disorder-specific effects of cbt for anxious and depressed...
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Disorder-specific Effects of CBT for Anxious and DepressedYouth: A Meta-analysis of Candidate Mediators of Change
Brian C. Chu Æ Tara L. Harrison
Published online: 6 November 2007
� Springer Science+Business Media, LLC 2007
Abstract The commonalities between anxiety and
depression have been discussed before, but few have
delineated the potentially different mechanisms through
which treatments work for these populations. The current
study conducted a comprehensive review of child and
adolescent randomized clinical trials that tested cognitive-
behavioral therapy (CBT) for anxiety or depression. All
studies were required to have assessed both treatment
outcomes and at least one theory-specific process target,
including behavioral, physiological, cognitive, and coping
variables. Using a meta-analytic approach, CBT demon-
strated positive treatment gains across anxiety, depression,
and general functioning outcomes. CBT for anxiety also
produced moderate to large effects across behavioral,
physiological, cognitive, and coping processes, with
behavioral targets demonstrating potentially the greatest
change. CBT for depression produced small effects for
cognitive processes but nonsignificant effects for behav-
ioral and coping variables. Findings were generally
consistent with CB theory but suggest potentially different
mediators in the treatment of anxiety and depression.
Results are discussed in terms of implications for mecha-
nisms research, theories of change, and treatment
development.
Keywords Child � Adolescent � Anxiety � Depression �CBT � Mechanisms of change
Introduction
The case for studying mediators of change in child and
adolescent treatment research has been made before
(Kazdin and Kendall 1998; Kazdin and Weisz 1998).
Identifying the critical ingredients and the mechanisms
through which treatments work is essential for maximizing
treatment efficacy, improving therapeutic techniques, and
improving methods for training therapists (Kazdin and
Nock 2003; Weersing and Weisz 2002). Despite the
importance of this research, there is a noted gap between
our knowledge of treatment outcomes and the processes
associated with those outcomes (Shirk 2005; Silverman
2006). The current review and meta-analysis will evaluate
the specific effects that cognitive-behavioral therapy (CBT)
produces in the treatment of anxious or depressed children
and adolescents.
Overlapping Features of Youth Anxiety and Depression
Combined, anxiety disorders such as generalized anxiety
disorder (GAD), separation anxiety disorder (SAD), social
phobia (SOC), and other phobic disorders are estimated to
represent the largest class of childhood emotional problems
with point prevalence rates ranging between 12 and 20%
(Cohen et al. 1993; Costello et al. 2005). Depression tends
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).
However, nearly 20% of youth may experience a depres-
sive disorder by the end of adolescence (Lewinsohn et al.
1993). Both disorders are associated with severe disrup-
tions in social, academic, and family functioning and have
B. C. Chu (&) � T. L. Harrison
Department of Psychology, Rutgers, The State University of
New Jersey, 152 Frelinghuysen Road, Piscataway,
NJ 08854, USA
e-mail: [email protected]
123
Clin Child Fam Psychol Rev (2007) 10:352–372
DOI 10.1007/s10567-007-0028-2
been connected with greater risk for more severe anxiety,
depression, and substance abuse in adulthood (Kendall et
al. 2003; Rohde et al. 1994).
There are several good reasons to examine anxiety,
depression, and their respective treatments together. A high
degree of co-occurrence has been established between
these disorders in both community and clinical samples. Up
to 69% of youth with primary anxiety have been diagnosed
with depression and up to 75% of depressed youth have
been diagnosed with an anxiety disorder (Angold et al.
1999; Brady and Kendall 1992; Kovacs 1990). Taxono-
metric approaches seeking to isolate uniquely identifying
symptom profiles have often found more commonalities
than differences (e.g., see Child Behavior Checklist
development; Achenbach 1991). Furthermore, longitudinal
studies have suggested a developmental relationship
between the disorders, in which problems in anxiety tend to
precede depression (Kessler et al. 1997; Kovacs et al.
1988). Of course, anxiety and depression are not com-
pletely overlapping phenomena. Several lines of research
(e.g., the tripartite theory; helplessness vs. hopelessness
theories) have identified cognitive and affective processes
that distinguish the disorders (Alloy et al. 1990; Barlow
et al. 1996; Clark and Watson 1991; Watson and Clark
1984), but overall, many commonalities exist.
Commonalities in Treatment Strategies and Treatment
Targets
A review of CBT programs targeting anxiety and depres-
sion reveals a number of similarities (Barlow et al. 2004;
Chorpita et al. 2002; Kazdin and Weisz 2003; Ollendick
and King 2000). As a whole, CBT aims to modify mal-
adaptive thinking and attitudes, increase skill sets, and
change unrewarding or avoidant behavioral patterns. Most
anxiety and depression treatments include general skills-
building strategies, such as self-monitoring, psychoeduca-
tion, problem-solving, social skills training, and reward
plans. The cognitive strategies for anxiety and depression
use many similar techniques, including identification of
thinking errors, Socratic questioning, and development of
coping thoughts. Even behaviorally oriented techniques
may be used to correct misperceptions and maladaptive
cognitions. For example, a child with social evaluation
concerns may be asked to give a speech in front of a mock
class. The in vivo exposure gives the youth an opportunity
to complete a difficult task and examine untested
assumptions about their abilities and the evaluations of
others. The specific target of cognitive restructuring may
vary across disorders (e.g., perceptions of threat and
unpredictability may be the target for anxious youth while
self-criticism and hopelessness may be emphasized in
depression), but replacing maladaptive thoughts with more
functional thinking is a common goal (Kendall et al. 2003;
Clarke et al. 2003; Weisz et al. 2003). Thus, successful
CBT would be expected to engender positive change in
cognitive processing including decreased negative auto-
matic thoughts, maladaptive attitudes and assumptions, and
decreased threat interpretations.
Behavioral techniques for treating anxiety and depres-
sion both make use of common learning and conditioning
principles. The primary behavioral target in anxiety treat-
ment is avoidance. Exposure tasks for anxious youth
assume that avoidance is prompted by emotional distress,
fear, and negative cognitions triggered by a feared event or
stimulus. Exposure therapy attempts to reduce avoidance
by having the child progressively work his or her way up a
graded fear hierarchy of feared situations while employing
coping skills or relaxation. Behavioral therapies for anxiety
also seek to reduce long-term physiological and subjective
fear responses to feared situations or challenges (Davis and
Ollendick 2005; Ollendick and King 1998). The specific
mechanisms through which exposures foster approach
behaviors are still a subject for debate (Craske and My-
stowski 2006; Foa and McNally 1996), but collectively,
successful CBT would be expected to be associated with
significant change across behavioral and physiological
processes (Davis and Ollendick 2005; Ollendick and King
1998).
Behavioral strategies for depression emphasize pleasant
activity scheduling and behavioral activation. Using these
strategies the therapist encourages activities that are indi-
vidually gratifying for the child to increase availability of
natural reinforcement in the child’s life and enhance the
child’s sensitivity to natural rewards (Lewinsohn and Graf
1973; Lewinsohn and Libet 1972). Recent conceptualiza-
tions of behavioral activation have also highlighted the role
of avoidance in depresso-typic behavior (Jacobson et al.
2001; Addis and Martell 2004). In this model, avoidance is
maintained in depression much like it is in anxiety;
avoidant behavior is triggered by a distressing event and
then is reinforced by the subsequent reduction in distress
even as it contributes to a number of secondary problems.
Continued avoidance perpetuates a cycle of inactivity,
withdrawal, and inertia that denies the child access or
opportunity to contact antidepressant sources of rein-
forcement (Jacobson et al. 2001). Thus, we would expect
successful CBT to be associated with increased activation,
frequency and enjoyment of pleasant activities, and a
possible decrease in avoidance. CBT also aims to teach
clients age appropriate skills, such as socialization and
social problem-solving skills. Increased skill sets are
expected to increase the child’s sense of mastery and the
likelihood that they will engage in social and pleasant
activities (Clarke et al. 2003; Weisz et al. 2003). Thus,
Clin Child Fam Psychol Rev (2007) 10:352–372 353
123
CBT for youth with depression should be associated with
increased skill sets (e.g., social skills) associated with
behavioral activation.
Cognitive-behavioral interventions also aim to improve
coping skills or alter coping styles in anxious and depres-
sed youth (Prins and Ollendick 2003). Coping is a broad
term that embodies cognitive, behavioral, and physiologi-
cal processes and refers to how youth respond to stressful
events and challenges (Compas et al. 2001). Problem
solving, wishful thinking, cognitive avoidance, and rumi-
nation are coping strategies that primarily involve
cognitive processes. Avoidance, escape, and inaction are
types of behavioral coping strategies. Relaxation is a
coping strategy that primarily targets one’s physiological
state. Although many coping processes overlap with cog-
nitive and behavioral outcomes, investigators often
measure coping skills separately from dysfunctional
behavioral or cognitive styles, so it makes sense to consider
coping styles as unique targets of treatment. In general,
changes in coping style from avoidant to active strategies,
such as planning, thinking about solutions, and positive
cognitive restructuring, are associated with enhanced psy-
chological adjustment (Compas et al. 2001; Prins and
Ollendick 2003). Improvements in child and parent
reported coping efficacy have also been associated with
symptom improvement following CBT (Kendall 1994;
Kendall et al. 1997; Barrett et al. 1996).
Established Efficacy
Built on these sound theoretical principles and practices,
CBT has collectively documented impressive empirical
support for its treatment outcomes. In the treatment of
youth anxiety disorders, narrative and quantitative reviews
suggest that cognitive and behavioral approaches are
effective compared to no-treatment controls and alternative
treatments (Compton et al. 2002; Kaslow and Thompson
1998; Ollendick and King 1998). A number of individual
CBT programs also meet criteria as probably efficacious
using APA Task Force on Promotion and Dissemination of
Psychological Procedures guidelines (APA Task Force
1995; Ollendick and King 2000). In individual treatment
studies, CBT has compared favorably to wait-list and no-
treatment controls across a range of formats, including
individual child (e.g., Kendall 1994; Kendall et al. 1997),
family-focused (e.g., Barrett et al. 1996; Wood et al.
2006), and group (Flannery-Schroeder and Kendall 2000).
Similar CBT protocols have been adapted for adolescents
(Albano et al. 1995) and transported to school (Masia-
Warner et al. 2005) and medical center settings (Child
Anxiety Multimodal Study, in progress). The consistent
support for the efficacy of CBT suggests it is an appropriate
time to understand the basic mediators through which CBT
helps alleviate anxiety.
Outcome trials with depressed youth have also docu-
mented promising results for CBT. Two CBT programs
have been listed as a ‘‘probably efficacious’’ according to
APA Task Force criteria (Kaslow and Thompson 1998;
Ollendick and King 2000): Stark’s self-control treatment
(Stark et al. 1987) for child depression and Lewinsohn and
colleagues’ Coping with Depression course for adolescents
(Lewinsohn et al. 1990). Meta-analyses that have pooled
findings across clinical trials also have documented con-
sistent large effect sizes for CBT, ranging from 0.72 to 1.27
(Lewinsohn and Clarke 1999; Michael and Crowley 2002;
Reinecke et al. 1998). Recently, the relative strength of
CBT for depression has been questioned due to the success
of anti-depressant medications in comparative clinical tri-
als (Treatment for Adolescent Depression Study [TADS]
2004). Similarly, Weisz et al. (2006) recently completed
the most comprehensive meta-analysis to date and found
that the overall effects of psychotherapy for youth with
depression lagged significantly behind the psychotherapy
effects for other childhood disorders. In addition, Weisz
et al. demonstrated that cognitive-based therapies did not
produce superior overall outcomes compared to noncog-
nitive therapies in depressed youth. These findings suggest
that there is still substantial room for improvement in
psychological treatments for depression and that the effects
of cognitive therapies could benefit from further
investigation.
Together, the literature suggests that a comparison of
change mediators in efficacious treatments for anxious and
depressed youth would be timely and potentially revealing.
An analysis of the specific effects that CBT produces may
help identify its strengths as a treatment approach as well
as isolate areas in need of improvement. Such an analysis
may also delineate the underlying relationship between
anxiety and depression. However, to date, there has been
no direct comparison of the specific effects that CBT has
for anxious and depressed youth and whether similar or
distinctive mechanisms are responsible for observed treat-
ment outcomes.
State of Mechanisms Research in Youth CBT
There have been significant methodological and analytic
advances in mediator research (Kraemer et al. 2002;
MacKinnon et al. 2002; Shadish and Sweeney 1991). A
mediator specifies how (or the mechanism through which)
a given effect occurs (Baron and Kenny 1986; Holmbeck
1997; MacKinnon et al. 2002). The most common method
used to demonstrate a variable acts as a mediator has been
the ‘‘causal steps approach’’ (MacKinnon et al. 2002)
354 Clin Child Fam Psychol Rev (2007) 10:352–372
123
based on Judd and Kenny (1981) and later elaborated on
by Baron and Kenny (1986). The Baron and Kenny model
outlines four specific conditions required to demonstrate
mediation, including that (a) the predictor must be sig-
nificantly associated with the mediator, (b) the predictor
must be significantly associated with the dependent
measure, (c) the mediator must be significantly associated
with the dependent variable, and (d) the impact of the
predictor on the dependent variable must be less after
controlling for the mediator (Baron and Kenny 1986;
Holmbeck 1997). Change in the mediator must also fol-
low the onset of the independent variable and precede
change in the dependent variable temporally (Judd and
Kenny 1981; Kazdin and Nock 2003). It then requires
several additional steps to establish a mediator as a
mechanism. Kraemer et al. (2002) remind us that ‘‘all
mechanisms are mediators but not all mediators are
mechanisms’’ (p. 878). However, demonstrating causality
is much more difficult than establishing mediator status.
