, 1993), anxiety-disor-dered youth were assigned to either a treatment or a wait-listcondition. Children receiving therapy were taught a variety ofstrategies, including relaxation, imagery, problem solving, andmodification of self-talk. These strategies enabled the child tochange the fearful, threat template into one that views anxiety-provoking situations as situations that can be managed. Theactive treatment integrates cognitive strategies, such as modifi-

cation of anxious self-talk and problem solving, with behavioralstrategies of relaxation, exposure, evaluation, and reward.These strategies were put into practice in graduated imaginaland in vivo exposure opportunities. At posttreatment assess-ment, treated subjects evidenced significant reductions in self-reported distress and pathological responses, and were oftenwithin normative ranges. Children's self-rated coping abilitywas also found to be significantly higher. Parents' reports alsoevidenced significant reductions in reports of anxiety in theirchildren. Diagnoses based on a structured interview were com-pared from pretreatment to posttreatment: Using the parents'diagnostic interview data, 64% of the treated cases had no diag-nosis at posttreatment. whereas only one subject in the wait-listcondition showed such change. These findings provide supportfor the use of cognitive-behavioral treatment for anxiety dis-orders in youth.

Depression in Children and Adolescents

Depression is a relatively common mood state, with 40% of14- and 15-year-olds in the Isle of Wight study reporting feelingsof misery and depression (Rutter, Tizard, & Whitmore, 1970).As with many areas of developmental psychopathology, somecontroversy exists about when the classification of disorderssuch as dysthymia and major depressive disorder begins on thiscontinuously distributed set of symptoms. Consistent age andgender effects have been noted on depressive symptomatology(Kazdin. 1989) with no sex differences evident in childhood,but with female adolescents having a higher rate of depressionthan male adolescents.

The nature of depressive symptoms shifts with age, with ado-lescents displaying more anhedonia, hopelessness, hypersom-nia. weight change, and lethality of suicide attempts and chil-dren having primarily depressive appearance, somatic com-plaints, and agitation (Ryan et al., 1987). Depressive disordersmay be combined with anxiety (Brady & Kendall, 1992) andconduct disorders (Kazdin. 1989). Major depressive disorder(MDD) includes a more severe set of symptoms than dysthy-mia, but MDD is not as stable over time as is dysthymic dis-order. The mean duration of MDD has been found to be only 32weeks, with 92% recovery rate for children 1.5 years later (Ko-vacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein,1984). Children who had an earlier onset of their depressivesymptoms had a more stable, chronic course for their depres-sive disorder.

What is the nature of cognitive functioning in depressedyouth? Research on the cognitive characteristics of depressedchildren and adolescents has found distortions in attributions,self-evaluation, and perceptions of past and present events.Kaslow, Rehm, Pollack, and Siegel (1988) found that depressedclinic children had more depressogenic attributions than didnondepressed clinic children or nonclinic children. Depressedchildren have a more external locus of control (Mullins, Siegel,& Hodges, 1985), indicating that they feel less capable of ob-taining valued consequences through their own behavior. Sepa-rating attributions for positive and negative events, Curry andCraighead (1990) found that adolescents with greater depres-sion attributed the cause of positive events to external, unstable,and specific causes, consistent with prior findings that adoles-


cents experience more anhedonia. Attributions for positiveevents were more closely associated with depression than wereattributions for negative events. The relationship between attri-butions and depression has been found only for currently de-pressed inpatient children, and not for children with resolveddepression (McCauley, Burke, Mitchell, & Moss, 1986).

Depressed children have low levels of self-esteem and lowperceived academic and social competence (Asarnow, Carlson,& Guthrie, 1987; Kaslow, Rehm, & Siegel, 1984). Kaslow et al.(1984) examined the nature of these self-evaluation difficultieson a design-copying task and found that depressed childrenexperienced more self-punishment and set more stringent stan-dards for poor scores. These depressed children were particu-larly concerned about not doing well on the task. The low self-evaluations of depressed children also seem to produce dis-torted perceptions of past and present (Haley, Fine, Marriage,Moretti, & Freeman, 1985; Rehm & Carter, 1990). Depressedchildren in the fifth to eighth grades display a variety of cogni-tive errors, including overgeneralizing their predictions of nega-tive outcomes, catastrophizing the consequences of negativeevents, incorrectly taking personal responsibility for negativeoutcomes, and selectively attending to negative features of anevent (Kendall, Stark, & Adam, 1990; Leitenberg, Yost, &Carroll-Wilson, 1986). In addition to these biased appraisalprocesses, depressed children also have displayed problem-solving deficits in some studies, with low rates of impersonal(but not interpersonal) problem solving (Mullins et al., 1985)and a high rate of depressogenic strategies (Asarnow et al.,1987).

