Journal of Consulting and Clinical Psychology1997. Vol. 65, No. 3, 366-380

Copyright 1997 by the Ai Psychological Association, Inc.0022-006X/97/S3.00

Therapy for 'fouths With Anxiety Disorders:

A Second Randomized Clinical Trial

Philip C. Kendall, Ellen Flannery-Schroeder, Susan M. Panichelli-Mindel,Michael Southam-Gerow, Aude Henin, and Melissa Warman

Temple University

Ninety-four children (aged 9-13 years) with anxiety disorders were randomly assigned to cognitive-

behavioral treatment or waiting-list control. Outcomes were evaluated using diagnostic status, childself-reports, parent and teacher reports, cognitive assessment and behavioral observation; maintenancewas examined using 1-year follow-up data. Analyses of dependent measures indicated significant

improvements over time, with the majority indicating greater gains for those receiving treatment.Treatment gains returned cases to within nondeviant limits (i.e., normative comparisons) and weremaintained at 1-year follow-up. Client age and comorbid status did not moderate outcomes. Apreliminary examination of treatment segments suggested that the enactive exposure (when it followscognitive-educational training) was an active force in beneficial change. Discussion includes sugges-tions for future research.

Children face developmental challenges, yet not all children

are prepared and not all of the challenges are met. The issue

facing clinical child psychology is how to best intervene to

reduce or remediate the cognitive, behavioral, and emotional

difficulties in childhood that are associated with distress and

psychopathology. Strides have been made in researching the

treatment of childhood psychopathology, but much work remains

(Kazdin, 1993; Kendall & Morris, 1991; Weisz, Weiss, Han,

Granger, & Morton, 1995). Estimates of the number of children

who may require mental health services is quite high, with recent

figures ranging from 12% to 22% in community samples (e.g.,

Costello, 1989). Among those children referred for treatment,

the acting-out, aggressive child dominates in number and has

received the lion's share of research. As a result, children with

internalizing problems may be underserviced and have been

underresearched. However, the prevalence and course of inter-

nalizing disorders, as well as the widespread interference associ-

ated with anxiety in children, necessitate a concurrent focus on

the treatment of internalizing disorders.

Editor's Note. Thomas Ollendick served as the Action Editor for thisarticle—PCK

Philip C. Kendall, Ellen Flannery-Schroeder, Susan M. Panichelli-

Mindel, Michael Southam-Gerow, Aude Henin, and Melissa Warman,Department of Psychology, Temple University.

This research was supported by Grant MH 44042 from the NationalInstitute of Mental Health. We thank the following individuals: the partic-ipating children and their families and the referring community agenciesand practicing clinicians; Tamar Chansky, Bonnie Howard, Martha Kane,Elizabeth Kortlander, Lynne Siqueland, and Kim Treadwell; associatesErica Brady, Serena Callahan, Brian dm, Elizabeth Gosch, MargotLevin, Abbe Marrs, Jennifer MacDonald, and Amy Sugarman; and PeterJ. Mikulka for his artistic renderings.

Correspondence concerning this article should be addressed to PhilipC. Kendall, Department of Psychology, Temple University, 1701 North13th Street, Weiss Hall, Philadelphia, Pennsylvania 19122.

Anxiety disorders in childhood have a chronic course and are

associated with anxiety problems in adulthood (e.g., Keller et

al., 1992; Last, 1988). Retrospective reports suggest that adults

with anxiety disorders suffered from anxiety-related symptoms

as children (Last, Hersen, Kazdin, Francis, & Grubb, 1987;

Weissman, Leckrnan, Merikangas, Gammon, & Prusoff, 1984).

Anxiety in childhood interferes with adjustment, including so-

cial adjustment and academic functioning (e.g., Chansky &

Kendall, 1997; Strauss, Frame, & Forehand, 1987; Strauss,

Lease, Kazdin, Dulcan, & Last, 1989). Epidemiological data

show anxious distress as common in childhood, and anxiety

disorders may be one of the most common psychological ail-

ments in childhood and adulthood (Anderson, 1994; Bell-Dolan,

Last, & Strauss, 1990). Anxiety disorders are often comorbid

with other difficulties (e.g., depression, attention deficit hyper-

activity disorders [ADHD], conduct problems) and may in-

crease risk for significant dysfunction (e.g., Brady & Kendall,

1992; Mattison, 1988). Anxiety disorders in childhood—al-

though not as dramatic in presentation as externalizing disor-

ders—represent a serious mental health problem for youths and

their families.