Thus, the investment of time and effort to narrow the
search for causal factors by focusing first on a search for
mediators is worthwhile.
To conduct a broad review of the child clinical litera-
ture, Weersing and Weisz (2002) adapted Baron and
Kenny’s definition to create a framework for evaluating
mediating mechanisms across randomized clinical trials.
Most relevant to the current review, they re-labeled Baron
and Kenny’s (1986) criterion (b) the ‘‘Intervention-speci-
ficity test’’ and examined which treatments demonstrated a
significant relationship with prospective mediators. This
analysis tested whether treatment affected the mechanism
of action hypothesized to produce intervention effects (i.e.,
tested the hypothesized theory of change).
Using this framework, Weersing and Weisz (2002)
found that CBT did produce consistent overall treatment
outcomes for both anxiety and depression but there was
less information regarding the Intervention-Specificity
Test. For example, they reported that CBT was associated
with change in cognitive mediators in all anxiety studies,
and CBT was associated with change in cognitive and
behavioral mediators in most depression studies. However,
no specific effect sizes were provided to indicate the rela-
tive strength of these associations. ‘‘Box-score’’ type
narrative summaries of this sort are more sensitive to
individual study sample sizes and can result in misleading
conclusions (Beaman 1991; Lipsey and Wilson 2001). The
authors only reviewed the evidence for cognitive mediators
in the treatment of anxiety; they did not include a review of
behavioral, physiological, or coping variables. They also
did not report on the effect of depression treatments on
coping variables. Thus, the review supported the CB theory
of change for several common processes, but it did not
present data on other possible mediators and it did not
directly compare effects across diagnostic groups to
determine if CBT had differential impact across anxiety
and depression.
Three additional reviews explored similar issues. Prins
and Ollendick (2003) specifically reviewed the evidence
for cognitive and coping variables as mediators of CBT for
anxious youth. Similar to previous reviews, they found few
studies formerly testing mediation but many assessed pre-
to post-treatment outcomes of cognitive or coping process
(e.g., 44% of studies assessed cognitive change, 40% of
studies assessed coping attitudes or behaviors). Of those
studies that did measure process variables, CBT demon-
strated consistent effects. All controlled studies that
included either a coping or a cognitive variable reported
significant positive change from pre- to post-treatment.
Prins and Ollendick also calculated summary effect size
statistics. In randomized clinical trials comparing individ-
ual child CBT to a waitlist, treatment produced a small
effect in cognitive measures based on child report
(d = 0.36; range = 0.00–0.70). A moderate to large effect
in coping-related measures was found depending on whe-
ther child (d = 0.49) or parent (d = 0.99) report was
considered.
Prins and Ollendick (2003) did note that, in comparisons
of CBT to an alternate active treatment, CBT produced
significant pre- to post-changes in cognitive and coping
processes, but these differences were not significantly dif-
ferent from the control conditions. Thus, CBT may be
associated with cognitive changes, but such change may
not be uniquely related to CBT. In sum, the review helped
demonstrate at least partial support for the role of cognitive
and coping processes as possible mediators. Like Weersing
and Weisz (2002), this review did not examine CBT’s
effect on behavioral or physiological processes and did not
include depressive samples.
Davis and Ollendick (2005) conducted a comprehensive
review of CBT in producing specific change in a broader
set of processes associated with specific phobia, including
cognitive, behavioral, physiological, and subjective fear.
They reviewed 22 clinical trials that compared a behavioral
or cognitive treatment to either an active or passive control
condition. The majority of studies reviewed had included
some measure of behavioral and subjective fear change, but
many fewer measured cognitive or physiological change.
Based on a box score summary of the literature, there was
significant evidence that behavioral treatments produced
positive change in most behavioral and fear measures. This
finding held whether compared to either passive or active
controls. Thus, behavior and subjective fear appear to be
both reliably produced by, and specific to, behavioral
treatments in the treatment of specific phobias. Davis and
Ollendick did not provide effect size calculations to sum-
marize the magnitude of effect that treatment has on
Clin Child Fam Psychol Rev (2007) 10:352–372 355
123
specific targets. The review also limited itself strictly to
treatment studies of specific phobia.
A final review conducted a meta-analysis evaluating the
overall outcomes of CBT for anxious and depressed youth
when compared against either a bona fide (active psycho-
logical treatment with a defined theory) or non-bona fide
(nonspecific active control) therapy (Spielmans et al.
2007). They divided outcome measures into dependent
variables that either directly measured anxiety or depres-
sion or measured some other outcome of interest. Their
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
depression measures into specific component processes of
cognitive, behavioral, coping, or physiological outcomes.
The Current Review
In the current report, we evaluate the specific effects that
CBT produces in the treatment of anxious or depressed
children and adolescents. Most previous meta-analyses
have reviewed overall treatment outcomes documenting
the general efficacy of CBT. Our review summarizes the
magnitudes of effect that CBT has on specific targets
related to the cognitive-behavioral theory of change,
including behavioral, physiological, cognitive, and coping
outcomes. Meta-analytic methods were used to summarize
and compare effect size (ES) calculations within and across
anxious and depressed study samples with special attention
paid to comparisons across diagnostic classes.
We hypothesized that CBT, when implemented with
anxious or depressed youth populations, would demon-
strate positive and significant effects for anxiety and
depression outcome measures. Based on previous reviews
(e.g., Weisz et al. 2006), we hypothesized that treatments
would produce larger effects for disorder-specific outcomes
(e.g., depression symptoms in CBT for depression) than
nonspecific outcomes (e.g., anxiety symptoms in CBT for
depression). Furthermore, based on the lower overall ES
values found for depression treatments in Weisz et al.
(2006), we also hypothesized that anxiety treatments would
produce larger effect sizes on treatment outcomes than
depression treatments.
In analyses focusing on specific behavioral, physiolog-
ical, cognitive, and coping change, we hypothesized that
CBT for anxiety would be associated with moderate to
large effects across all specific processes. We also
hypothesized that CBT for depression would produce
moderate to large effects in cognitive, behavioral, and
coping processes, but expected physiological processes to
be rarely assessed. We then compared magnitudes of ES
across process variables to determine if CBT had differ-
ential effects on specific targets. That is, within anxiety or
depression treatments, would mean ES values differ among
behavioral, physiological, cognitive, and coping outcomes?
These analyses were exploratory since we were not aware
of other attempts to make such a direct comparison.
Finally, we compared anxiety versus depression studies to
determine if CBT had differential effects on process out-
comes; these analyses were also exploratory given the
absence of previous comparisons.
Methods
Literature Review
Studies were obtained through reference trails and
computer index searches. We reviewed several recent,
comprehensive psychotherapy reviews and meta-analyses
(i.e., Compton et al. 2002; Kaslow and Thompson 1998;
Lewinsohn and Clarke 1999; Michael and Crowley
2002; Ollendick and King 1998; Prins and Ollendick
2003; Reinecke et al. 1998; Weersing and Weisz 2002;
Weisz et al. 2006) and included all relevant studies.
Studies were also obtained through computer index
searches using PsychINFO (1980–August, 2006) and
MEDLINE (1980–August, 2006) and by reference trails
that resulted from identified studies. Keywords used in
computer searches were: Depression, Major Depression,
Minor Depression, Dysthymia, Anxiety, Anxiety Disor-
ders, Generalized Anxiety Disorder, Separation Anxiety
Disorder, Social Phobia, CBT, cognitive-behavioral
therapy, cognitive therapy, behavior therapy, exposure
therapy, and behavioral activation. The auto-explode
option was used in computer searches so that all relevant
topics within the broader categories were searched as
well. Searches were limited to populations between ages
6 and 18 years.
Studies were obtained and included if they met the
following criteria: (a) study participants were selected for
a clinical diagnosis of anxiety or clinically significant
depression; (b) random assignment to treatment condi-
tions was used; (c) at least one of the treatment
conditions was identified as a behavioral, cognitive, or
cognitive-behavioral intervention (the comparison condi-
tions could be either a passive control or alternate
treatment); (d) sample age range was between 6 and
18 years old; and (e) the study was published in an
English language, peer-reviewed journal. Studies had to
report posttreatment data (means and standard deviation)
for at least one outcome measure that assessed anxiety or
depression. Studies also had to report data for at least
356 Clin Child Fam Psychol Rev (2007) 10:352–372
123
one cognitive, coping, behavioral, or physiological target
at posttreatment (studies did not have to report data for
all four process categories). Citations of included studies
appear in the reference list with asterisks.
Studies were not included if they explicitly described
the intervention as a prevention program. Studies were
not included if analyses only compared one CBT con-
dition against another CBT condition (e.g., individual
CBT vs. CBT + parent involvement), because the
study’s goal was to compare CBT versus active or
passive controls. Studies that targeted school refusal
were included. Studies were not included if the primary
treatment target was Specific Phobia, Obsessive-Com-
pulsive Disorder, Post-Traumatic Stress Disorder, Panic
Disorder, or test anxiety. CBT interventions were not
included if treatment format was primarily computer-
based or virtual reality. Finally, studies were not
included if the only CBT condition was a combined
CBT plus pharmacotherapy condition.
Study Coding Procedures
Studies were coded to identify (a) sample characteristics,
(b) treatment and design characteristics, (c) anxiety and
depression outcome measures used, and (d) mediator
(process) measures used. Treatment outcome measures
were included for ES coding if they assessed anxiety or
depression symptoms (e.g., parent or child-report ques-
tionnaires), diagnosis (e.g., structured interview), or
general functioning or improvement (e.g., Global Assess-
ment of Functioning scales, Clinical Global Improvement
scales). Process measures were included if they targeted
behavioral, physiological, cognitive, or coping constructs.
These could include parent- and child-report question-
naires, judge-rated observations, and independent reports
(e.g., school-reported attendance records, diary reports of
attended social events).
Two raters (the authors) independently coded 14 studies
each. To assess interrater reliability, both raters double
coded eight (28.6%) of the studies. Raters demonstrated
excellent 94.6% (k = 0.89) agreement in identifying which
outcome and process measures should be included for
coding. Intraclass correlation coefficients (ICC) were cal-
culated to assess rater reliability in coding means and
standard deviations and in calculating ESs. Raters dem-
onstrated excellent reliability in coding means
(ICC = 1.00, p \ .001) and standard deviations (ICC =
0.99, p \ 0.001) and in calculating ES scores from raw
data (ICC = 0.98, p \ 0.001). Raters were exceptionally
reliable in coding raw data from studies and calculating ES
scores.
Statistical Analyses
Cohen’s d (1988) was the measure of effect size. Cohen’s
d is the mean difference between the mean outcome in
the treatment group and the mean outcome in the control
group divided by the pooled (within-group) standard
deviation. In studies that included more than one CBT
condition (e.g., individual CBT, individual + parent
CBT), each intervention was compared to the control
condition (e.g., WL, educational support). All ES values
were corrected for small sample bias (Hedges and Olkin
1985, p. 81, Equation 10) and then pooled up to the level
of treatment. This permitted an evaluation of effect size
for an average CBT condition. ES values were then
weighted by the inverse of its variance, adjusting for
varying sample sizes and heterogeneity of variance across
studies (Hedges and Olkin 1985; Lipsey and Wilson
2001).
As a final step, when calculating mean ES values, a Q-
statistic was calculated to test the assumption that all ES
values estimated the same population (i.e., homogeneity in
ES distributions; Lipsey and Wilson 2001). When homo-
geneity is rejected, this indicates the variability among the
study effect sizes are greater than what is likely to have
resulted from subject-level sampling error alone. In these
cases, we adopted a random effects model which accounts
for random variability at both the study-level (studies
sampled from a population of studies) and the subject-level
(subjects in each study sampled from a population of
studies). This model uses a different inverse variance
weight than the fixed effects model (used when effect sizes
represent a homogeneous distribution). All ES means
reported hereafter are weighted least square effect sizes
based on the appropriate model (either random or fixed
effects) depending on the results of the Q-statistic. To
interpret ESs, we used Cohen’s (1992) definitions in which
an ES of 0.20 indicates a small effect, 0.50 a medium
effect, and 0.80 a large effect.
To compare mean ES values with zero, we used SPSS
macros that generate z tests based on the absolute value of
the mean ES divided by the standard error of the mean
ES (Lipsey and Wilson 2001; Wilson 2003). Consistent
with previous meta-analyses (e.g., Weisz et al. 2006), we
used paired t-tests to compare ES values of conceptually
different measures obtained from the same set of studies
(e.g., behavioral vs. physiological vs. cognitive vs. coping
ES means). Paired t-tests acknowledge dependencies
among the variables resulting from ESs calculated from
the same study samples. To compare mutually exclusive
categories of studies (e.g., Anxiety vs. Depression stud-
ies), we used a Q-statistic analog to analysis of variance
(Lipsey and Wilson 2001; Wilson 2003). In this analysis,
if the between-category variance is significant, then the
Clin Child Fam Psychol Rev (2007) 10:352–372 357
123
mean ES values across groups differ by more than sam-
pling error.
