Disorder-specific Effects of CBT for Anxious and Depressed Youth

22 Pages·2007·0.34 MB·English

ClinChildFamPsycholRev(2007)10:352–372
DOI10.1007/s10567-007-0028-2
Disorder-specific Effects of CBT for Anxious and Depressed
Youth: A Meta-analysis of Candidate Mediators of Change
Brian C. Chu Æ Tara L. Harrison
Publishedonline:6November2007
(cid:1)SpringerScience+BusinessMedia,LLC2007
Abstract The commonalities between anxiety and Introduction
depression have been discussed before, but few have
delineated the potentially different mechanisms through The case for studying mediators of change in child and
which treatments work for these populations. The current adolescent treatment research has been made before
study conducted a comprehensive review of child and (Kazdin and Kendall 1998; Kazdin and Weisz 1998).
adolescent randomized clinical trials that tested cognitive- Identifying the critical ingredients and the mechanisms
behavioral therapy (CBT) for anxiety or depression. All throughwhichtreatmentsworkisessentialformaximizing
studies were required to have assessed both treatment treatment efficacy, improving therapeutic techniques, and
outcomes and at least one theory-specific process target, improving methods for training therapists (Kazdin and
including behavioral, physiological, cognitive, and coping Nock 2003; Weersing and Weisz 2002). Despite the
variables. Using a meta-analytic approach, CBT demon- importance of this research, there is a noted gap between
strated positive treatment gains across anxiety, depression, our knowledge of treatment outcomes and the processes
and general functioning outcomes. CBT for anxiety also associated with those outcomes (Shirk 2005; Silverman
produced moderate to large effects across behavioral, 2006). The current review and meta-analysis will evaluate
physiological, cognitive, and coping processes, with thespecificeffectsthatcognitive-behavioraltherapy(CBT)
behavioral targets demonstrating potentially the greatest producesin the treatment ofanxious ordepressed children
change. CBT for depression produced small effects for and adolescents.
cognitive processes but nonsignificant effects for behav-
ioral and coping variables. Findings were generally
consistent with CB theory but suggest potentially different OverlappingFeaturesofYouthAnxietyandDepression
mediators in the treatment of anxiety and depression.
Results are discussed in terms of implications for mecha- Combined, anxiety disorders such as generalized anxiety
nisms research, theories of change, and treatment disorder (GAD), separation anxiety disorder (SAD), social
development. phobia (SOC), and other phobic disorders are estimated to
representthelargestclassofchildhoodemotionalproblems
Keywords Child (cid:1) Adolescent (cid:1) Anxiety (cid:1) Depression (cid:1) with point prevalence rates ranging between 12 and 20%
CBT (cid:1) Mechanisms of change (Cohenet al.1993;Costelloet al.2005).Depressiontends
to affect a smaller number of youth, wherein 5–8% of
adolescents and even fewer pre-adolescents meet criteria
for a depressive disorder at any point in time (Angold and
Costello 2001; Birmaher et al. 1996; Cohen et al. 1993).
B.C.Chu(&)(cid:1)T.L.Harrison However, nearly 20% of youth may experience a depres-
DepartmentofPsychology,Rutgers,TheStateUniversityof
sive disorder by the end of adolescence (Lewinsohn et al.
NewJersey,152FrelinghuysenRoad,Piscataway,
1993). Both disorders are associated with severe disrup-
NJ08854,USA
e-mail:[email protected] tions in social, academic, and family functioning and have
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ClinChildFamPsycholRev(2007)10:352–372 353
been connected with greater risk for more severe anxiety, depression),butreplacingmaladaptive thoughtswithmore
depression, and substance abuse in adulthood (Kendall et functionalthinkingisacommongoal(Kendallet al.2003;
al. 2003; Rohde et al. 1994). Clarke et al. 2003; Weisz et al. 2003). Thus, successful
There are several good reasons to examine anxiety, CBT would be expected to engender positive change in
depression,andtheirrespectivetreatmentstogether.Ahigh cognitive processing including decreased negative auto-
degree of co-occurrence has been established between maticthoughts,maladaptiveattitudesandassumptions,and
thesedisordersinbothcommunityandclinicalsamples.Up decreased threat interpretations.
to69%ofyouthwithprimaryanxietyhavebeendiagnosed Behavioral techniques for treating anxiety and depres-
with depression and up to 75% of depressed youth have sion both make use of common learning and conditioning
been diagnosed with an anxiety disorder (Angold et al. principles. The primary behavioral target in anxiety treat-
1999; Brady and Kendall 1992; Kovacs 1990). Taxono- ment is avoidance. Exposure tasks for anxious youth
metric approaches seeking to isolate uniquely identifying assume that avoidance is prompted by emotional distress,
symptom profiles have often found more commonalities fear,andnegativecognitionstriggeredbyafearedeventor
than differences (e.g., see Child Behavior Checklist stimulus. Exposure therapy attempts to reduce avoidance
development;Achenbach1991).Furthermore,longitudinal byhavingthechildprogressivelyworkhisorherwayupa
studies have suggested a developmental relationship gradedfearhierarchyoffearedsituationswhileemploying
betweenthedisorders,inwhichproblemsinanxietytendto copingskillsorrelaxation.Behavioraltherapiesforanxiety
precede depression (Kessler et al. 1997; Kovacs et al. also seek to reduce long-term physiological and subjective
1988). Of course, anxiety and depression are not com- fearresponsestofearedsituationsorchallenges(Davisand
pletely overlapping phenomena. Several lines of research Ollendick 2005; Ollendick and King 1998). The specific
(e.g., the tripartite theory; helplessness vs. hopelessness mechanisms through which exposures foster approach
theories) have identified cognitive and affective processes behaviors are still a subject for debate (Craske and My-
that distinguish the disorders (Alloy et al. 1990; Barlow stowski 2006; Foa and McNally 1996), but collectively,
et al. 1996; Clark and Watson 1991; Watson and Clark successful CBT would be expected to be associated with
1984), but overall, many commonalities exist. significant change across behavioral and physiological
processes (Davis and Ollendick 2005; Ollendick and King
1998).