Given the dominant focus of the literature on aggressive and

antisocial children, it is no surprise that the outcome research

with externalizing children has been far more common than

similar work with anxious children (e.g., see Borduin et al.,

1995; Kazdin, Siegel, & Bass, 1992; see Southam-Gerow &

Kendall, in press). Most of the early studies of anxiety in child-

hood concentrated on nighttime fears, fear of dental or medical

procedures, evaluation anxiety, and a few clinical case studies

(for reviews, see Kendall, Kortlander, Chansky, & Brady, 1992).

More recently, a few psychopharmacological studies have been

reported but the results have been disappointing: antidepressant

and anxiolytic medications such as clonazepam, imipramine,

and buspirone have not demonstrated benefits for children diag-

nosed with overanxious disorder or social phobia (OAD and

SP, respectively; e.g., Ambrosini, Bianchi, Rabinovich, & Elia,

366

TREATING YOUTHS WITH ANXIETY DISORDERS 367

1993; Graee, Milner, Rizzotto, & Klein, 1994; Klein, Kople-

wicz, & Kanner, 1992). For other anxiety disorders that occur in

childhood—panic disorder and obsessive-compulsive disorder

(Apter et al., 1994; Kutcher, Reiter, Gardner, & Klein, 1992) —

some positive psychopharmacologic results have been reported.

One recent study demonstrated the efficacy of fluoxetine for

children with separation anxiety disorder (SAD), OAD, and SP

(Birmaher et al., 1994), but the study was not a randomized

clinical trial. Overall, the status of pharmacotherapy for children

with anxiety disorders is, at best, uncertain.

Empirical study of psychosocial treatments for anxiety disor-

ders in youths is growing but, as yet, incomplete. With obses-

sive-compulsive youths, some work has demonstrated effective-

ness (March, Mulle, & Herbel, 1994; Piacentini, Gitow, Jaffer,

Graae, & Whitaker, 1994). Recently, Kendall and his colleagues

developed and tested a treatment for children with OAD, SAD,

or avoidant disorder (AD). The cognitive-behavioral approach

is enactive, with performance-based and cognitive interventions

to change thinking, feeling, and behaving (Kendall, 1993). The

cognitive-behavioral model emphasizes the learning process

and the influence of contingencies and models in the environ-

ment while underscoring the centrality of the individual's man-

ner of processing relevant information. The treatment strives to

reduce the influence of dysfunctional processing, to increase

active problem solving, and to build a functional coping outlook.

The enactive intervention capitalizes on creating behavioral ex-

periences with emotional involvement while paying attention to

the cognitive activities of the participant.

Specifically, treatment addresses (a) problematic thinking

patterns that contribute to anxious distress (e.g., Kendall &

MacDonald, 1993) and (b) behavioral avoidance that maintains

the child's distress. The treatment is manualized (Kendall, Kane,

Howard, & Siqueland, 1990) and combines skills training and

exposure components, both of which have demonstrated effec-

tiveness for anxiety-related problems with adults (e.g., Barlow,

Rapee, & Brown, 1992; Heimberg, Salzman, Holt, & Blendell,

1993; Ollendick & Francis, 1988). Results have been promising,

as evidenced by a multiple-baseline evaluation of four cases

(Kane & Kendall, 1989) and a randomized clinical trial with

1-year (Kendall, 1994) and longer term (3.35 years) follow-

ups (Kendall & Southam-Gerow, 1996). The first randomized

clinical trial (Kendall, 1994) found that treatment, compared

with waiting-list, was associated with positive changes in child-

and parent-reported coping, child- and parent-reported distress,

observations of child behavior, and diagnostic status. With re-

gard to diagnoses, 66% of treated cases at posttreatment did not

meet criteria for their pretreatment primary anxiety diagnosis.

Adapting the Kendall program (Kendall, 1994; Kendall et al.,

1990), Dadds, Heard, and Rapee (1992) described success in

a study (Barrett, Dadds, & Rapee, 1996) in which nearly 70%

of the children with anxiety disorders who completed treatment

in either an individual or a family program did not meet criteria

for an anxiety disorder at posttreatment. Although evidence sug-

gests that the therapy meets the criteria of the American Psycho-

logical Association (APA) Task Force on Promotion and Dis-

semination of Psychological Procedures (1995) for "probably

efficacious'' treatment, a replication and extension of the pro-

gram is needed, as is a preliminary consideration of active treat-

ment segments and the influence of comorbidity on outcome.