Results
Descriptive Characteristics of Reviewed Studies
The final sample consisted of 14 anxiety studies repre-
senting 22 CBT treatment conditions, and 14 depression
studies representing 20 CBT conditions. Of the anxiety
studies, nine studies used a waitlist control and five com-
pared CBT to an active control condition (e.g., educational
support, nonspecific treatment). Six anxiety studies inclu-
ded multiple forms of CBT (e.g., individual, group, or
parent condition). Of the depression studies, eight studies
used a waitlist or no-treatment control and six compared
CBT to an active treatment condition (e.g., Life skills,
nonspecific support). Four depression studies included
multiple forms of CBT (e.g., individual vs. family-based;
self-control vs. behavioral problem solving). Descriptive
information about study design, participants, and treat-
ments are reported in Tables 1 and 2.
Tables 1 and 2 also report the assessment measures used
to assess behavioral, physiological, cognitive, and coping
processes in anxiety and depression studies. Over 71%
(n = 10) of anxiety studies and 50% (n = 7) of depression
studies included an assessment of behavioral processes. In
the anxiety studies, a diverse range of methods were used
to assess behavioral processes, including behavioral
observation tasks (e.g., independent coding of a speech
task; choice of avoidant solutions during a family interac-
tion task), parent- or child-report measures (e.g., Friendship
measure; Social Skills Questionnaire), and subscales of
larger anxiety measures (e.g., Liebowitz Social Anxiety
Scale—social avoidance and performance subscales).
Behavioral observations were not used in depression
studies, but parent and youth report of pleasant activities
(e.g., Pleasant Events Scale; CBCL—social activities
subscale) and social skills (e.g., Social Adjustment Scale;
Social Adjustment Inventory for Children and Adolescents)
were common.
Only a small percentage of anxiety studies, 21.4%
(n = 3), and no depression studies assessed any physio-
logical process. Physiological processes were assessed
exclusively with subscales of larger anxiety measures (e.g.,
CBCL—health concerns subscale; State-Trait Anxiety
Inventory—somatic subscale). No direct measures of
physiology (e.g., heart rate, galvanic skin response) were
used.
Cognitive processes were consistently assessed, with
71.4% (n = 10) of anxiety studies and 78.6% (n = 11) of
depression studies including some cognitive assessment.
Youth self-report was the primary mode of assessment in
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-
cept), negative affectivity self-statements (e.g., NASSQ),
maladaptive beliefs (e.g., Cognitive Bias Questionnaire;
DAS), and distorted cognitions (ATQ; CNCEQ; SAS—
Fear of Negative Evaluation subscale). One family inter-
action task was used (Barrett et al. 1996) in which threat
interpretations were assessed before and after a family
discussion of an ambiguous situation.
Finally, 42.9% (n = 6) of anxiety studies and few
depression studies, 14.3% (n = 2), included an assessment
of coping. In anxiety studies, coping was assessed pri-
marily with youth-report measures, assessing either general
strategies (e.g., Self-Efficacy Questionnaire; Children’s
Coping Strategies Checklist) or coping in specific situa-
tions (Coping Questionnaire—child and parent versions).
One study (Beidel et al. 2000) coded percentage of coping
statements identified in daily diary entries. One measure,
the adolescent- and parent-report Issues Checklist, was
used in the two depression studies.
Assessment of treatment outcomes (diagnosis, symp-
tom) was consistent with measurement typically found in
randomized clinical trials (RCTs). Diagnoses were deter-
mined using clinician-administered semi-structured
interviews (e.g., Anxiety Disorders Interview Schedule,
Kiddie-SADS, Hamilton Depression Rating Scale), and
symptom ratings of anxiety and depression were typically
evaluated with paper-and-pencil questionnaires using
child-report, parent-, and teacher-report. We also included
assessments of broad-based general functioning that were
not captured by specific anxiety and depression measures.
These included broadband scales (e.g., Child Behavior
Checklist—Internalizing and Anxiety/Depression scales)
and clinician rated global severity or improvement mea-
sures (e.g., Children’s Global Assessment Scale, Global
Assessment of Functioning, Clinical Global Impression).
Of note, anxiety studies more frequently assessed depres-
sion (78.6%, n = 11) and general functioning (64.3%,
n = 9) outcomes than did depression studies where only
35.7% (n = 5) assessed anxiety and 35.7% (n = 5)
assessed general functioning outcomes. (To conserve
archival space, outcome measures are not presented in a
table here. A complete list of anxiety, depression, and
general functioning measures included in analyses is
available from the authors.)
Relevant to the discussion of mechanisms, three
depression studies included some analysis of mediation
(Ackerson et al. 1998; Kaufman et al. 2005; Kolko et al.
2000). None of the identified anxiety studies reported
mediation analyses as part of the principal outcome study,
but one study (Treadwell and Kendall 1996) later reported
358 Clin Child Fam Psychol Rev (2007) 10:352–372
123
Ta
ble
1D
escr
ipti
ve
char
acte
rist
ics
of
stu
die
sev
alu
atin
gC
BT
for
yo
uth
anx
iety
(n=
14
)
Stu
dy
Par
tici
pan
tsS
elec
tio
ncr
iter
iaT
reat
men
tsT
xd
ura
tio
nB
ehav
iora
lm
easu
reP
hy
sio
mea
sure
sC
og
nit
ive
mea
sure
sC
op
ing
mea
sure
s
Bar
rett
etal
.(1
99
6)
n=
76
;7
–1
4y
oO
AD
,S
OP
,S
AD
CB
Tv
s.C
BT
+F
amM
gm
tv
s.W
L
12
ss,
60
–80
min
FE
AR
-AS
;C
E-a
vo
idF
EA
R-T
I
Bei
del
etal
.(2
00
0)
n=
50
;8
+1
2y
oS
OP
SE
T-C
vs.
No
nsp
ecT
x(T
estb
ust
ers)
24
ss,
60
–90
min
,1
2w
eeks
BO
:S
oci
alta
sk,
read
-al
oud
effe
ctiv
enes
s:se
lf&
ob
sra
ting
s
Dia
ry:
%o
fN
egat
ive
cop
ing
Fla
nn
ery
-S
chro
eder
and
Ken
dal
l(2
00
0)
n=
37
;8
–1
4y
oG
AD
,S
AD
,S
OP
Ind
CB
Tv
s.G
rpC
BT
vs.
WL
18
ss,
1h
,1
8w
eeks
FM
-C/P
;P
RS
CC
-soci
al;
SO
CS
-P;
SP
PC
-so
cial
acce
pt
CQ
-C/P
Gal
lag
her
etal
.(2
00
4)
n=
23
;8
–1
1y
oS
OP
Gro
up
CB
Tv
s.W
L3
ss,
3h
,3
wee
ks
CB
CL
-so
cial
com
pet
ence
,ac
tivit
ies,
sch
ool
Gar
cia-
Lo
pez
etal
.(2
00
2)
n=
59
;1
5–
17
yo
SO
PS
ET
-Av
s.C
BG
T-
Av
s.IA
FS
Gv
s.W
L
SE
T=
19
ss,
CB
GT
=1
6ss
,IA
FS
G=
12
ss
IS;
EH
SP
A;
PR
CS
RS
ES
Ken
dal
l(1
99
4)
n=
47
;9
–1
3y
oG
AD
,S
AD
,S
OP
CB
Tv
s.W
L1
6ss
BO
—sp
eech
,to
tal
sco
re;
CB
CL
-P-
soci
alC
BC
L-P
-hea
lth
NA
SS
QC
Q-C
Ken
dal
let
al.
(19
97)
n=
94
;9
–1
3y
oG
AD
,S
AD
,S
OP
CB
Tv
s.W
L1
6ss
BO
—sp
eech
:v
oic
e,fi
ng
ers
inm
ou
th,
eye
conta
ct
NA
SS
QC
Q-C
;C
Q-P
Kin
get
al.
(19
98)
n=
34
;5
–1
5y
oS
cho
ol
refu
sal
CB
Tv
s.W
L6
ss,
50
min
,4
wee
ks
SE
Q-S
S
Las
tet
al.
(19
98)
n=
41
;6
–1
7y
oS
cho
ol
ph
obia
CB
Tv
s.ed
uca
tio
nal
sup
po
rt
12
wee
ks
ST
AIC
-M-s
om
atic
ST
AIC
-M-c
og
Mas
ia-W
arner
etal
.(2
00
5)
n=
35
;1
3–
17
yo
SO
PS
choo
lG
CB
T—
SA
SS
vs.
WL
12
ssL
SA
S-C
A-s
oc
and
per
fav
oid
SA
S-A
/P-F
ear
Neg
Ev
al
Men
dlo
wit
zet
al.
(19
99)
n=
62
;7
–1
2y
oA
nx
Dx
CB
T-P
ar+
Ch
vs.
CB
T-C
hv
s.C
BT
-Par
vs.
WL
90
min
,1
2w
eek
sR
CM
AS
—P
hy
sio
RC
MA
S—
wo
rry
,o
ver
sen
,so
cial
,co
nce
ntr
atio
n
CC
SC
—ac
tiv
e,av
oid
,d
istr
act,
sup
po
rtco
pin
g
Mu
ris
etal
.(2
00
2)
n=
24
;8
–1
2y
oG
AD
,S
AD
,S
OP
Cog
Co
pin
gT
xv
s.n
on
spec
Tx
(em
oti
on
ald
iscl
osu
re)
6ss
,5
0m
inP
SW
Q-C
Sil
ver
man
etal
.(1
99
9)
n=
10
4;
6–
16
yo
SP
,S
OP
,A
go
rE
xp
osu
re+
self
con
tro
lv
s.ex
po
sure
+C
Mv
s.ed
uca
tio
nal
sup
po
rt
10
wee
ks
Fea
rth
erm
om
eter
insp
ecifi
csi
tuat
ion
sC
NC
EQ
Clin Child Fam Psychol Rev (2007) 10:352–372 359
123
analysis for participants included in previous research
(Kendall 1994; Kendall et al. 1997). Further, only one
anxiety study (Kendall et al. 1997) and one depression
study (Kolko et al. 2000) assessed process measures and
outcomes at more time points than just at pre- and post-
treatment.
Effect of CBT on Anxiety and Depression Outcomes
To show that the current sample resembled studies in
previous reviews, effect sizes of treatment outcome were
calculated. CBT produced moderate effect sizes across
anxiety, depression, and general functioning outcomes (see
Table 3). Across the 14 anxiety studies, mean ES for
anxiety outcomes was 0.64 (SD = 0.38; range = 0.18–
1.42) and significantly different from zero (z = 9.37,
p \ 0.001). Mean ES for depression outcomes was 0.55
(SD = 0.23; range = -0.06–0.92), and mean ES for
general functioning was 0.45 (SD = 0.53; range = -
0.54–1.72). Depression and general functioning ESs were
both significantly different from zero, p \ .001 and
p \ .01, respectively.
Similar treatment effects were found when CBT was
compared to wait-list control, but effects were lower when
compared to an alternate treatment. In the nine anxiety
studies where a waitlist was the comparison, CBT pro-
duced moderate mean ESs in anxiety (ES = 0.74,
p \ 0.001), depression (ES = 0.54, p \ 0.001), and gen-
eral functioning (ES = 0.66, p \ 0.001). In the five studies
that compared CBT to an active control, CBT produced
small to moderate mean ESs in anxiety (ES = 0.37,
p \ 0.01), depression (ES = 0.57, p \ 0.001), and general
functioning (ES = 0.24, p = n.s.).
Across the 14 depression studies, CBT produced vari-
able results in treatment outcomes (see Table 3). Mean ES
for depression outcomes was 0.60 (SD = 0.48; range = -
0.51–1.69) and significantly different from zero (z = 5.24,
p \ 0.001). A small effect for anxiety outcomes was
found; mean ES was 0.28 (SD = 0.44; range = -0.25–
1.62), which was significantly different from zero
(z = 1.95, p = 0.05). Mean ES for general functioning
was small, 0.46 (SD = 0.46; range = -0.19–1.05), and
significantly different from zero (z = 2.29, p \ 0.05).
A similar pattern of effects was found when CBT was
compared to no-treatment or wait-list controls, but effects
appeared slightly higher than the overall sample. In the
eight studies where a waitlist or no treatment was the
comparison, CBT produced a large mean ES in depression
outcomes (ES = 0.87, p \ 0.001), but small ESs for anx-
iety (ES = 0.40, p = n.s.) and general functioning
outcomes (ES = 0.46, p = n.s.) that were nonsignificantly
different from zero. In the six studies that compared CBTTa
ble
1co
nti
nu
ed
Stu
dy
Par
tici
pan
tsS
elec
tio
ncr
iter
iaT
reat
men
tsT
xd
ura
tio
nB
ehav
iora
lm
easu
reP
hy
sio
mea
sure
sC
og
nit
ive
mea
sure
sC
op
ing
mea
sure
s
Sp
ence
etal
.(2
00
0)
n=
50
;7
–1
4y
oS
OP
CB
T+
Par
vs.