Commonalities in Treatment Strategies and Treatment Behavioral strategies for depression emphasize pleasant
Targets activity scheduling and behavioral activation. Using these
strategies the therapist encourages activities that are indi-
A review of CBT programs targeting anxiety and depres- vidually gratifying for the child to increase availability of
sion reveals a number of similarities (Barlow et al. 2004; natural reinforcement in the child’s life and enhance the
Chorpita et al. 2002; Kazdin and Weisz 2003; Ollendick child’s sensitivity to natural rewards (Lewinsohn and Graf
and King 2000). As a whole, CBT aims to modify mal- 1973; Lewinsohn and Libet 1972). Recent conceptualiza-
adaptive thinking and attitudes, increase skill sets, and tionsofbehavioralactivationhavealsohighlightedtherole
change unrewarding or avoidant behavioral patterns. Most of avoidance in depresso-typic behavior (Jacobson et al.
anxiety and depression treatments include general skills- 2001;AddisandMartell2004).Inthismodel,avoidanceis
building strategies, such as self-monitoring, psychoeduca- maintained in depression much like it is in anxiety;
tion, problem-solving, social skills training, and reward avoidant behavior is triggered by a distressing event and
plans. The cognitive strategies for anxiety and depression then is reinforced by the subsequent reduction in distress
use many similar techniques, including identification of even as it contributes to a number of secondary problems.
thinking errors, Socratic questioning, and development of Continued avoidance perpetuates a cycle of inactivity,
coping thoughts. Even behaviorally oriented techniques withdrawal, and inertia that denies the child access or
may be used to correct misperceptions and maladaptive opportunity to contact antidepressant sources of rein-
cognitions. For example, a child with social evaluation forcement (Jacobson et al. 2001). Thus, we would expect
concernsmaybeaskedtogiveaspeechinfrontofamock successful CBT to be associated with increased activation,
class.Thein vivoexposuregivestheyouthanopportunity frequency and enjoyment of pleasant activities, and a
to complete a difficult task and examine untested possible decrease in avoidance. CBT also aims to teach
assumptions about their abilities and the evaluations of clients age appropriate skills, such as socialization and
others. The specific target of cognitive restructuring may social problem-solving skills. Increased skill sets are
vary across disorders (e.g., perceptions of threat and expected to increase the child’s sense of mastery and the
unpredictability may be the target for anxious youth while likelihood that they will engage in social and pleasant
self-criticism and hopelessness may be emphasized in activities (Clarke et al. 2003; Weisz et al. 2003). Thus,
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354 ClinChildFamPsycholRev(2007)10:352–372
CBT for youth with depression should be associated with timetounderstandthebasicmediatorsthroughwhichCBT
increased skill sets (e.g., social skills) associated with helps alleviate anxiety.
behavioral activation. Outcome trials with depressed youth have also docu-
Cognitive-behavioral interventions also aim to improve mented promising results for CBT. Two CBT programs
coping skills or alter coping styles in anxious and depres- have been listed as a ‘‘probably efficacious’’ according to
sed youth (Prins and Ollendick 2003). Coping is a broad APA Task Force criteria (Kaslow and Thompson 1998;
term that embodies cognitive, behavioral, and physiologi- Ollendick and King 2000): Stark’s self-control treatment
cal processes and refers to how youth respond to stressful (Starket al.1987)forchilddepressionandLewinsohnand
events and challenges (Compas et al. 2001). Problem colleagues’CopingwithDepressioncourseforadolescents
solving, wishful thinking, cognitive avoidance, and rumi- (Lewinsohn et al. 1990). Meta-analyses that have pooled
nation are coping strategies that primarily involve findings across clinical trials also have documented con-
cognitive processes. Avoidance, escape, and inaction are sistentlargeeffectsizesforCBT,rangingfrom0.72to1.27
types of behavioral coping strategies. Relaxation is a (Lewinsohn and Clarke 1999; Michael and Crowley 2002;
coping strategy that primarily targets one’s physiological Reinecke et al. 1998). Recently, the relative strength of
state. Although many coping processes overlap with cog- CBTfordepressionhasbeenquestionedduetothesuccess
nitive and behavioral outcomes, investigators often of anti-depressant medications in comparative clinical tri-
measure coping skills separately from dysfunctional als (Treatment for Adolescent Depression Study [TADS]
behavioralorcognitivestyles,soitmakessensetoconsider 2004). Similarly, Weisz et al. (2006) recently completed
coping styles as unique targets of treatment. In general, the most comprehensive meta-analysis to date and found
changes in coping style from avoidant to active strategies, that the overall effects of psychotherapy for youth with
such as planning, thinking about solutions, and positive depression lagged significantly behind the psychotherapy
cognitive restructuring, are associated with enhanced psy- effects for other childhood disorders. In addition, Weisz
chological adjustment (Compas et al. 2001; Prins and et al. demonstrated that cognitive-based therapies did not
Ollendick 2003). Improvements in child and parent produce superior overall outcomes compared to noncog-
reported coping efficacy have also been associated with nitivetherapiesindepressedyouth.Thesefindingssuggest
symptom improvement following CBT (Kendall 1994; that there is still substantial room for improvement in
Kendall et al. 1997; Barrett et al. 1996). psychologicaltreatmentsfordepressionandthattheeffects
of cognitive therapies could benefit from further
investigation.
Established Efficacy Together, the literature suggests that a comparison of
changemediatorsinefficacioustreatmentsforanxiousand
Built on these sound theoretical principles and practices, depressedyouthwouldbetimelyandpotentiallyrevealing.