The Diagnostic and Statistical Manual of Mental Disorders

(4th ed.; DSM-IV; American Psychiatric Association, 1994)

provided a change in the classification of childhood anxiety-

related disorders. Two disorders included in the revised third

edition of the DSM (DSM-IH-R; American Psychiatric Associ-

ation, 1987) have been removed from the nosology. OAD has

been subsumed under generalized anxiety disorder (GAD), and

AD has been subsumed under SP. Nevertheless, a comparison

of cases diagnosed independently by both systems revealed that

the change in the nosology has not changed the characteristics of

identified cases (Kendall & Warman, 1996). Therefore, OAD-

GAD is characterized by excessive and uncontrollable worry

about a variety of topics, including academic, social, and famil-

ial domains. AD-SP is marked by intense and often incapacitat-

ing anxiety in the face of specific or more general social situa-

tions. A third anxiety disorder occurring primarily in child-

hood—SAD—is characterized by an intense and chronic fear

reaction on separation from parents or caregivers. Other anxiety

disorders (e.g., obsessive-compulsive disorder, panic disorder)

also occur in childhood, but the treatment evaluated herein ad-

dresses OAD-GAD, AD-SP, and SAD.

The present investigation is a replication and extension of the

Kendall (1994) report, using an entirely new sample of youths

with anxiety disorders. The primary focus is on treatment out-

come and maintenance effects at 1-year follow-up. Ancillary to

this are preliminary analyses of the influence of comorbidity

and the effects of the segments of treatment. It was hypothesized

that treatment would be associated with beneficial changes ex-

ceeding those found for the waiting-list control condition. It was

also hypothesized that treatment effects would be maintained at

1-year follow-up. Ancillary analyses were undertaken as

exploratory.

Method

Participants

Ninety-four children (aged 9-13 years) diagnosed with a primary

anxiety disorder and who had been referred from multiple community

sources served as participants (60 in treatment condition, 34 in waiting-

list control condition). The 94 participants came from a total of 118

potential participants (attrition included 9 from treatment, 9 from wait-

ing-list, and 6 from treatment after the waiting-list). Of the 60 treated

participants, 58% were boys; 87% were Caucasian, 7% were African

American, 2% were Hispanic, 2% were Asian, and 3% self-identified

as "other" or mixed race. Forty-seven percent were 9-10 years old;

53% were 11-13 years old. Controls (n = 34) were treated after the

waiting-list period: they were not included in the treatment group for

analyses of outcome but were included in other analyses that did not

use the control condition comparison. Of the 34 waiting-list participants,

68% were boys; 82% were Caucasian, 3% were African American, 6%

were Asian, 2% were Hispanic, and 7% were identified as "other" or

mixed race. Sixty-two percent were 9-10 years old; 38% were 11-13

years old.

For the full sample, 38% were girls. Eighty-five percent were Cauca-

sian, 5% were African American, 2% were Hispanic, 2% were Asian,

and 5% were from other minorities. Fifty-two percent were 9-10 years

old, and 48% were 11-13 years old. Family income was below $20,000

for 6.4%, $40,000 for 27.7%, $60,000 for 33%, $80,000 for 23.5%, and

above $80,000 for 6.4%. With regard to educational attainment, 1.1%

of fathers and 7.4% of mothers had not completed high school, whereas

368 KENDALL ET AL.

38.3% of fathers and 4.28% of mothers were high school graduates

without college; 26.6% of fathers and 17% of mothers had some college

education, and 30.9% of fathers and 51% of mothers had completed a

4-year college education. Treatment and waiting-list participants did not

differ significantly on these variables.

Participants received primary anxiety disorder diagnoses (OAD, n =

55; SAD, n = 22; AD, n = 17) on the basis of structured interviews

conducted separately with both the parents and the participant. When

parent and child differed, diagnoses were based on parental reports.1

Children whose primary diagnosis was simple phobia (or phobias) were

not included; children with diagnosable specific phobias as secondary

problems were included. Forty-eight percent of the participants were

comorbid with simple phobia; 14%, with ADHD; 8%, with oppositional

defiant disorder; 6%, with major depression; and 1%, with conduct

disorder. Children were excluded if they displayed psychotic symptoms

or were currently using antianxiety medications.

Setting and Personnel

Therapy was provided by 11 doctoral candidates (9 women) within

the Child and Adolescent Anxiety Disorders Clinic (CAADC), Division

of Clinical Psychology, Temple University.

Measures

Multimethod assessment, as recommended in the child therapy litera-

ture (Kazdin, 1986; Kendall & Morris, 1991), was used.