CB
Tv
s.W
L1
2ss
,2
bo
ost
erB
AT
-CR
;S
CQ
-P;
SS
Q-P
;S
cho
ol
ob
sra
ting
-so
cial
SW
Q-P
U
No
te:
yo
=y
ears
old
;O
AD
=o
ver
anx
iou
sd
iso
rder
;S
OP
=so
cial
ph
ob
ia;
SA
D=
sep
arat
ion
anx
iety
dis
ord
er;
GA
D=
gen
eral
ized
anx
iety
dis
ord
er;
SE
T-C
=so
cial
effe
ctiv
enes
sth
erap
y;
IAF
SG
=th
erap
yfo
rad
ole
scen
tsw
ith
gen
eral
ized
soci
alp
ho
bia
;ss
=se
ssio
ns.
Mea
sure
sa
rep
rese
nte
din
alp
ha
bet
ica
lo
rder
:B
AT
-CR
=re
vis
edb
ehav
ior
asse
rtiv
enes
ste
stfo
rch
ild
ren
;
BO
=b
ehav
iora
lo
bse
rvat
ion
s;C
BC
L=
chil
db
ehav
ior
chec
kli
st—
soci
alco
mp
eten
ce,
acti
vit
ies,
sch
oo
l,h
ealt
hsu
bsc
ales
,p
aren
tv
ersi
on
;C
CS
C=
chil
dre
n’s
cop
ing
stra
teg
ies
chec
kli
st—
acti
ve,
avo
idan
t,d
istr
acti
on
,su
pp
ort
sub
scal
e;C
E=
clin
ical
eval
uat
ion
,av
oid
ant
beh
avio
r;C
NC
EQ
=ch
ild
ren
’sn
egat
ive
cog
nit
ive
erro
rq
ues
tio
nn
aire
;C
Q-C
/P=
cop
ing
qu
esti
on
nai
re,
chil
d,
par
ent
ver
sio
ns;
EH
SP
A=
soci
alsk
ills
scal
efo
rad
ole
scen
ts;
FE
AR
-AS
=F
EA
Rta
sk-a
vo
idan
tso
luti
on
s;F
EA
R-T
I=
FE
AR
task
-th
reat
inte
rpre
tati
on
;F
M-C
/P=
frie
nd
ship
mea
sure
,ch
ild
,
par
ent
ver
sio
ns;
IS=
inad
apta
tio
nsc
ale;
LS
AS
-CA
=L
ieb
ow
itz
soci
alan
xie
tysc
ale
for
chil
dre
nan
dad
ole
scen
ts—
soci
alav
oid
ance
,p
erfo
rman
cesu
bsc
ales
;N
AS
SQ
=ch
ild
ren
’sn
egat
ive
affe
ctiv
ity
self
stat
emen
tq
ues
tio
nn
aire
;P
RC
S=
pu
bli
cre
po
rto
fco
nfi
den
ceas
spea
ker
;P
RS
CC
=p
aren
tra
tin
gsc
ale
of
chil
dco
mp
eten
ce—
soci
alsc
ale;
PS
WQ
-C=
Pen
nst
ate
wo
rry
qu
esti
on
nai
refo
rch
ild
ren
;R
CM
AS
=re
vis
edch
ild
ren
’sm
anif
est
anx
iety
scal
e—p
hy
sio
log
ical
,w
orr
y,
ov
erse
nsi
tiv
ity
,so
cial
con
cern
s,co
nce
ntr
atio
nsu
bsc
ales
;R
SE
S=
Ro
sen
ber
gse
lf-
este
emsc
ale;
SA
S-A
/P-F
NE
=so
cial
anx
iety
scal
e-fe
aro
fn
egat
ive
eval
uat
ion
sub
scal
e,ad
ole
scen
t,p
aren
tv
ersi
on
s;S
OC
S-P
=so
cial
acti
vit
ies
scal
e;S
CQ
-P=
soci
alco
mp
eten
ceq
ues
-
tio
nn
aire
;S
EQ
-SS
=se
lf-e
ffica
cyq
ues
tio
nn
aire
for
sch
oo
lsi
tuat
ion
s;S
PP
C=
Har
ter’
sse
lfp
erce
pti
on
pro
file
for
chil
d—
soci
alac
cep
tan
cesu
bsc
ale;
SS
Q-P
=so
cial
skil
lsq
ues
tio
nn
aire
;
ST
AIC
-M=
mo
difi
edst
ate-
trai
tan
xie
tyin
ven
tory
for
chil
dre
n-
som
atic
,co
gn
itiv
esu
bsc
ales
;S
WQ
-PU
=so
cial
wo
rrie
sq
ues
tio
nn
aire
-pu
pil
360 Clin Child Fam Psychol Rev (2007) 10:352–372
123
Ta
ble
2D
escr
ipti
ve
char
acte
rist
ics
of
stu
die
sev
alu
atin
gC
BT
for
yo
uth
dep
ress
ion
(n=
14
)
Stu
dy
Par
tici
pan
tsS
elec
tio
ncr
iter
iaT
reat
men
tsT
xd
ura
tio
nB
ehav
iora
l
mea
sure
s
Co
gn
itiv
e
mea
sure
s
Co
pin
g
mea
sure
s
Ack
erso
net
al.
(19
98)
n=
22
;7
–1
2th
gra
de
CD
I&
HR
SD
C1
0C
og
nit
ive
bib
lio
ther
apy
vs.
WL
4w
eek
sA
TQ
;D
AS
;C
og
BT
DeC
uy
per
etal
.(2
00
4)
n=
20
;9
–1
1y
oC
DI
C1
1;
CB
CL
A/D
TC
63
;D
SM
-III
-R
bas
edin
terv
iew
;1
MD
Dcr
iter
ion
CB
Tv
s.W
L1
6ss
,1
h,
2
bo
ost
ers
SP
PC
Fin
eet
al.
(19
91
)n
=4
7;
13
–1
7y
oM
DD
or
Dy
sS
oci
alsk
ills
trai
nin
gv
s.
ther
apeu
tic
sup
po
rt
12
ssC
BQ
C;
OS
IQ
Kah
net
al.
(19
90)
n=
68
;1
0–
14
yo
CD
IC
15
;
RA
DS
C7
2;
BID
C2
0
CB
Tv
s.re
lax
atio
nv
s.
self
-mo
del
ing
vs.
WL
12
ss,
60
min
;
6–
8w
eek
s
PH
CS
CS
Kau
fman
etal
.(2
00
5)
n=
93
;1
3–
17
yo
MD
D&
CD
CB
Tv
s.li
fesk
ills
16
ss,
2h
;8
wee
ks
PE
S—
rela
xat
ion
,
ple
asan
tac
ts,
soci
alsk
ills
AT
Q;
DA
SIC
-A
Ko
lko
etal
.(2
00
0)
n=
77
;1
3–
18
yo
MD
DC
BT
vs.
SB
FT
vs.
NS
T1
2–
16
ss,
2–
4
bo
ost
ers
CN
CE
Q
Lew
inso
hn
etal
.(1
99
0)
n=
59
;1
4–
18
yo
MD
D,
Min
Dep
,o
r
inte
rmit
ten
tD
ep
CB
Tv
s.C
BT
+p
aren
t
vs.
WL
14
ss2
h;
7w
eek
sIC
-P
Lid
dle
and
Sp
ence
(19
90)
n=
31
;7
–1
2y
oC
DI
C1
9;
CD
RS
[4
0S
oci
alco
mp
eten
ce
trai
nin
gv
s.at
ten
tio
n
pla
ceb
ov
s.N
oT
x
8ss
ME
SS
Y;
LS
SP
Rey
no
lds
and
Co
ats
(19
86)
n=
24
;m
ean
=1
5.6
yo
BD
IC
12
;
RA
DS
C7
2;
BID
C2
0
CB
Tv
s.re
lax
atio
nv
s.
WL
10
ss,
50
min
;
5w
eek
s
RS
ES
;A
SC
S-H
S
Ro
hd
eet
al.
(20
04
)n
=9
1;
13
–1
7y
oM
DD
&C
DC
BT
vs.
life
skil
ls1
6ss
,2
h;
8w
eek
sS
AS
-SR
Ro
ssel
loan
dB
ern
al
(19
99)
n=
58
;1
3–
17
yo
MD
Do
rD
ys
CB
Tv
s.IP
Tv
s.W
L1
2ss
,1
h;
12
wee
ks
SA
SC
A;
CB
CL
-
P/A
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Clin Child Fam Psychol Rev (2007) 10:352–372 361
123
to an active control, CBT produced small mean ESs in
depression (ES = 0.29, p \ 0.05), anxiety (ES = 0.19,
p = n.s.), and general functioning (ES = 0.48, p = n.s.).
The inconsistency between magnitude of ES and statistical
significance testing reflects the variability among the small
number of studies assessing anxiety and general function-
ing outcomes.
Specific Processes Change in CBT for Anxiety
CBT for anxiety was associated with consistent moderate to
large mean ES values across behavioral, physiological,
cognitive, and coping processes (see Table 3). Across the
14 anxiety studies, CBT produced a large mean ES for
behavioral processes, ES = 1.02 (SD = 0.95; range =
0.002–3.59; z = 4.09) and moderate mean ESs for physi-
ological processes, ES = 0.49 (SD = 0.35; range = 0.29–
1.25; z = 3.79), cognitive processes, ES = 0.50 (SD =
0.46; range = 0.00–1.77; z = 4.19), and coping, ES =
0.73 (SD = 0.45; range = 0.12–1.65; z = 4.46). All mean
ESs were significantly different from zero (p \ 0.001).
We conducted six paired t-tests to compare mean ESs
across process variables (e.g., behavioral vs. physiological;
behavioral vs. cognitive; behavioral vs. coping; etc.). For
each analysis, only studies including both process variables
were included. In the anxiety studies, two comparisons
approached significance. A paired t-test comparing physi-
ological processes (ES = 0.54, SD = 0.41) and cognitive
processes (ES = 0.20, SD = 0.23) was marginally signif-
icant, t(4) = 2.76, p = 0.051, and a comparison of coping
(ES = 0.61, SD = 0.49) and cognitive processes (ES =
0.19, SD = 0.23) approached significance, t(4) = -2.48,
p = 0.07. In the seven studies (11 treatment comparisons)
that assessed both behavioral and cognitive processes,
mean behavioral ES (1.25, SD = 1.13) was larger than
mean cognitive ES (0.74, SD = 0.55), but this difference
was not statistically significant, t(10) = 1.47, p = 0.17.
Specific Processes Change in CBT in Depression
In contrast to anxiety studies, CBT for depression was
associated with a small but significant effect in cognitive
processes but not in behavioral or coping processes (see
Table 3). Across the 14 depression studies, CBT was
associated with a small cognitive effect, ES = 0.35
(SD = 0.49; range = -0.64–1.36) that was significantly
different from zero, z = 2.64, p \ 0.01. Mean ES for
behavioral processes was 0.01 (SD = 0.26; range = -
0.38–0.39; z = 0.03) and 0.05 (SD = 0.06; range = -
0.03–0.14; z = 0.31) for coping processes. Neither
behavioral nor coping ESs were significantly different from
zero (p = n.s.). No depression studies reported assessment
of physiological processes.
We attempted three paired t-tests to compare mean
behavioral, cognitive, and coping ESs (i.e., behavioral vs.
cognitive; behavioral vs. coping; cognitive vs. coping).
Table 3 Weighted mean effect sizes (ES) for process variables and symptom outcomes
Behavior ES Physiology ES Cognitive ES Coping ES Anxiety ES Depression ES GF ES
All anxiety studies
Mean ES 1.02* 0.49* 0.50* 0.73* 0.64* 0.55* 0.52**
n (Treatments) 16 5 16 9 22 16 12
Anx: CBT vs. WL
Mean ES 1.08* 0.48* 0.58* 0.77* 0.74* 0.54* 0.66*
n (Treatments) 13 4 12 8 17 12 8
Anx: CBT vs. Active Ctrl
Mean ES 0.78* 0.56 0.35*** 0.48 0.37** 0.57* 0.24
n (Treatments) 3 1 4 1 5 4 4
All depression studies
Mean ES 0.01 – 0.35** 0.05 0.28*** 0.60* 0.46***
n (Treatments) 8 16 3 7 20 7
Dep: CBT vs. WL
Mean ES 0.18 – 0.62* 0.06 0.40 0.87* 0.46
n (Treatments) 4 10 2 5 13 5
Dep: CBT vs. Active Ctrl
Mean ES -0.05 – 0.04 0.04 0.19 0.29** 0.48
n (Treatments) 4 6 1 2 7 2
Note: GF = General Functioning; Mean ESs are weighted least squares effect sizes; *p \ 0.001; **p \ 0.01; ***p \ 0.05
362 Clin Child Fam Psychol Rev (2007) 10:352–372
123
Only one depression study assessed both behavioral and
coping processes, and only one study assessed both cog-
nitive and coping variables, so paired t-tests could not be
performed. In studies assessing both behavioral and cog-
nitive processes (n = 5 studies; six treatment
comparisons), no significant differences were found,
t(5) = -1.09, p = 0.33. In these studies, mean behavioral
ES was -0.01 (SD = 0.29) and mean cognitive ES was
0.14 (SD = 0.42).