What are the outcomes of cognitive-behavioral treatments ofdepression in youth? Cognitive-behavioral treatment pro-grams have been developed to address the cognitive distortionsseen in depressed children. The treatment components con-tained in these interventions include (a) self-control skills in-volving self-consequation (reinforcing themselves more andpunishing themselves less), self-monitoring (paying attention topositive things they do), self-evaluation (setting less perfection-istic standards for their performance), and assertiveness train-ing; (b) social skills, including methods of initiating interac-tions, maintaining interactions, handling conflict, and usingrelaxation and imagery; and (c) cognitive restructuring, involv-ing confronting children about the lack of evidence for theirdistorted perceptions (e.g., Stark et al, 1991).

Only a few studies have been reported on the posttreatmenteffects of the full cognitive-behavioral therapy with depressedchildren (Kazdin, 1989; Stark et al, 1991). For example, Reyn-olds and Coats (1986) compared a cognitive-behavioral inter-vention and a relaxation intervention with a wait-list controlcondition. Thirty moderately depressed adolescents were ran-domly assigned to the three conditions. The two interventionsmet twice weekly for 5 weeks. Both the cognitive-behavioraland the relaxation training interventions, compared with thewait-list control condition, produced significant reductions indepression symptoms according to self-reports and clinical rat-ings. These treatment effects were maintained at a 5-week fol-low-up, along with reductions in anxiety and improvements inacademic self-concept.

Stark, Reynolds, and Kaslow (1987) assigned 29 moderatelyto severely depressed children (aged 9-12 years) to self-control,

behavioral problem-solving, or wait-list conditions. At post-treatment and at an 8-week follow-up, the self-control and be-havioral problem-solving conditions produced significant re-ductions in depression using self-report and clinical interviewsin comparison with the wait-list subjects. However, between-group treatment effects were not evident on mothers' behav-ioral checklist ratings. This study provided some evidence forthe generalization of the treatment effects to home setting(Stark etal, 1991).

The clearest evidence for the specific effects of cognitive-be-havioral treatment emerged in the study reported by Stark et al.(1991) with 24 depressed children (Grades 4 to 7) assigned tocognitive-behavioral therapy or to traditional counseling. Bothinterventions lasted 24 to 26 sessions over 3.5 months and wereconducted in small groups. The cognitive-behavioral treatmentwas a more broad-band intervention than in previous studiesand included self-control, social skills, and cognitive restructur-ing components (see Stark, 1990; Stark et al, 1991). At post-treatment, cognitive-behavioral therapy produced greater im-provements in depression and reductions in depressive cogni-tion than did traditional counseling. However, because thesetreatment gains were not maintained at the 7-month follow-up,the long-term effects of cognitive-behavioral therapy with de-pressed children have yet to be documented.

Attention-Deficit Hyperactivity Disorder (ADHD)

Currently, the diagnostic category of ADHD reflects a con-ceptualization in which motor and cognitive components coex-ist. ADHD involves heightened motor activity, impulsivity, defi-cits in attention, and deficits in rule-governed behavior (Bark-ley, 1990). In addition to the cognitive and behavioralcomponents, ADHDoften involves a relatively high associationwith conduct problems and aggression (Hinshaw, 1987).