CBT has collectively documented impressive empirical An analysis of the specific effects that CBT produces may
support for its treatment outcomes. In the treatment of help identify its strengths as a treatment approach as well
youth anxiety disorders, narrative and quantitative reviews as isolate areas in need of improvement. Such an analysis
suggest that cognitive and behavioral approaches are may also delineate the underlying relationship between
effectivecomparedtono-treatmentcontrolsandalternative anxiety and depression. However, to date, there has been
treatments (Compton et al. 2002; Kaslow and Thompson no direct comparison of the specific effects that CBT has
1998; Ollendick and King 1998). A number of individual for anxious and depressed youth and whether similar or
CBT programs also meet criteria as probably efficacious distinctive mechanisms are responsible for observed treat-
usingAPATaskForceonPromotionandDisseminationof ment outcomes.
Psychological Procedures guidelines (APA Task Force
1995; Ollendick and King 2000). In individual treatment
studies, CBT has compared favorably to wait-list and no- State of Mechanisms Research in Youth CBT
treatment controls across a range of formats, including
individual child (e.g., Kendall 1994; Kendall et al. 1997), There have been significant methodological and analytic
family-focused (e.g., Barrett et al. 1996; Wood et al. advances in mediator research (Kraemer et al. 2002;
2006), and group (Flannery-Schroeder and Kendall 2000). MacKinnon et al. 2002; Shadish and Sweeney 1991). A
Similar CBT protocols have been adapted for adolescents mediator specifies how (or the mechanism through which)
(Albano et al. 1995) and transported to school (Masia- a given effect occurs (Baron and Kenny 1986; Holmbeck
Warner et al. 2005) and medical center settings (Child 1997; MacKinnon et al. 2002). The most common method
Anxiety Multimodal Study, in progress). The consistent used todemonstrate avariable actsas a mediator has been
supportfortheefficacyofCBTsuggestsitisanappropriate the ‘‘causal steps approach’’ (MacKinnon et al. 2002)
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ClinChildFamPsycholRev(2007)10:352–372 355
based on Judd and Kenny (1981) and later elaborated on directly compare effects across diagnostic groups to
by Baron and Kenny (1986). The Baron and Kenny model determine if CBT had differential impact across anxiety
outlines four specific conditions required to demonstrate and depression.
mediation, including that (a) the predictor must be sig- Three additional reviews explored similar issues. Prins
nificantly associated with the mediator, (b) the predictor and Ollendick (2003) specifically reviewed the evidence
must be significantly associated with the dependent forcognitiveandcopingvariablesasmediatorsofCBTfor
measure, (c) the mediator must be significantly associated anxiousyouth.Similartopreviousreviews,theyfoundfew
with the dependent variable, and (d) the impact of the studies formerly testing mediation but many assessed pre-
predictor on the dependent variable must be less after to post-treatment outcomes of cognitive or coping process
controlling for the mediator (Baron and Kenny 1986; (e.g., 44% of studies assessed cognitive change, 40% of
Holmbeck 1997). Change in the mediator must also fol- studies assessed coping attitudes or behaviors). Of those
low the onset of the independent variable and precede studies that did measure process variables, CBT demon-
change in the dependent variable temporally (Judd and strated consistent effects. All controlled studies that
Kenny 1981; Kazdin and Nock 2003). It then requires included either a coping or a cognitive variable reported
several additional steps to establish a mediator as a significant positive change from pre- to post-treatment.
mechanism. Kraemer et al. (2002) remind us that ‘‘all Prins and Ollendick also calculated summary effect size
mechanisms are mediators but not all mediators are statistics. In randomized clinical trials comparing individ-
mechanisms’’ (p. 878). However, demonstrating causality ual child CBT to a waitlist, treatment produced a small
is much more difficult than establishing mediator status. effect in cognitive measures based on child report
Thus, the investment of time and effort to narrow the (d = 0.36;range = 0.00–0.70).Amoderatetolargeeffect
search for causal factors by focusing first on a search for in coping-related measures was found depending on whe-
mediators is worthwhile. ther child (d = 0.49) or parent (d = 0.99) report was
To conduct a broad review of the child clinical litera- considered.
ture, Weersing and Weisz (2002) adapted Baron and PrinsandOllendick(2003)didnotethat,incomparisons
Kenny’s definition to create a framework for evaluating of CBT to an alternate active treatment, CBT produced
mediating mechanisms across randomized clinical trials. significant pre- to post-changes in cognitive and coping
Most relevant to the current review, they re-labeled Baron processes, but these differences were not significantly dif-
and Kenny’s (1986) criterion (b) the ‘‘Intervention-speci- ferent from the control conditions. Thus, CBT may be
ficitytest’’andexaminedwhichtreatmentsdemonstrateda associated with cognitive changes, but such change may
significant relationship with prospective mediators. This not be uniquely related to CBT. Insum, the review helped
analysis tested whether treatment affected the mechanism demonstrateatleastpartialsupportfortheroleofcognitive
ofactionhypothesizedtoproduceinterventioneffects(i.e., andcopingprocessesaspossiblemediators.LikeWeersing
tested the hypothesized theory of change). and Weisz (2002), this review did not examine CBT’s
Using this framework, Weersing and Weisz (2002) effectonbehavioralorphysiologicalprocessesanddidnot
found that CBT did produce consistent overall treatment include depressive samples.
outcomes for both anxiety and depression but there was DavisandOllendick(2005)conductedacomprehensive
less information regarding the Intervention-Specificity review of CBT in producing specific change in a broader
Test. For example, they reported that CBT was associated set of processes associated with specific phobia, including
with change in cognitive mediators in all anxiety studies, cognitive, behavioral, physiological, and subjective fear.
and CBT was associated with change in cognitive and Theyreviewed22clinicaltrialsthatcomparedabehavioral
behavioralmediatorsinmostdepressionstudies.However, orcognitivetreatmenttoeitheranactiveorpassivecontrol
no specific effect sizes were provided to indicate the rela- condition. The majority of studies reviewed had included
tive strength of these associations. ‘‘Box-score’’ type somemeasureofbehavioralandsubjectivefearchange,but
narrative summaries of this sort are more sensitive to many fewer measured cognitive or physiological change.