Structured Diagnostic Interview

The Anxiety Disorder Interview Schedule for Children (ADIS-C) and

the ADIS for parents (ADIS-P) were developed for diagnosis of child-

hood anxiety disorders (Silverman, 1987). These consist of independent

parent and child interviews for DSM-I11-R categories that enable the

diagnostician to obtain information about symptomatology, course, etiol-

ogy, and severity of problem behaviors, and to screen out additional

disorders. The interview has interrater reliability (e.g., r = .98 for parent

interview and r — .93 for child interview; Silverman & Nelles, 1988)

and retest reliability (e.g., k = .76 for parent interview; Silverman &

Eisen, 1992), and it has shown sensitivity to treatment effects in studies

of youths with anxiety disorders (e.g., Albano, Knox, & Barlow, 1995;

Kendall, 1994).

Children's Self-Report Measures

Revised Children's Manifest Anxiety Scales (RCMAS). These 37

items, 9 of which compose a Lie scale, measure a child's chronic or

trait anxiety (Reynolds & Richmond, 1978). The scale reveals three

anxiety factors (Physiological Symptoms, Worry and Oversensitivity,

and Social Concern-Concentration), and factor-analytic studies support

the presence of an overall trait as well as the distinction between factors.

The RCMAS has high internal consistency, moderate retest reliability (r

= .68; Reynolds & Richmond, 1985), and reasonable construct validity

(RCMAS correlated .85 with the State-Trait Anxiety Inventory for

Children, Trait Anxiety subscale (STAIC, A-Trait) but had little correla-

tion with the State Anxiety subscale (A-State; Spielberger, 1973). Na-

tional reliability and normative data are available (Reynolds & Paget,

1982).

The STAIC. The STAIC (Spielberger, 1973) has two 20-item self-

report scales assessing both enduring tendencies to experience anxiety

(A-Trait) and temporal and situational variations in anxiety (A-State).

Normative and reliability data are available. Evidence for the STAIC's

discriminant and convergent validity has been reported (Hodges, 1990),

and the Trait version of the STAIC correlates with other measures of

anxiety in children (e.g., RCMAS; Carey, Faulstich, & Carey, 1994;

Reynolds & Paget, 1982). Factor-analytic studies support the state-trait

distinction (Finch, Kendall, & Montgomery, 1974).

Fear Survey Schedule far Children—Revised (FSSC-R). Ollendick

(1983) revised the 80-item, 5-point scale (Scherer & Nakamura, 1968)

to create a 3-point scale assessing specific fears in children, with eight

fear categories including school, social, and physical fears. The scale

has solid internal consistency (alpha coefficients in the range of .92),

adequate retest reliability (Ollendick, 1983), and has been shown to

correlate with trait anxiety (as measured by the STAIC A-Trait; range,

.46-.51). Normative data are available (Ollendick, King, & Frary, 1989;

Ollendick, Matson, & Helsel, 1985).

Children's Depression Inventory (CDI). The CDI (Kovacs, 1981)

has 27 items related to the cognitive, affective, and behavioral signs of

depression. Each item contains three statements, and children select the

one that best characterizes them during the past 2 weeks. The scale has

high internal consistency, moderate retest reliability, and correlates in

expected directions with measures of related constructs (self-esteem,

negative attributions, and hopelessness; Kazdin, French, Unis, Esveldt-

Dawson, & Sherick, 1983; Saylor, Finch, Spirito, & Bennett, 1984; see

review by Kendall, Cantwell, & Kazdin, 1989). Normative data are

available (Finch, Saylor, & Edwards, 1985).

Coping Questionnaire-child version (CQ-C). The CQ-C (Kendall,

1994) assesses children's perceived ability to manage highly anxiety-

provoking situations. The assessment is situationally based and individu-

alized: Three areas of difficulty specific to each child are chosen based

on information obtained in the interviews, and children rate their ability

to cope with each situation on a 7-point scale ranging from not at all

able to help myself (1) incompletely able to help myself feel comfortable

(7). Acceptable retest reliability was obtained for the CQ-C, and the

measure is sensitive to treatment.

Children's Negative Affectivity Self-Statement Questionnaire (NASSQ).

The NASSQ includes self-statements that children endorse on a scale

ranging from not at all (1) to all the time (5), representing the frequency

with which each thought occurred during the past week (Ronan, Ken-

dall, & Rowe, 1994). Within the NASSQ are separate scales of anxious

self-talk for 7- to 10-year-olds (11 items) and 11- to 15-year-olds (31

items). Scores for the two age groups were converted to a uniform

metric and combined. The NASSQ was found to be internally reliable,

and retest reliability over a 2-month interval was .73. Analyses support

the concurrent and construct validity of the measure.