What is the nature of the cognitive dysfunction in ADHD?That impulsive children often act without thinking is generallyaccepted and has been widely researched for decades. Althoughvarious labels have been used, these children nevertheless havemany essential features in common. Douglas and Peters (1979)traced the difficulties of hyperactive children to deficiencies inthe "mechanisms that govern (a) sustained attention and effort,(b) inhibitory controls, and (c) the modulation of arousal levelsto meet task or situational demands" (p. 67). Barkley (1990) hasdiscussed the "holy trinity" of ADHD symptoms, two of which(inattention and impulsivity) are cognitively related. Recently,the current conception of ADHD has been summarized as astyle that shows deficiencies in higher order problem solving, inmodulation of behavior to match environmental demands, andin overall self-regulation (Hinshaw & Erhardt, 1991; Whalen,1989; Douglas, Barr, Amin, O'Neill, & Britton, 1988).

Numerous studies document the various cognitive deficien-cies that are found in hyperactive and impulsive children (seeBarkley, 1990). For example, research demonstrates that hyper-active children are deficient in their ability to sustain andmaintain attention to tasks (e.g., Barkley & Ullman, 1975;Douglas, 1983; Routh & Schroder, 1976; Zentall, 1985), withthe attentional deficiency being most dramatic in situationsinvolving dull, repetitive tasks (Luk, 1985; Milich, Loney, &Landau, 1982; Ullman, Barkley, & Brown, 1978; Zentall, 1985).


Research focusing on distractors has shown that hyperactivechildren encounter the most difficulty in focusing attentionwhen distractors are integrated into the particular task (Ceci &Tishman, 1984; Mclntyre, Blackwell, & Denton, 1978) or whendistractors are especially appealing (Radosh & Gittleman,1981; Rosenthal & Allen, 1990). Pearson, Lane, and Swanson(1990) reported that impulsive hyperactive children were un-able to allocate attention during complex tasks, whereas theirnonhyperactive peers were able to do so.

Other research has suggested that the cognitive functioningof hyperactive children is characterized by an inability to cogni-tively mediate their behavior. Douglas (1980) summarized thecognitive difficulties of ADHD youngsters as an inability to"stop, look, and listen" and considered this inability to be themost important symptom of the disorder. Cognitive impulsivityhas been assessed, with the data suggesting that hyperactiveand impulsive children have considerably more difficulty usingproblem-solving strategies and inhibiting responses on this taskthan do nonhyperactive children and that they possess ineffi-cient search strategies (Douglas & Peters, 1979) and problem-solving skills (Tant & Douglas, 1982). Measures of cognitiveproblem solving have been shown to be strong discriminatorsof hyperactive and nonhyperactive children (Homatidis &Konstantareas, 1981).

What treatments are best for ADHD? The multifaceted na-ture of ADHD has implications for determining the type oftreatment to follow. For instance, treatment that produces posi-tive effects in one symptom area may not affect functioning inanother area. The most widely used treatment approach, stimu-lant medication, effectively addresses attention but may notalways improve symptoms in complex cognitive skills. The ap-peal of stimulant medication lies in the relatively rapid behav-ior improvements that medication produces. However, Wha-len, Henker, and Hinshaw (1985) warned that improvement inthe most salient areas of the ADHD child's disruptive behavior(e.g., excessive motor activity in young children) may lead to afailure to address deficits in other areas of functioning such asacademic performance. Medication has also been shown to re-duce motor activity, aggression, and noncompliance and to pro-duce improvements in relationships with mothers, peers, andteachers (Barkley & Cunningham, 1979, 1980; Barkley, Karl-son, Strzelecki, & Murphy, 1984; Whalen, Henker, & Dotem-moto, 1980,1981). Despite the apparent effectiveness of medi-cation in addressing facets of ADHD, this treatment approachremains controversial.

Reacting to the negative factors associated with medication,researchers and clinicians have sought alternative treatments(e.g., behavior modification, cognitive-behavioral treatment,and parent training). Broadly speaking, research on alternativetreatments has involved examining their efficacy both indepen-dent of medication and in combination with medication. Forpresent purposes, I focus on cognitive-behavioral therapy.