individual study sample sizes and can result in misleading Based on a box score summary of the literature, there was
conclusions(Beaman1991;LipseyandWilson2001).The significant evidence that behavioral treatments produced
authorsonlyreviewedtheevidenceforcognitivemediators positivechangeinmostbehavioralandfearmeasures.This
inthetreatmentofanxiety;theydidnotincludeareviewof finding held whether compared to either passive or active
behavioral, physiological, or coping variables. They also controls. Thus, behavior and subjective fear appear to be
did not report on the effect of depression treatments on both reliably produced by, and specific to, behavioral
copingvariables.Thus,thereviewsupportedtheCBtheory treatments in the treatment of specific phobias. Davis and
of change for several common processes, but it did not Ollendick did not provide effect size calculations to sum-
present data on other possible mediators and it did not marize the magnitude of effect that treatment has on
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specific targets. The review also limited itself strictly to across process variables to determine if CBT had differ-
treatment studies of specific phobia. ential effects on specific targets. That is, within anxiety or
Afinalreviewconductedameta-analysisevaluatingthe depressiontreatments,wouldmeanESvaluesdifferamong
overall outcomes of CBT for anxious and depressed youth behavioral,physiological,cognitive,andcopingoutcomes?
when compared against either a bona fide (active psycho- These analyses were exploratory since we were not aware
logical treatment with a defined theory) or non-bona fide of other attempts to make such a direct comparison.
(nonspecific active control) therapy (Spielmans et al. Finally, we compared anxiety versus depression studies to
2007). They divided outcome measures into dependent determine if CBT had differential effects on process out-
variables that either directly measured anxiety or depres- comes; these analyses were also exploratory given the
sion or measured some other outcome of interest. Their absence of previous comparisons.
analysis suggested that CBT did produce significant treat-
ment effects in both anxiety- and depression-specific and
more general outcomes when compared to active controls.
However, the analyses did not divide the anxiety and Methods
depression measures into specific component processes of
cognitive, behavioral, coping, or physiological outcomes. Literature Review
Studies were obtained through reference trails and
The Current Review computer index searches. We reviewed several recent,
comprehensive psychotherapy reviews and meta-analyses
In the current report, we evaluate the specific effects that (i.e., Compton et al. 2002; Kaslow and Thompson 1998;
CBT produces in the treatment of anxious or depressed Lewinsohn and Clarke 1999; Michael and Crowley
children and adolescents. Most previous meta-analyses 2002; Ollendick and King 1998; Prins and Ollendick
have reviewed overall treatment outcomes documenting 2003; Reinecke et al. 1998; Weersing and Weisz 2002;
the general efficacy of CBT. Our review summarizes the Weisz et al. 2006) and included all relevant studies.
magnitudes of effect that CBT has on specific targets Studies were also obtained through computer index
related to the cognitive-behavioral theory of change, searches using PsychINFO (1980–August, 2006) and
including behavioral, physiological, cognitive, and coping MEDLINE (1980–August, 2006) and by reference trails
outcomes. Meta-analytic methods were used to summarize that resulted from identified studies. Keywords used in
andcompareeffectsize(ES)calculationswithinandacross computer searches were: Depression, Major Depression,
anxiousanddepressedstudysampleswithspecialattention Minor Depression, Dysthymia, Anxiety, Anxiety Disor-
paid to comparisons across diagnostic classes. ders, Generalized Anxiety Disorder, Separation Anxiety
We hypothesized that CBT, when implemented with Disorder, Social Phobia, CBT, cognitive-behavioral
anxious or depressed youth populations, would demon- therapy, cognitive therapy, behavior therapy, exposure
strate positive and significant effects for anxiety and therapy, and behavioral activation. The auto-explode
depression outcome measures. Based on previous reviews option was used in computer searches so that all relevant
(e.g., Weisz et al. 2006), we hypothesized that treatments topics within the broader categories were searched as
wouldproducelargereffectsfordisorder-specificoutcomes well. Searches were limited to populations between ages
(e.g., depression symptoms in CBT for depression) than 6 and 18 years.
nonspecific outcomes (e.g., anxiety symptoms in CBT for Studies were obtained and included if they met the
depression). Furthermore, based on the lower overall ES following criteria: (a) study participants were selected for
values found for depression treatments in Weisz et al. a clinical diagnosis of anxiety or clinically significant
(2006),wealsohypothesizedthatanxietytreatmentswould depression; (b) random assignment to treatment condi-
produce larger effect sizes on treatment outcomes than tions was used; (c) at least one of the treatment
depression treatments. conditions was identified as a behavioral, cognitive, or
In analyses focusing on specific behavioral, physiolog- cognitive-behavioral intervention (the comparison condi-
ical, cognitive, and coping change, we hypothesized that tions could be either a passive control or alternate
CBT for anxiety would be associated with moderate to treatment); (d) sample age range was between 6 and
large effects across all specific processes. We also 18 years old; and (e) the study was published in an
hypothesized that CBT for depression would produce English language, peer-reviewed journal. Studies had to
moderate to large effects in cognitive, behavioral, and report posttreatment data (means and standard deviation)
coping processes, but expected physiological processes to for at least one outcome measure that assessed anxiety or
be rarely assessed. We then compared magnitudes of ES depression. Studies also had to report data for at least
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ClinChildFamPsycholRev(2007)10:352–372 357
one cognitive, coping, behavioral, or physiological target Statistical Analyses
at posttreatment (studies did not have to report data for
all four process categories). Citations of included studies Cohen’s d (1988) was the measure of effect size. Cohen’s
appear in the reference list with asterisks. d is the mean difference between the mean outcome in
Studies were not included if they explicitly described the treatment group and the mean outcome in the control
the intervention as a prevention program. Studies were group divided by the pooled (within-group) standard
not included if analyses only compared one CBT con- deviation. In studies that included more than one CBT
dition against another CBT condition (e.g., individual condition (e.g., individual CBT, individual + parent
CBT vs. CBT + parent involvement), because the CBT), each intervention was compared to the control
study’s goal was to compare CBT versus active or condition (e.g., WL, educational support). All ES values
passive controls. Studies that targeted school refusal were corrected for small sample bias (Hedges and Olkin
were included. Studies were not included if the primary 1985, p. 81, Equation 10) and then pooled up to the level
treatment target was Specific Phobia, Obsessive-Com- of treatment. This permitted an evaluation of effect size
pulsive Disorder, Post-Traumatic Stress Disorder, Panic for an average CBT condition. ES values were then
Disorder, or test anxiety. CBT interventions were not weighted by the inverse of its variance, adjusting for
included if treatment format was primarily computer- varying sample sizes and heterogeneity of variance across
based or virtual reality. Finally, studies were not studies (Hedges and Olkin 1985; Lipsey and Wilson
included if the only CBT condition was a combined 2001).