Does CBT Have Different Effects on Process or
Outcomes in Anxious Versus Depressed Samples?
To compare mutually exclusive categories of studies (i.e.,
anxiety vs. depression studies), we used a Q-statistic analog
to analysis of variance (Lipsey and Wilson 2001; Wilson
2003). If the between-category variance is significant, then
the mean ESs across groups differ by more than sampling
error. The Q-statistic is distributed as a chi-square with k–j
degrees of freedom, where k is the number of ESs (Hedges
and Olkin 1985), and j is the number of groups. We con-
ducted all analyses using maximum likelihood, random
effects models weighted by the inverse of the variance.
We compared the 10 anxiety studies (16 treatments) against
the seven depression studies (eight treatments) that assessed
behavioral processes. Mean behavioral ES was significantly
greater in studies testing CBT for anxiety (ES = 1.01, SE =
0.21) than in studies testing CBT for depression (ES = 0.05,
SE = 0.29), Q(1, 22) = 7.13, p \ 0.01. To compare differ-
ential effects on cognitive processes, we compared the 10
anxiety studies (16 treatments) to the 12 depression studies (16
treatments) that assessed cognitive outcomes. Anxiety and
depression studies were nonsignificantly different in mean
cognitive ES, Q(1, 30) = 0.84, p = 0.36. Mean cognitive ES
for anxiety samples was 0.50 (SE = 0.12) and 0.34 (SE =
0.34) for depressed samples. Anxiety studies (nine treatments)
did produce significantly greater effects on coping processes
than depression studies (three treatments), Q(1, 10) = 7.27,
p \ 0.01. Mean coping ES for anxiety samples was 0.71
(SE = 0.13) and 0.05 (SE = 0.21) for depressed samples. We
also compared anxiety and depression studies on treatment
outcomes and found a significant difference between anxiety
and depression studies on mean anxiety ES, Q(1, 27) = 3.97,
p \ 0.05, but not on depression or general functioning mean
ESs. Mean anxiety ES for anxious youth was 0.66 (SE = 0.08)
and 0.30 (SE = 0.16) for depressed youth.
Discussion
We conducted a comprehensive search to identify pub-
lished RCTs that tested CBT for anxiety or depression that
included measurement of both treatment and process out-
comes. Our review is unique in its attempt to summarize
the magnitudes of effect that CBT has on specific theory-
related targets, including behavioral, physiological, cogni-
tive, and coping outcomes. Using a meta-analytic
approach, analyses produced both anticipated and surpris-
ing results.
Assessment of Process and Outcomes
We identified 14 anxiety studies and 14 depression studies
that met our criteria. In general, these studies represent a
moderate proportion of all RCTs testing CBT for youth
internalizing problems. Weisz et al. (2006), for example,
identified 25 total clinical trials between 1980 and 2004
testing CBT for depression. Compton et al. (2002) and
Prins and Ollendick (2003) identified between 16 and 18
CBT trials for anxiety using various criteria. In our own
search, we identified 11 other anxiety trials and five
depression studies that met all other inclusion criteria
except for reporting data for a process variable. Thus, a
substantial proportion of our most rigorous clinical trials
does not routinely assess and/or report process outcomes.
This sadly represents missed opportunities to examine
important treatment effects.
Further, only four studies reported formal tests of
mediation and two studies assessed processes or outcomes
at timepoints other than at pre- and post-treatment. As
discussed earlier, both statistical mediation and temporal
precedence must be demonstrated to establish a variable as
a mediator (Judd and Kenny 1981; Kazdin and Nock 2003).
That is, change in the mediator must follow initiation of the
treatment but precede change in the outcome. Without
repeated assessment of process and outcome throughout
therapy, this relationship cannot be demonstrated. Signifi-
cant change in how RCTs are designed and conducted is
necessary before questions about mediation can be
addressed.
In absence of formal mediation tests, we hoped to
identify potential mediators by evaluating CBT’s effect on
specific processes. Of the 14 anxiety studies identified for
this review, process measurement was reasonably well
represented. The majority of studies reported behavioral
(71%) or cognitive (71%) outcomes, but fewer reported
physiological (21%) or coping (42%) outcomes. Of the 14
depression studies, the large majority reported cognitive
outcomes (78%), fewer assessed behavioral (50%), and
coping (14%) processes, and no studies assessed physio-
logical outcomes. These results highlight revealing trends
in the outcomes literature. Cognitive and behavioral pro-
cesses were regularly assessed in anxiety studies, but
physiological outcomes were only rarely reported. This is
Clin Child Fam Psychol Rev (2007) 10:352–372 363
123
surprising given the central role attributed to habituation
and distress tolerance in exposure-based treatments (Craske
and Mystkowski 2006). Likewise, cognitive measures were
routinely assessed in depression studies, but only half the
studies measured a behavioral outcome and a small fraction
of studies assessed coping. This is surprising given the
central roles that behavioral activation and skill-building
have in CBT for depression (Clarke et al. 2003; Jacobson
et al. 2001; Weisz et al. 2003). The range of different
measures was also limited in several categories. Three
different measures were used to assess physiological pro-
cesses in anxiety studies and only one measure was used to
assess coping in depression studies.
These trends could reflect unstated investigator bias
toward particular theories of change, such that anxiety
researchers view behavioral and cognitive change as more
central to outcomes than physiological and coping change.
Depression researchers may believe that cognitive change
represents the critical process to monitor. Pragmatic con-
siderations may overlap with theoretical leanings. In the
face of multiple design choices, limited resources, and a
desire to minimize participant burden, investigators likely
prioritize the outcomes they believe most central to their
theory of change or those variables they believe would
likely evidence the greatest association with treatment.
These measurement trends may also reflect the relative
challenges in assessing various constructs. In the case of
depression-focused treatments, it may be less clear what
behavioral outcomes are expected or how to operationalize
them for the purpose of assessment. In depression studies,
behavioral outcomes were primarily assessed by child- or
parent-reported questionnaires of pleasant activities or
social skills. Problem-solving skills, communication skills,
and access to and use of social support are other important
outcomes, but they may be more challenging to accurately
assess. Direct behavioral observation may seem more
appropriate for assessing markers of anxiety, which
explains their greater use in anxiety trials. A youth with a
fear of a specific stimulus or situation can participate in a
BAT and be assessed for approach and avoidance
behaviors.
A comparable tool for assessing behavioral indices in
depression is less apparent, but anxiety studies may be able
to provide relevant models. Several studies used a speech
task and developed a coding system for assessing behav-
ioral indicators of anxiety (e.g., fidgeting, poor eye contact,
poor initiation of speech topics; Kendall 1994; Kendall
et al. 1997). A similar task could be adapted to evaluate
behavior change in depressed youth. For instance, the
Primary and Secondary Control Enhancement Treatment
developed by Weisz et al. (1997) includes a module that
helps the child identify their negative self-presentation
styles and then provides practice in presenting a more
‘‘positive’’ self. A behavioral task could be developed to
assess change in the interpersonal styles of depressed youth
(e.g., poor eye contact, flat affect, paucity of speech, neg-
ative content). Other anxiety studies employ a family
discussion task in which the youth’s decision-making
process is evaluated (e.g., threat interpretations, choice of
avoidant solutions; Barrett et al. 1996). An equivalent
family discussion could be developed to test a depressed
youth’s skill level at posttreatment. Does the youth dem-
onstrate greater use of problem solving or communication
skills or greater pro-social or proactive decision-making?
Treatment Outcomes in CBT for Anxiety and
Depression
CBT for anxious youth produced reliable moderate effects
across anxiety, depression, and general functioning out-
comes. A moderate ES of 0.50 suggests that the average
treated child would score better than 69% of the control
group (Weisz et al. 1995), which is consistent with success
rates documented in the treatment literature (e.g., Barrett
et al. 1996; Kendall 1994). The ES calculated for anxiety
outcomes (0.64) was also comparable to previous meta-
analyses. For example, Prins and Ollendick (2003) calcu-
lated mean ESs for anxiety symptoms of 0.99 and 0.49 for
parent- and child-report measures, respectively.
When compared to a waitlist control, CBT produced
effects similar to the overall sample, but when CBT was
compared to an active treatment, CBT appeared to produce
smaller ESs in the small to moderate range. We did not
statistically test for differences in ESs produced by studies
using passive versus active controls because of the small
sample of studies employing active controls. However, a
visual inspection suggests that CBT may produce a smaller
effect for anxiety and general functioning outcomes when
compared against an active control. Further examination is
warranted with a larger sample of studies using active
controls.
CBT for depression demonstrated greater variation
across treatment outcomes. CBT produced moderate
effects for depressive symptoms, near moderate effects for
general functioning, but small effects for anxiety outcomes.
The ES calculated for depression outcomes (0.60) was
smaller than those reported in some previous meta-analyses
(Lewinsohn and Clarke 1999; Reinecke et al. 1998) but
larger than those reported in others (Weisz et al. 2006).
Our study sample was larger than either Lewinsohn and
Clarke (1999) or Reinecke et al. (1998) and we employed
more rigorous statistical controls when calculating effect
sizes. This may have contributed to our smaller ES cal-
culations. Weisz et al. (2006) calculated an ES of 0.34 for
depression measures across all psychotherapy studies and
364 Clin Child Fam Psychol Rev (2007) 10:352–372
123
an ES of 0.35 for cognitive treatments. We used near
identical statistical analysis as Weisz and colleagues, but
we did not include dissertation studies, nor did we directly
contact authors for missing data.
Depression treatments produced a small ES for anxiety
symptoms (ES = 0.28), which was reliably different from
zero. However, it was also significantly smaller than the
anxiety ES produced by CBT in anxiety studies. A small
ES of 0.20 suggests that the average treated child would
score better than 58% of a control group. This suggests a
statistically reliable relationship but one with potentially
small clinical significance. These effects are consistent
with findings from other meta-analyses in which depres-
sion-focused treatments are associated with significant but
small effects on anxiety symptomatology (e.g., anxiety
symptom ES = 0.39; Weisz et al. 2006).
Process Outcomes in CBT for Anxiety and Depression
Consistent with cognitive-behavioral theory, CBT for
anxious youth produced consistent moderate to large
effects across process variables, with the largest effect
found for behavioral outcomes. The large ES of 1.02
suggests that youth receiving CBT perform better than
about 84% of control participants on behavioral indicators
(Weisz et al. 1995). ES for physiological, cognitive, and
coping outcomes all fell in the moderate range with coping
outcomes approaching a large effect. Upon visual inspec-
tion, the mean behavioral ES appears larger than the
moderate ES values for physiological, cognitive, or coping
outcomes. These results suggest that CBT is particularly
effective in targeting behavioral outcomes. This is certainly
consistent with current theories of anxiety that prioritize
exposure and activation of fear networks in producing
greater approach behaviors (Craske and Mystkowski 2006;
Foa and McNally 1996). Behavioral change would also be
expected given the large proportion of therapy sessions
generally dedicated to exposure exercises. It is common for
anxiety treatments to dedicate at least half of their sessions
to in vivo exposure exercises in which the youth partici-
pates in direct practice in approaching challenging
situations (e.g., Barrett et al. 1996; Beidel et al. 2000;
Kendall 1994; Kendall et al. 1997).
We conducted paired t-tests to directly compare ES
values across process variables within anxiety studies.
These comparisons made use of a smaller sample of studies
because they only included studies in which at least two
process variables were assessed. Here, different trends
emerged. The ES for physiological outcomes (0.54) was
significantly greater than cognitive change (0.20), and a
comparison of coping (0.61) and cognitive change (0.19)
approached significance. Given the results from the overall
sample, we were particularly interested in how behavioral
outcomes compared to others. In 11 studies comparing
behavioral to cognitive change, mean ES for behavioral
outcomes (1.25) appeared larger than cognitive change
(0.74) but they were not statistically different. In the five
studies comparing behavioral (1.10) to coping (1.15) pro-
cesses, no difference was found. It is not clear why these
direct comparisons did not replicate the patterns observed
in the overall sample. It may highlight some methodolog-
ical differences between the studies in the smaller and
larger samples. It may also highlight differences in the
effectiveness of the treatments that comprised the smaller
versus larger sample. It is difficult to make confident
interpretations given the small number of studies that
included assessment of multiple processes. Nevertheless, in
all direct comparisons, cognitive change appeared smaller
than behavioral, coping, or physiological change. Future
investigations might benefit from analyzing differences
between the particular treatment packages that produced
different outcomes.
CBT for depression produced a consistent, but small
effect in cognitive processes. The ES of 0.35 suggests that
64% of treated youth would show greater change than
control participants. This is consistent with cognitive
conceptualizations of CBT that emphasize the importance
of identifying and changing maladaptive thoughts and
beliefs patterns (Beck et al. 1979; Weisz et al. 2003).