With its attention to cognitive processes (e.g., problem solvingand anticipation of the consequences of actions), as well as ob-servable behavior, cognitive-behavioral therapy appears partic-ularly well suited to the problems of the ADHD child, many ofwhich have been linked to deficits in cognitive processing. How-ever, the data suggest that although cognitive-behavioral train-ing can reduce one feature of ADHD—impulsivity (Kendall &

Braswell, 1982,1985)—it has not been uniformly found to rec-tify other features of ADHD. Despite the promising results withimpulsive children and the apparent theoretical match of cog-nitive-behavioral therapy with symptoms of ADHD, the effec-tiveness of cognitive-behavioral therapy as a treatment ofADHD has remained relatively inconsistent. Although somestudies have shown promising preliminary results (e.g., Cam-eron & Robinson, 1980; Douglas, Parry, Marton, & Garson,1976), others have failed to show a positive impact (e.g., Brown,Wynne, & Medenis, 1985: see Abikoff, 1987, for a review; Hin-shaw & Erhardt, 1991; Whalen et al., 1985).

Research has considered the effectiveness of certain versionsof cognitive-behavioral treatment in combination with medica-tion. Results of several studies, however (Abikoff, Ganeles,Reiter, Blum, Foley, & Klein, 1988; Abikoff& Gittelman, 1985;Brown et al., 1985), did not show a cognitive-behavioral treat-ment to be as effective as medication or as providing an enhanc-ing effect over medication when the two treatments were com-bined. However, it is worth noting that the form of cognitive-behavioral treatment used varies substantially across studies.For instance, Kendall and Reber (1987) noted that the treat-ment used by Abikoffand Gittelman (1985) did not include thefull behavioral component of contingent reinforcement and re-sponse costs for learning the problem-solving skills. In light ofthis situation, suggestions for refinement both in the assess-ment of children's functioning and in treatment approacheshave emerged. More specifically, Abikoff (1987) argued thateffective cognitive-behavioral treatment will require under-standing the specific nature of the child's problems accompa-nied by a more tailored application of the various componentsof the treatment to the particular child's needs. In a similarvein, Whalen et al. (1985) noted that different situations (e.g.,academic vs. social) may require different cognitive strategies,with the former creating a situation in which the task demandsare much more clear-cut than the latter, which may involve suchvariables as inconsistent or ambiguous feedback about thechild's behavior. It should also be noted that contemporary ap-plications of cognitive-behavioral therapy for ADHD place agreater emphasis on the role of the parents and family in pro-gram implementation (Braswell & Bloomquist, 1991).

Summary. Although the outcomes of reports provide evi-dence to support the continued development and evaluation ofpsychosocial treatments (e.g., cognitive-behavioral interven-tions) for disorders in youth, there is reason to draw differentconclusions depending on the specific disorder. When treatingaggression, for example, the data are supportive and the encour-agement of continued research is appropriate, although thera-pies of longer duration are recommended. Portions of the prob-lems seen in ADHD can be addressed, but the comparisonswith medications suggest limited optimism until greater speci-ficity is achieved. Applications with internalizing disorders,such as anxiety and depression, are much fewer, although theresults are very encouraging and continued work should besupported.

Emerging Developments

To assume that there is a single monolithic "right" way tothink, behave, and feel is to make a fatal error. Indeed, quite the


contrary is true (Kendall, 1992). The human experience, in-cluding childhood and adolescence, is replete with opportuni-ties for a diversity of thoughts, feelings, and actions. The defini-tion of what is "normal" is broad and inclusive; thoughts, feel-ings, and actions are abnormal only when they are maladaptivefor the individual or interfering or destructive for others. Cover-age of interventions for children does not suggest that all chil-dren should conform to a single-minded definition of appro-priate childhood behavior. Rather, interventions are designedto remove detrimental cognitive, affective, or behavioral stylesthat children may be developing and to offer—at an early pointin life—valuable educational experience that can modify un-wanted features of their developmental trajectory.

Consistent Treatment Strategies

Interventions with youth are perhaps best when they mesheffectively with the normal developmental trajectory. In the tar-get years of development, the move toward autonomy and inde-pendence is a central developmental challenge. A decidedstrength of the cognitive-behavioral strategy is that it works in acollaborative fashion with the youth and, correspondingly, fos-ters independent development and prosocial behavior change.