CBT plus pharmacotherapy condition. As a final step, when calculating mean ES values, a Q-
statistic was calculated to test the assumption that all ES
valuesestimatedthesamepopulation(i.e.,homogeneityin
ES distributions; Lipsey and Wilson 2001). When homo-
Study Coding Procedures geneity is rejected, this indicates the variability among the
study effect sizes are greater than what is likely to have
Studies were coded to identify (a) sample characteristics, resulted from subject-level sampling error alone. In these
(b) treatment and design characteristics, (c) anxiety and cases, we adopted a random effects model which accounts
depression outcome measures used, and (d) mediator for random variability at both the study-level (studies
(process) measures used. Treatment outcome measures sampledfromapopulationofstudies)andthesubject-level
were included for ES coding if they assessed anxiety or (subjects in each study sampled from a population of
depression symptoms (e.g., parent or child-report ques- studies). This model uses a different inverse variance
tionnaires), diagnosis (e.g., structured interview), or weightthanthefixedeffectsmodel(usedwheneffectsizes
general functioning or improvement (e.g., Global Assess- represent a homogeneous distribution). All ES means
ment of Functioning scales, Clinical Global Improvement reported hereafter are weighted least square effect sizes
scales). Process measures were included if they targeted based on the appropriate model (either random or fixed
behavioral, physiological, cognitive, or coping constructs. effects) depending on the results of the Q-statistic. To
These could include parent- and child-report question- interpretESs,weusedCohen’s(1992)definitionsinwhich
naires, judge-rated observations, and independent reports an ES of 0.20 indicates a small effect, 0.50 a medium
(e.g., school-reported attendance records, diary reports of effect, and 0.80 a large effect.
attended social events). To compare mean ES values with zero, we used SPSS
Tworaters(theauthors)independentlycoded14studies macros that generate ztests based on the absolute value of
each. To assess interrater reliability, both raters double the mean ES divided by the standard error of the mean
coded eight (28.6%) of the studies. Raters demonstrated ES (Lipsey and Wilson 2001; Wilson 2003). Consistent
excellent94.6%(k = 0.89)agreementinidentifyingwhich with previous meta-analyses (e.g., Weisz et al. 2006), we
outcome and process measures should be included for used paired t-tests to compare ES values of conceptually
coding. Intraclass correlation coefficients (ICC) were cal- different measures obtained from the same set of studies
culated to assess rater reliability in coding means and (e.g., behavioral vs. physiological vs. cognitive vs. coping
standard deviations and in calculating ESs. Raters dem- ES means). Paired t-tests acknowledge dependencies
onstrated excellent reliability in coding means among the variables resulting from ESs calculated from
(ICC = 1.00, p\.001) and standard deviations (ICC = the same study samples. To compare mutually exclusive
0.99, p\0.001) and in calculating ES scores from raw categories of studies (e.g., Anxiety vs. Depression stud-
data (ICC = 0.98, p\0.001). Raters were exceptionally ies), we used a Q-statistic analog to analysis of variance
reliableincodingrawdatafromstudiesandcalculatingES (Lipsey and Wilson 2001; Wilson 2003). In this analysis,
scores. if the between-category variance is significant, then the
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358 ClinChildFamPsycholRev(2007)10:352–372
mean ES values across groups differ by more than sam- Youth self-report was the primary mode of assessment in
pling error. both anxiety and depression studies and assessed various
constructs, such as self-esteem (e.g., Rosenberg Self
Esteem Scale), self-concept (Piers-Harris Child Self-Con-
Results cept), negative affectivity self-statements (e.g., NASSQ),
maladaptive beliefs (e.g., Cognitive Bias Questionnaire;
Descriptive Characteristics of Reviewed Studies DAS), and distorted cognitions (ATQ; CNCEQ; SAS—
Fear of Negative Evaluation subscale). One family inter-
The final sample consisted of 14 anxiety studies repre- action task was used (Barrett et al. 1996) in which threat
senting 22 CBT treatment conditions, and 14 depression interpretations were assessed before and after a family
studies representing 20 CBT conditions. Of the anxiety discussion of an ambiguous situation.
studies, nine studies used a waitlist control and five com- Finally, 42.9% (n = 6) of anxiety studies and few
paredCBTtoanactivecontrolcondition(e.g.,educational depressionstudies,14.3%(n = 2),includedanassessment
support, nonspecific treatment). Six anxiety studies inclu- of coping. In anxiety studies, coping was assessed pri-
ded multiple forms of CBT (e.g., individual, group, or marilywithyouth-reportmeasures,assessingeithergeneral
parent condition). Of the depression studies, eight studies strategies (e.g., Self-Efficacy Questionnaire; Children’s
used a waitlist or no-treatment control and six compared Coping Strategies Checklist) or coping in specific situa-
CBT to an active treatment condition (e.g., Life skills, tions (Coping Questionnaire—child and parent versions).