Indeed, depression studies assessed a wide range of cog-
nitive constructs including, self-esteem, self-concept,
negative automatic thoughts, and dysfunctional beliefs.
Thus, CBT appears to have a consistent impact in both
specific and general measures of cognition.
Of interest, the mean cognitive ES was close to zero
(0.04) when CBT was compared to active controls. This
appeared significantly smaller than mean cognitive ES
produced by CBT when compared to passive controls
(0.62). Thus, when CBT is compared to other active ther-
apies, often life skills or nonspecific support conditions,
CBT does not lead to greater cognitive change. This raises
the question of treatment specificity for cognitions in CBT.
It is clear that CBT regularly produces cognitive change,
but is cognitive change specific to CBT? The preliminary
evidence here does not support this. There are noted
examples to the contrary in the literature. Kolko et al.
(2000) found CBT did result in significantly less cognitive
distortions when compared to either a behavioral family or
nonspecific support treatment. These conflicting findings
encourage further research and analysis.
Inconsistent with our hypotheses, CBT did not evidence
significant change in behavioral and coping measures. This
was surprising given the importance of behavioral princi-
ples in CB conceptualizations for depression (Clarke et al.
2003; Jacobson et al. 2001). Development of coping skills
Clin Child Fam Psychol Rev (2007) 10:352–372 365
123
has also been associated with the presence or absence of
depression (Compas et al. 2001). Further, the majority of
reviewed treatments included at least some treatment
modules specifically targeting behavioral patterns (e.g.,
pleasant event scheduling) and teaching coping skills (e.g.,
social, communication, problem-solving skills). The small
sample of studies assessing coping change (n = 2) and the
fact that only one measure was employed (Issues Check-
list) suggest that the calculated value for mean coping ES is
still preliminary. However, behavioral change was assessed
in seven studies employing 10 different measures. These
findings appear more stable.
These results are interesting in light of recent findings
from the adult literature in which a behavioral activation
treatment produced equivalent outcomes to antidepressant
medication and superior outcomes to cognitive therapy in
treating severe depression (Dimidjian et al. 2006). Di-
midjian et al. (2006) did not include analysis of specific
process outcomes, but this dismantling study suggests that
a treatment focused exclusively on behavioral processes
can produce outcomes superior to cognitive interventions
under some circumstances (see also Jacobson et al. 1996).
In contrast, the current results suggest that cognitive vari-
ables are the only processes being activated, or successfully
targeted, during youth treatment. Behavioral processes did
not seem to improve following CBT at all.
One possible interpretation of these results is that CBT
potentially works through different mechanisms in youth
and adults. Cognitive processes may be more central to
change in CBT for child and adolescent populations. This
would be consistent with conclusions made by previous
prevention studies (Allart-van Dam et al. 2003; Munoz
et al. 1995) and by one of our included studies (Kaufman
et al. 2005), which demonstrated that negative automatic
thoughts met criteria as a potential mediator of CBT, but
increased pleasant activities did not. These findings would
be inconsistent, however, with earlier meta-analyses that
suggested cognitive-based therapies were not as effective
with younger versus older children (Durlak et al. 1991).
Alternatively, our results could suggest that youth are
not receiving a sufficient dose of behavioral interventions
to make an impact on behavioral processes. The 16-week,
24-session behavioral activation treatment in Dimidjian
et al. (2006) focused exclusively on behavioral strategies.
In contrast, nearly all of the treatments included here
integrated cognitive and behavioral strategies. It is possible
that treatment developers prioritized cognitive techniques
at the sacrifice of behavioral interventions, or they may
have underestimated the number of sessions necessary to
adequately address behavioral targets. We reviewed our
studies to assess if mean behavioral ES was related to
number of sessions focused on behavioral strategies. Our
preliminary review provided mixed results. Stark et al.
(1987) tested a behavioral problem-solving treatment that
dedicated the majority of its 12 sessions to behavioral
activities and produced the largest mean behavioral ES
(0.39) among depression studies. The second largest mean
behavioral ES (0.30) was found by Rohde et al. (2004) who
implemented the Coping with Depression program
(CWDA). CWDA, an empirically supported treatment for
adolescents, commits at least parts of 12 of its 16 sessions
to behavioral skills, including pleasant activities, social and
communication skills, and problem solving. In contrast, the
lowest mean ES (-0.38) was produced by Vostanis et al.
(1996) who tested a fairly brief integrated CBT program
that dedicated only three out of nine sessions to self-rein-
forcement and social problem-solving. However, the study
that produced the next lowest mean behavioral ES (-0.19)
was Kaufman et al. (2005) who had also employed
CWDA. Thus, dose and treatment differences do not
appear to account entirely for the null behavioral results.
A third possible explanation is that youth-focused
behavioral strategies have not yet been sufficiently
developed to produce significant impact. As a compari-
son, the behavioral activation treatment employed by
Dimidjian et al. (2006) presented treatment within a self-
contained behavioral framework that marks a departure
from traditional reinforcement strategies (Jacobson et al.
2001). Activity scheduling is used as before, but the new
model highlights the centrality of patterns of avoidance
and withdrawal. It places increased focus on functional
assessment, treatment of avoidance behaviors, and
practice in maintaining regularized routines. It also
addresses cognitive rumination as a process rather than
challenging specific cognitive content. As evidence
mounts that behavioral interventions may be more effi-
cacious and possibly easier to disseminate than some
cognitive programs (Dimidjian et al. 2006; Jacobson et
al. 1996), it may be judicious to re-consider how
behavioral principles are put to work in youth-targeted
interventions.
Each interpretation provides avenues for future research,
treatment development, and clinical application. If one
follows the first interpretation, that cognitive processes are
the critical variables to target, then future treatment
development might focus on enhancing cognitive inter-
ventions. Therapy itself might prioritize use of cognitive
strategies to ensure that a youth receives a sufficient dose
of cognitive interventions. Following the latter two inter-
pretations, development and research of behavioral
strategies may represent the domain with greatest growth
potential. Based on the impressive treatment outcomes
documented in the adult literature, enhanced behavioral
strategies might represent the investment with the greatest
potential return. Future direct comparisons (e.g., disman-
tling studies) of cognitive, behavioral, and coping-based
366 Clin Child Fam Psychol Rev (2007) 10:352–372
123
treatment components will help specify for whom and
through which mechanisms each brand of strategy effects
change. As a caveat, there was little difference between
behavioral and cognitive variables when compared directly
against each other. In the five depression studies that
assessed both cognitive and behavioral processes, no sig-
nificant differences were found between the ESs. The
sample size for this comparison is small, so continued
examination is warranted.
To compare anxiety versus depression studies in their
differential impact on process variables, we used a Q-
statistic analog to analysis of variance. The results
showed significant differences in the degree to which
anxiety and depression studies produced change in
behavioral and coping processes, but not in cognitive
variables. This brand of analysis seems counter-intuitive
since it compares effects produced in distinct samples,
assigned to different treatments. The analog analysis,
however, is specifically designed to compare effect sizes
across mutually exclusive categories (e.g., study) on the
basis of an independent variable (e.g., anxiety vs.
depression; Lipsey and Wilson 2001). The findings here
support the interpretation that meaningful differences
exist in how CBT impacts youth across anxious and
depressed samples. In the case of behavioral processes,
the results could reflect the interpretations offered earlier.
Anxiety treatments may commit greater proportion of
treatment to exposure-based strategies and/or the appli-
cation of behavioral strategies may be more fully
developed in anxiety treatments.
A second possibility is that these results support the
existence of actual mechanistic differences in CBT for
anxious and depressed youth. Although CBT was equally
effective in producing primary symptom change in both
anxiety and depression studies, CBT produced compara-
tively greater behavioral and coping change in anxiety
samples. Although far from definitive, the results support
further research to determine if CBT operates through
varying mediational pathways in anxious and depressed
youth. Over time, such findings may have implications for
many domains of clinical research. For example, the field is
currently reconsidering the basis under which disorders are
classified within DSM-V (Krueger et al. 2005). Conceptual
and taxonometric models are being considered (Brown and
Barlow 2005; Watson 2005). The results from the current
review suggest that how individuals respond to treatment
may be another criterion used to classify disorders. To the
extent that common change mechanisms are identified,
disorders may be closely linked. To the extent that different
mechanisms are evident, classification into separate groups
may be supported. The results here support the possibility
that different processes may mediate CBT for anxious and
depressed youth.
Disentangling Mechanism from Outcome
In truth, mediational pathways are more complex than we
can present here. Multiple pathways (e.g., multi-causality,
reciprocal causality, bi-directional changes) tend to be the
rule rather than the exception (Kazdin and Nock 2003).
Behavioral interventions may work through behavioral
processes, cognitive mediators, or both. For example,
behavioral activation may increase a youth’s contact with
natural reinforcers (thus increasing the likelihood of future
behavior) or it may provide the opportunity to disconfirm
negative beliefs about the situation. Sequence of change
and suppression effects may also complicate matters. To
continue our example, initial contact with natural rein-
forcers may be necessary to achieve cognitive change (e.g.,
increased self-efficacy). However, if the latter cognitive
change is more salient to the youth, or if the youth ascribes
more explanatory power to cognitive processes, the role of
the initial behavioral change may be difficult to detect if
assessed exclusively at posttreatment.
In the current archival review, which relied on published
data of posttreatment assessments, it is impossible to dis-
entangle the magnitude and sequence of change in such
complex pathways. Indeed, two of our included studies
(Fine et al. 1991; Stark et al. 1987) identified delayed
effects for candidate mediators. In Fine et al. (1991)
Therapeutic Support produced superior posttreatment
scores on a measure of self-concept compared to Social
Skills Training. However, by 9-month follow-up, both
treatments demonstrated comparable effects. Stark et al.
(1987) found no differences between a Behavioral Problem
Solving and a Self Control treatment at post-treatment on
measures of social withdrawal. By 8-week follow-up,
Behavioral Problem Solving achieved superior effects in
reducing withdrawal. These sleeper effects emphasize the
need for continuous assessment throughout and following
treatment, and remind investigators to think broadly about
the timeframe selected for analysis.
In the end, our findings provide evidence partially
consistent with Weersing and Weisz’s (2002) Intervention-
Specificity Test. On average, CBT produced consistent
change in theory-specific variables for anxious samples and
was associated with cognitive change in depressed sam-
ples. As discussed earlier, narrowing the field of possible
mediators is worthwhile as a first step to identifying
mechanisms (Kraemer et al. 2002). The same can be said
for documenting that theory-specific change occurs as we
expect. Process variables shown to have consistent rela-
tions with CBT should be assessed systematically in
comparative clinical trials comparing CBT with other
therapies. Demonstration that the process is reliably and
specifically related to CBT would elevate the variable’s
standing as a potential mediator of CBT. To determine if
Clin Child Fam Psychol Rev (2007) 10:352–372 367
123
the variable formerly mediates the effects of CBT, one
would have to demonstrate that the mediator meets the
established criteria for mediation (Baron and Kenny 1986;
MacKinnon et al. 2002). To establish the mediator as a
mechanism, a subsequent RCT could be conducted in
which a treatment enhanced with those components asso-
ciated with the mediator can be tested against the original
treatment. Demonstration that the enhanced treatment is
more effective than the original treatment would establish
the mediator as a mechanism (Kraemer et al. 2002). In
sum, the current review helps identify potential mediators
but several further steps are required to demonstrate formal
mediation or to establish any causal relationships associ-
ated between mechanisms and outcomes.
Limitations
There are several limitations to the current review. As in
any meta-analysis, the results are limited to the studies
included in analyses. Our inclusion criteria were focused
and included only treatments rigorously tested in an RCT
that assessed both process and outcome. These strict cri-
teria eliminated several prominent RCTs from both the
depression (e.g., TADS 2004; Weisz et al. 1997) and
anxiety literatures (e.g., Bernstein et al. 2005; Nauta et al.
2003). These RCTs represent important and methodologi-
cally rigorous studies. Had these trials assessed and
reported process outcomes, we may have observed differ-
ent outcomes in our own analyses.
Further, analysis of process and outcome variables was
limited to assessments conducted in the original trials. This
presented several limitations. First, very few studies
assessed process and outcome at multiple time points. This
limits any detailed analysis of time course, an important
factor in demonstrating a sequential relationship between
mediator and outcome. Second, many but not all studies
used distinct measures to assess process and outcome. For
example, the RCMAS and STAIC were common indicators
of treatment outcome, and our analyses used subscales of
these measures to represent cognitive and physiological
processes. This leads to potential confounds on both con-
ceptual and methodological grounds. Analyses in the
current report were not affected by this overlap because
mediator and outcome measures were never correlated or
compared directly. Comparisons were either across various
process variables or across different types of outcome;
thus, issues of shared variance and multicollinearity were
avoided. When interpreting results, the reader should be
cautious in directly comparing process and outcome effect
sizes, because changes in subscales (process variables)
would likely be correlated with changes in total scores
(outcome variables). Future analyses that make direct
comparisons should consider this overlap, and prospective
clinical trials should aim to measure process and outcome
using conceptually distinct and methodologically diverse
approaches (e.g., multi-method, multi-source) to facilitate
mediation analysis.