The cognitive-behavioral therapies are neither monolithicnor narrow minded (Mahoney, 1977). Quite the opposite istrue: Although there are treatment strategies that appear intherapies for the various disorders (see Table 1), there are norules carved in stone, and the emphasis on cognitive informa-tion processing within a context that uses social reward andbehavioral procedures to modify maladaptive methods of ad-justing is intentionally flexible. Therapy workbooks are oftenused with youthful clients, thus providing concrete content andenjoyable activities as well as a guide for the implementation ofthe treatment (e.g., Kendall, 1990).

Table 1General Treatment Strategies, With Specific Instances, Used inthe Cognitive-Behavioral Therapies With Youth

General strategy Specific instances

Modeling

Building a copingtemplate

Rewards

Enactive procedures

Affective education

Training tasks

Use of coping modeling, with therapistself-talk

Changing client self-talk, reframing ofproblems

Use of different contingencies, giventhe nature of the disorder beingtreated

Modifying the frequency and standardsof self-evaluation, depending on thedisorder

Role-play exercisesOpportunities for practiceIn vivo exposureBehavioral experimentsLearning about feelings, in self and

othersLearning to use coping skills when

emotionally arousedIn-session tasks (i.e., workbooks)Homework (out-of-session)

assignments

Broader Treatment Applications

Contemporary cognitive-behavioral therapy has movedbeyond the sole focus on the child client and has incorporatedstrategies that involve parents, peers, and school personnel. Theliterature clearly suggests the movement to include interper-sonal and social contexts and parents as collaborators or co-clients, but treatment evaluation studies have not kept pacewith these expanded clinical applications.

When significant others (peers, teachers, and parents) pro-vide positive feedback for a child's efforts and change their per-ceptions and attributions about the child, the child's behavioralchange is likely to be maintained. However, if these interper-sonal systems are not accepting of the child's recent behaviorchanges, then the child's behavior and cognitions can easilyrevert to earlier maladaptive levels. Thus, cognitive-behavioraltherapy should actively intervene with key individuals in thechild's social environment (parents, teacher, and, possibly,peers) to maintain therapeutic change (see Braswell, 1991; Ken-dall & Morris, 1991). The direction and movement arestrengths; the emerging need is for additional evaluation of thebroader interventions.

Comparative Treatment Outcomes

The basic applications of cognitive-behavioral therapy needadded research in terms of the relative efficacy of the treatmentas compared with alternative forms of psychological and phar-macological intervention. For example, there are needed com-parisons with parent training, parent therapy, family therapy,and behavior modification. As additional alternative therapies(e.g., psychodynamic) begin to be examined empirically, furthercomparative studies will be needed. Multimethod assessmentsare needed for all such studies, along with tests of clinical signif-icance (e.g., normative comparisons; Kendall & Grove, 1988)and statistical significance and consideration of cost-effective-ness (e.g., professional cost and child and family time commit-ment). Comparative studies of medications and cognitive-be-havioral therapy for anxiety and depression are much needed.These outcome comparisons need to include and examine thecomorbid status of the clients. For instance, there may be dif-ferential outcomes for ADHD with or without comorbid con-duct problems or anxiety disorders with or without comorbiddepression.

Nonspecific factors that affect treatment outcome haverarely been examined (e.g., Reynolds & Coats, 1986). Nonspe-cific factors concern, for example, the relationship between thetherapist and the child (Kendall & Morris, 1991) and the child'sinvolvement in treatment (Braswell et al., 1985). The social rein-forcement provided by the therapist can be a major source ofmotivation for children. The therapeutic relationship assumesparticular importance because many behaviorally and emo-tionally disordered children have weak relationships with par-ents and teachers, and thus have been minimally motivated byadults' reinforcement. When a positive therapeutic relationshipdevelops, children are more accepting of therapists' percep-tions of events and more open to reframing their own percep-tions of events.

Cognitive-behavioral therapies with youth are intentionally


integrative. Nevertheless, studies of the active and nonactive(less active) components of the treatment modality are needed.Identification of active components will not only benefit futureapplications of cognitive-behavioral therapy, but also enhanceother models of psychotherapy with youth.

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Received December 20,1991Revision received June 19,1992

Accepted July 2,1992 •

cognitive-behavioral therapies with youth: guiding theory, current

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