nonspecific support). Four depression studies included One study(Beidel et al.2000)coded percentage ofcoping
multiple forms of CBT (e.g., individual vs. family-based; statements identified in daily diary entries. One measure,
self-control vs. behavioral problem solving). Descriptive the adolescent- and parent-report Issues Checklist, was
information about study design, participants, and treat- used in the two depression studies.
ments are reported in Tables 1 and 2. Assessment of treatment outcomes (diagnosis, symp-
Tables 1and2alsoreporttheassessmentmeasuresused tom) was consistent with measurement typically found in
to assess behavioral, physiological, cognitive, and coping randomized clinical trials (RCTs). Diagnoses were deter-
processes in anxiety and depression studies. Over 71% mined using clinician-administered semi-structured
(n = 10)ofanxietystudiesand50%(n = 7)ofdepression interviews (e.g., Anxiety Disorders Interview Schedule,
studies included an assessment of behavioral processes. In Kiddie-SADS, Hamilton Depression Rating Scale), and
the anxiety studies, a diverse range of methods were used symptom ratings of anxiety and depression were typically
to assess behavioral processes, including behavioral evaluated with paper-and-pencil questionnaires using
observation tasks (e.g., independent coding of a speech child-report, parent-, and teacher-report. We also included
task; choice of avoidant solutions during a family interac- assessments of broad-based general functioning that were
tiontask),parent-orchild-reportmeasures(e.g.,Friendship not captured by specific anxiety and depression measures.
measure; Social Skills Questionnaire), and subscales of These included broadband scales (e.g., Child Behavior
larger anxiety measures (e.g., Liebowitz Social Anxiety Checklist—Internalizing and Anxiety/Depression scales)
Scale—social avoidance and performance subscales). and clinician rated global severity or improvement mea-
Behavioral observations were not used in depression sures (e.g., Children’s Global Assessment Scale, Global
studies, but parent and youth report of pleasant activities Assessment of Functioning, Clinical Global Impression).
(e.g., Pleasant Events Scale; CBCL—social activities Of note, anxiety studies more frequently assessed depres-
subscale) and social skills (e.g., Social Adjustment Scale; sion (78.6%, n = 11) and general functioning (64.3%,
SocialAdjustmentInventoryforChildrenandAdolescents) n = 9) outcomes than did depression studies where only
were common. 35.7% (n = 5) assessed anxiety and 35.7% (n = 5)
Only a small percentage of anxiety studies, 21.4% assessed general functioning outcomes. (To conserve
(n = 3), and no depression studies assessed any physio- archival space, outcome measures are not presented in a
logical process. Physiological processes were assessed table here. A complete list of anxiety, depression, and
exclusivelywithsubscalesoflargeranxietymeasures(e.g., general functioning measures included in analyses is
CBCL—health concerns subscale; State-Trait Anxiety available from the authors.)
Inventory—somatic subscale). No direct measures of Relevant to the discussion of mechanisms, three
physiology (e.g., heart rate, galvanic skin response) were depression studies included some analysis of mediation
used. (Ackerson et al. 1998; Kaufman et al. 2005; Kolko et al.
Cognitive processes were consistently assessed, with 2000). None of the identified anxiety studies reported
71.4% (n = 10) of anxiety studies and 78.6% (n = 11) of mediation analyses as part of the principal outcome study,
depression studies including some cognitive assessment. but one study (Treadwell and Kendall 1996) later reported
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ClinChildFamPsycholRev(2007)10:352–372 359
Copingmeasures Diary:%ofNegativecoping CQ-C/P CQ-C CQ-C;CQ-P SEQ-SS CCSC—active,avoid,distract,supportcoping
al
v
s E
ognitivemeasure EAR-TI SES ASSQ ASSQ TAIC-M-cog AS-A/P-FearNeg CMAS—worry,oversen,social,concentration SWQ-C NCEQ
C F R N N S S R P C
hysiomeasures BCL-P-health TAIC-M-somatic CMAS—Physio
P C S R
Behavioralmeasure FEAR-AS;CE-avoid BO:Socialtask,read-aloudeffectiveness:self&obsratings FM-C/P;PRSCC-social;SOCS-P;SPPC-socialaccept CBCL-socialcompetence,activities,school IS;EHSPA;PRCS BO—speech,totalscore;CBCL-P-social BO—speech:voice,fingersinmouth,eyecontact LSAS-CA-socandperfavoid Fearthermometerinspecificsituations