Our target comparison was CBT versus passive or active
controls. We did not compare CBT to other theoretical
approaches, such as to Interpersonal Therapy, even though
one trial was available to do so (e.g., Rossello and Bernal
1999). We also did not compare different forms of CBT,
such as individual versus family or group CBT. There were
several studies that included multiple forms of CBT, but
the number of studies is still too small to make meaningful
use of meta-analytic procedures.
We pooled ES values up to the level of treatment rather
than to individual studies. There are potential risks to this
approach in that multiple CBT conditions studied within a
single study are more likely to be similar than CBT treat-
ments across studies. There is precedence for this approach
(e.g., Weisz et al. 2006) in which it was acceptable to pool
ES values up to the most conservative level appropriate to
each test, based on the conceptual goals of the analysis.
Weisz et al. (2006) did not collapse ES values across
treatment groups. In the current review, the principal
interest was establishing the effect of an average CBT
protocol on specific targets when compared to a control
condition.
We also did not conduct separate analyses for parent
from child reported measures. Previous meta-analyses have
identified some significant differences in mean ES for
parent and child reported outcomes (e.g., Prins and Ol-
lendick 2003). Given the often divergent perspectives of
child and parent reporters, this approach should be pursued
in future meta-analyses. The goal here was to provide an
overview of the overall effects of CBT.
Our analysis may also be susceptible to what Smith et
al. (1980) described as measure reactivity. Measures that
conceptually mirror the nature of the treatment they are
evaluating may yield higher effect sizes. We exclusively
included process variables considered conceptually
important to CBT. Future meta-analyses could include
specific and nonspecific (e.g., alliance, engagement) tar-
gets, as well as processes from contrasting theoretical
approaches (e.g., intrapsychic insight). This approach may
provide a fuller picture of the specific and nonspecific
effects of CBT and other therapies.
Conclusion
Limitations notwithstanding, the current study provides the
most comprehensive review to date of specific effects of
CBT for anxious and depressed youth. It also provides
368 Clin Child Fam Psychol Rev (2007) 10:352–372
123
evidence for potentially differentiating mechanisms in the
treatment of anxiety and depression. Alternately, it pro-
vides areas for research and development in treatment.
Results from the anxiety literature document significant
support for several theory-specific process variables.
Anxiety researchers may now pursue mediator and mech-
anism research confident that multiple behavioral and
psychological processes make good candidates for exami-
nation. Results from the depression literature suggest that
additional groundwork may be wise. Although CBT
appears to achieve consistent significant effects on
depression outcomes, there are few consistent candidate
variables to explain how effects are mediated. Cognitive
processes currently receive the most support, but lessons
from the adult literature remind us of the great potential in
behavioral treatments and related mechanisms. Meaningful
work remains to be done to develop effective behavioral
treatments and to establish reliable and valid methods for
assessing behavioral change.
Acknowledgment The authors thank Kelly Pugh and Jessica Dahan
for their tireless efforts and organization in tracking down the many
journal articles that informed study analyses.
References
Achenbach, T. M. (1991). The derivation of taxonometric constructs:
A necessary stage in the development of developmental
psychopathology. In D. Cicchetti & S. Toth (Eds.), Rochestersymposium on developmental psychopathology: Models andintegrations (Vol. 3, pp. 43–74). Hillsdale: Erlbaum.
*Ackerson, J., Scogin, F., McKendree-Smith, N., & Lyman, R. D.
(1998). Cognitive bibliotherapy for mild and moderate adoles-
cent depressive symptomatology. Journal of Consulting andClinical Psychology, 66, 685–690.
Addis, M. E., & Martell, C. R. (2004). Overcoming depression onestep at a time. Oakland: New Harbinger Publications, Inc.
Albano, A., Marten, P. A., Holt, C. S., Heimberg, R. G., & Barlow, D.
H. (1995). Cognitive-behavioral group treatment for social
phobia in adolescents: A preliminary study. The Journal ofNervous and Mental Disease, 183, 649–656.
Allart-van Dam, E., Hosman, C. M. H., Hoogduin, C. A. L., &
Schaap, C. P. D. R. (2003). The Coping with Depression Course:
Short-term outcomes and mediating effects of a randomized
controlled trial in the treatment of subclinical depression.
Behavior Therapy, 34, 381–396.
Alloy, L., Kelly, K., Mineka, S., & Clements, C. (1990). Comorbidity
in anxiety and depressive disorders: A helplessness/hopelessness
perspective. In J. D. Maser & C. R. Cloninger (Eds.), Comor-bidity of mood and anxiety disorders (pp. 499–543). Washington,
DC: American Psychiatry Press.
American Psychological Association [APA] Task Force on Promotion
and Dissemination of Psychological Procedures (1995). Training
in and dissemination of empirically-validated psychological
treatments: Report and recommendations. The Clinical Psychol-ogist, 48, 3–23.
Angold, A., & Costello, E. J. (2001). The epidemiology of depression
in children and adolescents. In I. M. Goodyer (Ed.), The
depressed child and adolescent (2nd ed., pp. 143–178). New
York: Cambridge University Press.
Angold, A., Costello, E. J., & Erkanli, A. (1999). Comorbidity.
Journal of Child Psychology and Psychiatry, 40, 57–87.
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified
treatment for emotional disorders. Behavior Therapy, 35,
205–230.
Barlow, D. H., Chorpita, B. F., & Turovsky, J. (1996). Fear, panic,
anxiety, and disorders of emotion. In D. A. Hope (Eds.),
Nebraska symposium on motivation, 1995: Perspectives onanxiety, panic, and fear. Current theory and research inmotivation (Vol. 43, pp. 251–328). Lincoln: University of
Nebraska Press.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator
variable distinction in social psychological research: Conceptual,
strategic, and statistical considerations. Journal of Personalityand Social Psychology, 51, 1173–1182.
*Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family
treatment of childhood anxiety: A controlled trial. Journal ofConsulting and Clinical Psychology, 64, 333–342.
Beaman, A. L. (1991). An empirical comparison of meta-analytic and
traditional reviews. Personality and Social Psychology Bulletin,17, 252–257.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitivetherapy of depression. New York: Guilford.
*Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral
treatment of childhood social phobia. Journal of Consulting andClinical Psychology, 68, 1072–1080.
Bernstein, G. A., Layne, A. E., Egan, E. A., & Tennison, D. M.
(2005). School-based interventions for anxious children. Journalof the American Academy of Child and Adolescent Psychiatry,44, 1118–1127.
Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman,
J., Dahl, R. E., Perel, J., & Nelson, B. (1996). Childhood and
adolescent depression: A review of he past 10 years. Part I.
Journal of the American Academy of Child and AdolescentPsychiatry, 35, 1427–1439.
Brady, E. U., & Kendall, P. C. (1992). Comorbidity of anxiety and
depression in children and adolescents. Psychological Bulletin,111, 244–255.
Brown, T. A., & Barlow, D. H. (2005). Dimensional versus
categorical classification of mental disorders in the fifth edition
of the DSM and beyond: Comment on the special section.
Journal of Abnormal Psychology, 114, 551–556.
Chorpita, B. F., Yim, L., Donkervoet, J. C., Aresdorf, A., Amundsen,
M. J., McGee, C., et al. (2002). Toward large-scale implemen-
tation of empirically supported treatments for children: A review
and observations by the Hawaii Empirical Basis to Services Task
Force. Clinical Psychology: Science and Practice, 9, 165–190.
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and
depression: Psychometric evidence and taxonomic implications.
Journal of Abnormal Psychology, 100, 316–336.
Clarke, G. N., DeBar, L. L., & Lewinsohn, P. M. (2003). Cognitive-
behavioral group treatment for adolescent depression. In A. E.
Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapiesfor children and adolescents (pp. 120–134). New York: The
Guilford Press.
Cohen, J. (1988). Statistical power analysis for the behavioralsciences (2nd ed.). Hillsdale: Lawrence Earlbaum Associates.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112,
155–159.
Cohen, R., Cohen, J., Kasen, S., Veelez, C. N., Hartmark, C., Johnson,
J., Rojas, M., Brook, J., & Steuning, E. L. (1993). An
epidemiological study of disorders in late childhood and
adolescence – I. Age- and gender-specific prevalence. Journal
Clin Child Fam Psychol Rev (2007) 10:352–372 369
123
of Child Psychology and Psychiatry and Allied Disciplines, 34,
851–867.
Compas, B. E., Connor-Smith, J. K., Saltzman, H., Thomsen, A. H.,
& Wadsworth, M. E. (2001). Coping with stress during
childhood and adolescence: Problems, progress, and potential
in theory and research. Psychological Bulletin, 127, 87–127.
Compton, S. N., Burns, B. J., Egger, H. L., & Robertson, E. (2002).
Review of the evidence base for treatment of childhood
psychopathology: Internalizing disorders. Journal of Consultingand Clinical Psychology, 70, 1240–1266.
Costello, E. J., Egger, H. L., & Angold, A. (2005). Prevalence and
comorbidity. Child and Adolescent Psychiatric Clinics of NorthAmerica, 14, 631–648.
Craske, M. G., & Mystkowski, J. L. (2006). Exposure therapy and
extinction: Clinical studies. In M. G. Craske, D. Hermans & D.
Vansteenwegen (Eds.), Fear and learning: From basic processesto clinical implications (pp. 217–233). Washington, DC: Amer-
ican Psychological Association.
Davis, T. E., & Ollendick, T. H. (2005). Empirically supported
treatments for specific phobia in children: Do efficacious
treatments address the components of a phobic response?
Clinical Psychology: Science and Practice, 12, 144–160.
*De Cuyper, S., Timbremont, B., Braet, C., De Backer, V., &
Wullaert, T. (2004). Treating depressive symptoms in school
children: A pilot study. Journal of European Child andAdolescent Psychiatry, 13, 105–114.
Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B.,
Kohlenberg, R. J., Addis, M. E., et al. (2006). Randomized trial
of behavioral activation, cognitive therapy, and antidepressant
medication in the acute treatment of adults with major depres-
sion. Journal of Consulting and Clinical Psychology, 74,
658–670.
Durlak, J. A., Furhman, T., & Lampman, C. (1991). Effectiveness of
cognitive-behavior therapy for maladapting children: A meta-
analysis. Psychological Bulletin, 110, 204–214.
*Fine, S., Forth, A., Gilbert, M., & Haley, G. (1991). Group therapy
for adolescent depressive disorder. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 30, 79–85.
*Flannery-Schroeder, E., & Kendall, P. C. (2000). Group and
individual cognitive-behavioral treatments for youth with anx-
iety disorders: A randomized clinical trial. Cognitive Therapyand Research, 24, 251–278.
Foa, E. B., & McNally, R. J. (1996). Mechanisms of change in
exposure therapy. In M. Rapee (Ed.), Current controversies inthe anxiety disorders (pp. 329–343). New York: The Guilford
Press.
*Gallagher, H. M., Rabian, B. A., & McCloskey, M. S. (2004). A
brief group cognitive-behavioral intervention for social phobia in
childhood. Journal of Anxiety Disorders, 18, 459–479.
*Garcia-Lopez, L. J., Olivares, J., Turner, S. M., Beidel, D., Albano,
A. M., & Sanchez-Meca, J. (2002). Results at long-term among
three psychological treatments for adolescents with generalized
social phobia (II): Clinical significance and effect size. Psico-logia Conductual Revista Internacional de Psicologia Clinica delas Salud, 10, 371–385.
Hedges, L. V., & Olkin, I. (1985). Statistical methods for meta-analysis. San Diego: Academic Press.
Holmbeck, G. N. (1997). Toward terminological, conceptual, and
statistical clarity in the study of mediators and moderators:
Examples from the child-clinical and pediatric psychology
literatures. Journal of Consulting and Clinical Psychology, 65,
599–610.
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner,
K., Gollan, J. K., et al. (1996). A component analysis of
cognitive–behavioral treatment for depression. Journal of Con-sulting and Clinical Psychology, 64, 295–304.
Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral
activation treatment for depression: Returning to contextual
roots. Clinical Psychology: Science and Practice, 8, 255–270.
Judd, C. M., & Kenny, D. A. (1981). Process analysis: Estimating
mediation in treatment evaluations. Evaluation Review, 5, 602–619.
*Kahn, J. S., Kehle, T. J., Jenson, W. R., & Clark, E. (1990).
Comparison of cognitive-behavioral, relaxation, and self-mod-
eling interventions for depression among middle school students.
School Psychology Review, 19, 196–211.
Kaslow, N. J., & Thompson, M. P. (1998). Applying the criteria for
empirically supported treatments to studies of psychosocial
interventions for child and adolescent depression. Journal ofClinical Child Psychology, 27, 146–155.
*Kaufman, N. K., Rohde, P., Seeley, J. R., Clarke, G. N., & Stice, E.
(2005). Potential mediators of cognitive-behavioral therapy for
adolescents with co-morbid major depression and conduct
disorder. Journal of Consulting and Clinical Psychology, 73,
38–46.
Kazdin, A. E., & Kendall, P. C. (1998). Current progress and future
plans for developing effective treatments: Comments and
perspectives. Journal of Clinical Child Psychology, 27, 217–226.