nxiety(=14) Txduration 12ss,60–80min 24ss,60–90min,12weeks 18ss,1h,18weeks 3ss,3h,3weeks SET=19ss,CBGT=16ss,IAFSG=12ss 16ss 16ss 6ss,50min,4weeks 12weeks 12ss 90min,12weeks 6ss,50min 10weeks
n
CBTforyoutha Treatments CBTvs.CBT+FamMgmtvs.WL SET-Cvs.NonspecTx(Testbusters) IndCBTvs.GrpCBTvs.WL GroupCBTvs.WL SET-Avs.CBGT-Avs.IAFSGvs.WL CBTvs.WL CBTvs.WL CBTvs.WL CBTvs.educationalsupport SchoolGCBT—SASSvs.WL CBT-Par+Chvs.CBT-Chvs.CBT-Parvs.WL CogCopingTxvs.nonspecTx(emotionaldisclosure) Exposure+selfcontrolvs.exposure+CMvs.educationalsupport
g
studiesevaluatin Selectioncriteria OAD,SOP,SAD SOP GAD,SAD,SOP SOP SOP GAD,SAD,SOP GAD,SAD,SOP Schoolrefusal Schoolphobia SOP AnxDx GAD,SAD,SOP SP,SOP,Agor
of
cs o yo o o yo o o o o yo o o yo
characteristi articipants =76;7–14y =50;8+12 =37;8–14y =23;8–11y =59;15–17 =47;9–13y =94;9–13y =34;5–15y =41;6–17y =35;13–17 =62;7–12y =24;8–12y =104;6–16
ve P n n n n n n n n n n n n n
Table1Descripti Study Barrettetal.(1996) Beideletal.(2000) Flannery-SchroederandKendall(2000) Gallagheretal.(2004) Garcia-Lopezetal.(2002) Kendall(1994) Kendalletal.(1997) Kingetal.(1998) Lastetal.(1998) Masia-Warneretal.(2005) Mendlowitzetal.(1999) Murisetal.(2002) Silvermanetal.(1999)
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360 ClinChildFamPsycholRev(2007)10:352–372
Table1continued StudyParticipantsSelectioncriteriaTreatmentsTxdurationBehavioralmeasurePhysiomeasuresCognitivemeasuresCopingmeasures nSWQ-PUSpenceetal.=50;7–14yoSOPCBT+Parvs.12ss,2boosterBAT-CR;SCQ-P;SSQ-P;(2000)CBTvs.WLSchoolobsrating-social Note:yo=yearsold;OAD=overanxiousdisorder;SOP=socialphobia;SAD=separationanxietydisorder;GAD=generalizedanxietydisorder;SET-C=socialeffectivenesstherapy;Measuresarepresentedinalphabeticalorder:IAFSG=therapyforadolescentswithgeneralizedsocialphobia;ss=sessions.BAT-CR=revisedbehaviorassertivenesstestforchildren;BO=behavioralobservations;CBCL=childbehaviorchecklist—socialcompetence,activities,school,healthsubscales,parentversion;CCSC=children’scopingstrategieschecklist—active,avoidant,distraction,supportsubscale;CE=clinicalevaluation,avoidantbehavior;CNCEQ=children’snegativecognitiveerrorquestionnaire;CQ-C/P=copingquestionnaire,child,parentversions;EHSPA=socialskillsscaleforadolescents;FEAR-AS=FEARtask-avoidantsolutions;FEAR-TI=FEARtask-threatinterpretation;FM-C/P=friendshipmeasure,child,parentversions;IS=inadaptationscale;LSAS-CA=Liebowitzsocialanxietyscaleforchildrenandadolescents—socialavoidance,performancesubscales;NASSQ=children’snegativeaffectivityselfstatementquestionnaire;PRCS=publicreportofconfidenceasspeaker;PRSCC=parentratingscaleofchildcompetence—socialscale;PSWQ-C=Pennstateworryquestionnaireforchildren;RCMAS=revisedchildren’smanifestanxietyscale—physiological,worry,oversensitivity,socialconcerns,concentrationsubscales;RSES=Rosenbergself-esteemscale;SAS-A/P-FNE=socialanxietyscale-fearofnegativeevaluationsubscale,adolescent,parentversions;SOCS-P=socialactivitiesscale;SCQ-P=socialcompetenceques-tionnaire;SEQ-SS=self-efficacyquestionnaireforschoolsituations;SPPC=Harter’sselfperceptionprofileforchild—socialacceptancesubscale;SSQ-P=socialskillsquestionnaire;STAIC-M=modifiedstate-traitanxietyinventoryforchildren-somatic,cognitivesubscales;SWQ-PU=socialworriesquestionnaire-pupil doicaecoswp01(a(pg0baffas(1pppfotETpcaTaccsdetserhKooSuzittmopionbnannooriuu..e.o.uruefoaguu\\\\\atg5654afaruneDlmpmanlxfxxmmttttcy=eabfAASsnddaclhet1242evcchcncldeeiiieentlluiysiyioptpoeoceepp–)–)ftimd00.00ecardrl=ecfiermdshio,0ul1ttttssemaammaaa11er;....roposam(yyyacssoiu(e00100ni3o.nrrrrelsa..iEonsttmrmKt9ila,67eieeeeenlw0sm00,01cdou)setnuagewlwmsfaiSn5dddsss.sdo92stt.d111)onlflisropddnrf.2irfettt,,lhlCuehu))eo1s.)))sorl(gueolna(sii,aat=Atmat3t.kp..,ditisoyEnleetfiEod9tohnhvraBdrr,tpoconic;prisCorrseDme(c0cge9cdSnoeiMaiSynheoCnieeTEdAwemnpp0edtnr.ar=gh4BteddpaeisaEm4coierawwarg.BSo1tn=oeop=nta;ztefspa4on(aaerT6tottsSltCmst-f4atiniKeureirieTsherwytnr(00rssshltenoit=vfieaKaent,eEsreiatByrgms-e0gwae0,.eire(nncasoetdlwrcelps0itpcrenShSl.Aeenee.t.niTnsooms,lgs.aaaet4Eaetw8rm5h0isrnyifnaiitiDedicponmtln2apidonfipt6gofI7m=)e.So=tse.dmoltraua2eaemnndt.t0ridxa,ehlnc,cnwnn(oesasflffleairn=c=4edu0fuiaEey0eoplifsar1fterspleM-tsn0etfta,gcee(o0nnolctwreah.ntfsSa4ase0gpto.E2sw\eernef=fepnmnsttn)r00y6eitnnec.edaoefulwe8teodtriidS6td...=6yaatehonizEinofiiaaisct4t0dt=snsa0n4taafnsnccn0a,razer.enstltaicl66(eSE=nsfdg).amelcst,ocxtin..pessrS40ex0a.awpss;–ws0ssdlsiealSantle(mrbE.ftrf5nmD.uoi..t\riaf00nSttooslus5e)6.0osefe1tavwurerthmatSDdrdste.h1seefDhardn1t7ofl0.pri9usoegt9t.niee(ee5yye=satrrue)(n)hane0est9i,ml9dizer-2teaeddr,dS.s4e(efninngparnl.c(9a=pa7inc)lfSoofi0se,Dob=smcsteer0tofn,nft7sfoo),tprnD\da.e0tefrevetjursiaot.pnwxo)uaumziunugo0ertee4f=si1cCnet.=uoatm2Iaiofncgerdtnasso\snem.e4tr)er=nexfhp0nonn3nTB.sorctisetxeniodn.arucFe;t2epforioe-maadm.di8deemnny0ialltIefeTrte0nawnu9rtsn0te,rlE,i0s;cnerebte.rtwheaz0ta0oi,gntr,b5twrsa.yoac.enocrsSzlvtyteC0elso.oOp41ntmorn3lehappmhltorpmloo1tneohahrmie0amlur8)ienBgl;eriooenurmu9semnueeo\e,Ednn\13nete;esso((ner,eu,tetT–aclngtdaigffnEE)i)i-fSs,cficpprrocanaszngbouudd1,.rnu((e=aastCoo0saSSon.vClwsoeeCEazznumnnee.owtMpd0cennammr0u.meusBmn=rppwBitccf0nSe.ree0Bggn====E5-raeefiagdoEodettrredresd5lT1eseeedeTasssiiT)IneeaycSeiradtsSoo)s00sf,neewsucssxanp5900nCww.ufv==nnag..0szasspd(rnewwwie21o....aoaahcaniiBeiiesro2373.eetterfEfcitrnnnnno58so5rnecehhexnraaaoeoolrri--ts4747atTitSydnddn––dnohn5gygeeeeeessssss-----rrl,,,,
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ClinChildFamPsycholRev(2007)10:352–372 361
Table2nDescriptivecharacteristicsofstudiesevaluatingCBTforyouthdepression(=14) StudyParticipantsSelectioncriteriaTreatmentsTxdurationBehavioralCognitiveCopingmeasuresmeasuresmeasures nAckersonetal.(1998)=22;7–12thgradeCDI&HRSDC10Cognitivebibliotherapy4weeksATQ;DAS;CogBTvs.WL nCBTvs.WL16ss,1h,2SPPCDeCuyperetal.(2004)=20;9–11yoCDIC11;CBCLA/DTC63;DSM-III-Rboostersbasedinterview;1MDDcriterion nFineetal.(1991)=47;13–17yoMDDorDysSocialskillstrainingvs.12ssCBQC;OSIQtherapeuticsupport nKahnetal.(1990)=68;10–14yoCDIC15;CBTvs.relaxationvs.12ss,60min;PHCSCSRADSC72;self-modelingvs.WL6–8weeksBIDC20 nKaufmanetal.(2005)=93;13–17yoMDD&CDCBTvs.lifeskills16ss,2h;8weeksPES—relaxation,ATQ;DASIC-Apleasantacts,socialskills nKolkoetal.(2000)=77;13–18yoMDDCBTvs.SBFTvs.NST12–16ss,2–4CNCEQboosters nLewinsohnetal.(1990)=59;14–18yoMDD,MinDep,orCBTvs.CBT+parent14ss2h;7weeksIC-PintermittentDepvs.WL n[LiddleandSpence=31;7–12yoCDIC19;CDRS40Socialcompetence8ssMESSY;LSSP(1990)trainingvs.attentionplacebovs.NoTx nReynoldsandCoats=24;mean=15.6yoBDIC12;CBTvs.relaxationvs.10ss,50min;RSES;ASCS-HS(1986)RADSC72;WL5weeksBIDC20 nRohdeetal.(2004)=91;13–17yoMDD&CDCBTvs.lifeskills16ss,2h;8weeksSAS-SR nRosselloandBernal=58;13–17yoMDDorDysCBTvs.IPTvs.WL12ss,1h;12weeksSASCA;CBCL-PHCSCS(1999)P/A-beh,social nStarketal.(1987)=28;10–12yoCDIC13;CDRSSelfcontrolvs.behav12ss,45–50min;CBCL—socialCSEIprobsolvingvs.WL5weekswithdrawal nVostanisetal.(1996)=57;8–17yoMDD,MinDep,orDysCBTvs.NFI9ss;upto6mosSAICA-13-peersSEI-C/P nWoodetal.(1996)=48;9–17yoMDDorMinDep,CBTvs.relaxation5–8ssABSWJSMFQC14 Note:yo=yearsold;MDD=majordepressiondisorder;Dys=dysthymia;CD=conductdisorder;MinDep=minordepression;SBFT=systemicbehavioralfamilytherapy;NST=non-Measuresarepresentedinalphabeticalorder:specificsupporttherapy;IPT=interpersonaltherapy;NFI=nonfocusedintervention;ss=sessions.ABS=parentantisocialbehaviorscale;ASCS-HS=academicself-concept-HSversion;ATQ=automaticthoughtsquestionnaire;BID=Bellevueindexofdepression;CBCL-P/A=childbehaviorchecklist—parent,adolescentversions,behavior,socialsubscales;CBQC=cognitivebiasquestionnaireforchildren;CDI=childdepressioninventory;CDRS=childdepressionratingscale;CNCEQ=children’snegativecognitiveerrorsquestionnaire;CogBT=cognitivebibliotherapytest;CSEI=Coopersmithself-esteeminventory;DAS=dysfunctionalattitudescale;HRSD=Hamiltonratingscalefordepression;IC-A/P=issueschecklist,adolescent,parentversion;LSSP=listofsocialsituationproblems;OSIQ=offerselfimagequestionnaire;MESSY=Matsonevaluationofsocialskillsforyoungsters,totalscore;MFQ=moodandfeelingsquestionnaire;PES=pleasanteventsschedule—relaxation,pleasantactivities,socialskillssubscales;PHCSCS=Piers-Harrischildren’sself-conceptscale;RSES=Rosenbergselfesteemscale;SAICA-13=socialadjustmentinventoryforchildrenandadolescents,peerssubscale;SASCA=socialadjustmentscaleforchildrenandadolescents;SAS-SR=socialadjustmentselfreport;SEI-C/P=selfesteeminventory,child,parentversions;SPPC=selfperceptionprofileforchildren;WJS=ParentWarrandJacksonselfesteemscale
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