Kazdin, A. E., & Nock, M. K. (2003). Delineating mechanisms of
change in child and adolescent therapy: Methodological issues
and research recommendations. Journal of Child Psychology andPsychiatry, 44, 1116–1129.
Kazdin, A. E., & Weisz, J. R. (1998). Identifying and developing
empirically supported child and adolescent treatments. Journalof Consulting and Clinical Psychology, 66, 19–36.
Kazdin, A. E., & Weisz, J. R. (2003). Context and background of
evidence-based psychotherapies for children and adolescents. In
A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychother-apies for children and adolescents (pp. 3–21). New York: The
Guilford Press.
*Kendall, P. C. (1994). Treating anxiety disorders in youth: Results of
a randomized clinical trial. Journal of Consulting and ClinicalPsychology, 62, 100–110.
Kendall, P. C., Aschenbrand, S. G., & Hudson, J. L. (2003). Child-
focused treatment of anxiety. In A. E. Kazdin & J. R. Weisz
(Eds.), Evidence-based psychotherapies for children and ado-lescents (pp. 3–21). New York: The Guilford Press.
*Kendall, P. C., Flannery-Schroeder, E. C., Panichelli-Mindel, S. P.,
Southam-Gerow, M. A., Henin, A., & Warman, M. J. (1997).
Treating anxiety disorders in youth: A second randomized
clinical trial. Journal of Consulting and Clinical Psychology, 65,
366–380.
Kessler, R. C., Zhao, S., Blazer, D. G., & Swartz, M. (1997).
Prevalence, correlates, and course of minor depression and major
depression in the national comorbidity survey. Journal ofAffective Disorders, 45, 19–30.
*King, N. J., Tonge, B. J., Heyne, D., Pritchard, M., Rollings, S.,
Young, D., Myserson, N., & Ollendick, T. H. (1998). Cognitive–
behavioral treatment of school-refusing children: A controlled
evaluation. Journal of the American Academy of Child andAdolescent Psychiatry, 37, 395–403.
*Kolko, D., Brent, D., Baugher, M., Bridge, J., & Birmaher, B.
(2000). Cognitive and family therapies for adolescent depres-
sion: Treatment specificity, mediation and moderation. Journalof Consulting and Clinical Psychology, 68, 603–614.
Kovacs, M. (1990). Comorbid anxiety disorders in childhood-onset
depressions. In J. D. Maser & C. R. Cloninger (Eds.), Comor-bidity of mood and anxiety disorders (pp. 272–281). Washington,
DC: American Psychiatric Press.
Kovacs, M., Paulauskas, S., Gatsonis, C., & Richards, C. (1988).
Depressive disorders in childhood: III. Longitudinal study of
comorbidity with and risk for conduct disorders. Journal ofAffective Disorders, 15, 205–217.
370 Clin Child Fam Psychol Rev (2007) 10:352–372
123
Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S.
(2002). Mediators and moderators of treatment effects in
randomized clinical trials. Archives of General Psychiatry, 59,
877–883.
Krueger, R. F., Watson, D., & Barlow, D. H. (2005). Introduction to
the special section: Toward a dimensionally based taxonomy of
psychopathology. Journal of Abnormal Psychology, 114,
491–493.
*Last, C. G., Hansen, C., & Franco, N. (1998). Cognitive-behavioral
treatment of school phobia. Journal of the American Academy ofChild and Adolescent Psychiatry, 37, 404–411.
Lewinsohn, P. M., & Clarke, G. N. (1999). Psychosocial treatments for
adolescent depression. Clinical Psychology Review, 19, 329–342.
*Lewinsohn, P. M., Clarke, G. N., Hops, H., & Andrews, J. (1990).
Cognitive-behavioral treatment for depressed adolescents.
Behavior Therapy, 21, 385–401.
Lewinsohn, P. M., & Graf, M. (1973). Pleasant activities and
depression. Journal of Consulting and Clinical Psychology, 41,
261–268.
Lewinsohn, P. M., Hops, H., Roberts, R. E., Seeley, J. R., & Andrews,
J. A. (1993). Adolescent psychopathology: I. Prevalence and
incidence of depression and other DSM-III-R disorders in high
school students. Journal of Abnormal Psychology, 102,
133–144.
Lewisohn, P. M., & Libet, J. (1972). Pleasant events, activity
schedules, and depression. Journal of Abnormal Psychology, 79,
291–295.
*Liddle, B., & Spence, S. H. (1990). Cognitive-behaviour therapy
with depressed primary school children: A cautionary note.
Behavioural Psychotherapy, 18, 85–102.
Lipsey, M. W., & Wilson, D. B. (2001). Practical meta-analysis(Applied Social Research Methods Series, Vol. 49). Thousand
Oaks: Sage.
MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., &
Sheets, V. (2002). A comparison of methods to test mediation
and other intervening variable effects. Psychological Methods, 7,
83–104.
*Masia-Warner, C., Klein, R. G., Dent, H. C., Fisher, P. H., Alvir, J.,
Albano, A., & Guardino, M. (2005). School-based intervention
for adolescents with social anxiety disorder: Results of a
controlled study. Journal of Abnormal Child Psychology, 33,
707–722.
*Mendlowitz, S. L., Manassis, K., Bradley, S., Scapillato, D.,
Miezitis, S., & Shaw, B. F. (1999). Cognitive–behavioral group
treatments in childhood anxiety disorders: The role of parental
involvement. Journal of the American Academy of Child andAdolescent Psychiatry, 38, 1223–1229.
Michael, K. D., & Crowley, S. L. (2002). How effective are
treatments for child and adolescent depression? A meta-analytic
review. Clinical Psychology Review, 22, 247–269.
Munoz, R. F., Ying, Y. W., Bernal, G., Perez-Stable, E. J., Sorensen,
J. L., Hargreaves, W. A., et al. (1995). Prevention of depression
with primary care patients: A randomized controlled trial.
American Journal of Community Psychology, 23, 199–222.
*Muris, P., Meesters, C., & Gobel, M. (2002). Cognitive coping
versus emotional disclosure in the treatment of anxious children:
A pilot-study. Cognitive Behaviour Therapy, 31, 59–67.
Nauta, M. H., Scholing, A., Emmelkamp, P. M. G., & Minderaa, R. B.
(2003). Cognitive-behavioral therapy for children with anxiety
disorders in a clinical setting: No additional effect of a cognitive
parent training. Journal of the American Academy of Child andAdolescent Psychiatry, 42, 1270–1278.
Ollendick, T. H., & King, N. J. (1998). Empirically supported
treatments for children with phobic and anxiety disorders:
Current status. Journal of Clinical Child Psychology, 27,
156–167.
Ollendick, T. H., & King, N. J. (2000). Empirically supported
treatments for children and adolescents. In P. C. Kendall (Ed.),
Child & adolescent therapy: cognitive–behavioral procedures(2nd ed.). New York: Guilford Press.
Prins, P. J. M., & Ollendick, T. H. (2003). Cognitive change and
enhanced coping: Missing mediational links in cognitive behav-
ior therapy with anxiety-disordered children. Clinical Child andFamily Psychology Review, 6, 87–105.
Reinecke, M. A., Ryan, N. E., & DuBois, D. L. (1998). Cognitive–
behavioral therapy of depression and depressive symptoms during
adolescence: A review and meta-analysis. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 37, 26–34.
*Reynolds, W. M., & Coats, K. I. (1986). A comparison of cognitive-
behavioral therapy and relaxation training for the treatment of
depression in adolescents. Journal of Consulting and ClinicalPsychology, 54, 653–660.
*Rohde, P., Clarke, G. N., Mace, D. E., Jorgensen, J. S., & Seeley, J.
R. (2004). An efficacy/effectiveness study of cognitive-behav-
ioral treatment for adolescents with co-morbid major depression
and conduct disorder. Journal of the American Academy of Childand Adolescent Psychiatry, 43, 660–668.
Rohde, P., Lewisohn, P. M., & Seeley, J. R. (1994). Are adolescents
changed by an episode of major depression? Journal of theAmerican Academy of Child and Adolescent Psychiatry, 33,
1289–1298.
*Rossello, J., & Bernal, G. (1999). The efficacy of cognitive-
behavioral and interpersonal treatments for depression in Puerto
Rican adolescents. Journal of Consulting and Clinical Psychol-ogy, 67, 734–745.
Shadish, W. R., & Sweeney, R. B. (1991). Mediators and moderators
in meta-analysis: There’s a reason we don’t let dodo birds tell us
which psychotherapies should have prizes. Journal of Consultingand Clinical Psychology, 59, 883–893.
Shirk, S. R. (2005). Research in service of children and adolescents.
In Balance: Society of Clinical Child and Adolescent PsychologyNewsletter, 20(1), 1.
Silverman, W. K. (2006). Nothing is as practical as a good theory: A
mantra for our efforts to disseminate evidence-based practice. InBalance: Society of Clinical Child and Adolescent PsychologyNewsletter, 21(1), 1.
*Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F.,
Rabian, B., & Serafini, L. T. (1999). Contingency management,
self-control, and education support in the treatment of childhood
phobic disorders: A randomized clinical trial. Journal ofConsulting and Clinical Psychology, 67, 675–687.
Smith, M. L., Glass, G. V., & Miller, T. L. (1980). The benefits ofpsychotherapy. Baltimore: Johns Hopkins University Press.
Spielmans, G. I., Pasek, L. F., & McFall, J. P. (2007). What are the
active ingredients in cognitive and behavioral psychotherapy for
anxious and depressed children? A meta-analytic review.
Clinical Psychology Review, 27, 642–654.
*Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (2000). The
treatment of childhood school phobia: The effectiveness of a
social skills training-based, cognitive-behavioral intervention,
with and without parental involvement. Journal of ChildPsychology and Psychiatry and Allied Disciplines, 41, 713–726.
*Stark, K. D., Reynolds, W. M., & Kaslow, N. J. (1987). A
comparison of the relative efficacy of self-control therapy and a
behavioral problem-solving therapy for depression in children.
Journal of Abnormal Child Psychology, 15, 91–113.
Treadwell, K. R. H., & Kendall, P. C. (1996). Self-talk in youth with
anxiety disorders: States of mind, content specificity, and
treatment outcome. Journal of Consulting and Clinical Psychol-ogy, 64, 941–950.
Treatment for Adolescents with Depression Study (TADS). (2004).
Fluoxetine, cognitive–behavioral therapy, and their combination
Clin Child Fam Psychol Rev (2007) 10:352–372 371
123
for adolescents with depression. Journal of the AmericanMedical Association, 292, 807–820.
*Vostanis,P.,Feehan,C.,Grattan,E.,&Bickerton,W. (1996).Treatment for
children and adolescents with depression: Lessons from a controlled
trial. Clinical Child Psychology and Psychiatry, 1, 199–212.
Watson, D. (2005). Rethinking the mood and anxiety disorders: A
quantitative hierarchical model for DSM-V. Journal of Abnor-mal Psychology, 114, 522–536.
Watson, D., & Clark, L. A. (1984). Negative affectivity: The
disposition to experience aversive emotional states. Psycholog-ical Bulletin, 96, 465–490.
Weersing, V. R., & Weisz, J. R. (2002). Mechanisms of action in
youth psychotherapy. Journal of Child Psychology and Psychi-atry, 43, 3–29.
Weisz, J. R., Donenberg, G. R., Han, S. S., & Weiss, B. (1995).
Bridging the gap between laboratory and clinic in child and
adolescent psychotherapy. Journal of Consulting and ClinicalPsychology, 63, 688–701.
Weisz, J. R., McCarty, C. A., & Valeri, S. M. (2006). Effects of
psychotherapy for depression in children and adolescents: A
meta-analysis. Psychological Bulletin, 132, 132–149.
Weisz, J. R., Southam-Gerow, M. A., Gordis, E. B., & Connor-Smith,
J. (2003). Primary and secondary control enhancement training
for youth depression: Applying the deployment-focused model
of treatment development and testing. In A. E. Kazdin & J. R.
Weisz (Eds.), Evidence-based psychotherapies for children andadolescents (pp. 148–164). New York: The Guilford Press.
Weisz, J. R., Thurber, C. A., Sweeney, L., Proffitt, V. D., &
LeGagnoux, G. L. (1997). Brief treatment of mild-to-moderate
child depression using primary and secondary control enhance-
ment training. Journal of Consulting and Clinical Psychology,65, 703–707.
Wilson, D. B. (2003). SPSS macros. http://mason.gmu.edu/*dwilsonb/ma.html. Retrieved 1 September 2006.
*Wood, A., Harrington, R., & Moore, A. (1996). Controlled trial of a
brief cognitive-behavioural intervention in adolescent patients
with depressive disorders. Journal of Child Psychology andPsychiatry, 37, 737–746.
Wood, J. J., Piacentini, J. C., Southam-Gerow, M., Chu, B. C., &
Sigman, M. (2006). Family cognitive behavioral therapy for
child anxiety disorders. Journal of the American Academy ofChild and Adolescent Psychiatry, 45, 314–321.
372 Clin Child Fam Psychol Rev (2007) 10:352–372
123
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