Parent Measures

Child Behavior Checklist (CBCL). The CBCL is a 118-item scale

assessing behavioral problems and social competencies (Achenbach,

199la). Items are rated from not true (0) to very true or often true

(2). The CBCL has broadband internalizing and externalizing factors

and eight specific scales (e;g., anxiety-depression). Normative data are

available. The CBCL has high retest reliability, interparent agreement,

and validity. It was highly correlated with similar parent measures of

child behavior, and scaled scores and clinical cutpoints discriminated

between referred and nonreferred children. In addition, the CBCL in-

cludes items that can form a separate anxiety score (CBCL Anxiety

Scale; CBCL-A; Kendall, MacDonald, Benin, & Treadwell, 1997).

STAIC—Modification of trait version for parents ( STAIC- A-Trait-P).

Strauss (1987) modified the trait version of the STAIC to be used as a

complementary parent rating of the child's trait anxiety.

Coping Questionnaire-parent version (CQ-P), The CQ-P parallels

1 In one case, a diagnosis was based on a participant's report. The

parents' report approached but did not yield a diagnosis; because the

participant was an adolescent, his or her report was deemed reliable and

used.

TREATING YOUTHS WITH ANXIETY DISORDERS 369

the CQ-C described earlier. Parents rate the child's ability to cope with

three anxiety-provoking situations identified from the interview. Out-

come data (Kendall, 1994) support the sensitivity of this measure to

treatment.

Parent Self-Report Measures

The State-Trait Anxiety Inventory. Twenty items assess how respon-

dents generally feel (A-Trait) and 20 items assess respondents' feelings

at that moment (A-State; Spielberger, Gorsuch, & Lushene, 1970). Nor-

mative, reliability, and validity data are available (Spielberger, 1973);

factor analyses support the state-trait distinction.

Beck Depression Inventory (BDI). This 21-item inventory measures

depressive symptoms (Beck, Rush, Shaw, & Emery, 1979). Reliability,

validity, and normative data are available and the scale has widespread

application (Kendall, Hollon, Beck, Hammen, & Ingram, 1987).

Teacher Report

The CBCL—Teacher Report Form (TRF) mirrors the parent version

of the CBCL and provides a picture of the child's classroom functioning

(Achenbach, 1991b). This measure was completed by the child's pri-

mary teacher; however, children often changed grades over the course

of the program so that die primary classroom teacher could vary across

assessments. The TRF possesses high retest reliability (2-week interval),

moderate interteacher agreement, and the ability to discriminate between

referred and nonreferred children.

Behavioral Observations

The coding system was applied to observations during performance

of a videotaped task. Six observational codes were used during task

performance: gratuitous verbalizations (e.g., stating a physical com-

plaint, negative performance evaluation, dislike for the task); gratuitous

body movements (e.g., kicking or shaking leg; rocking body); avoiding

task (e.g., leaving the room, not talking); absence of eye contact (e.g.,

not looking at camera for the observational interval); fingers in mouth

(e.g., biting fingernails, touching hand to lips); and trembling voice

(giggling within observational interval; inaudible speech). The occur-

rence of each code during ten 30-s intervals was scored and reported

as a percentage of the observed units.

Therapy Measures

Child's Perception of Therapeutic Relationship (CPTR). This 10-

item, 5-point scale assesses the child's perception of the quality of the

child-therapist relationship. Five items tap the child's liking, feeling

close to, feeling comfortable with, talking to, and wanting to spend time

with the therapist. Other items refer to the quality and closeness of the

relationship. The CPTR was included to examine the correlation between

the therapist-child relationship and outcome (Kendall &. Morris, 1991;

Strupp & Hadley, 1979) and was given by a diagnostician (not the

therapist) at posttreatment.

Parental Involvement Ratings (PIRs). At completion of treatment,

the therapist rated parental involvement on 7-point scales. The PIR taps

three aspects of involvement: (a) amount of contact with parent (or

parents), (b) degree of beneficial parental involvement, and (c) degree

of parental interference.

Procedure

Cases were referred to CAADC through multiple sources in the com-

munity including clinics and practitioners, public and nonpublic counsel-

ors, and media descriptions. Within a week, staff contacted parents and

arranged an intake evaluation. Parent (or parents) and the child signed

informed consents, participated in the interviews, and completed ques-

tionnaires. The TRF was completed by the child's primary teacher and

returned directly to the clinic. For behavioral observations, the child was

prompted, "Tell us about yourself" for 5 min while being videotaped.

Sample topics (e.g., friends; favorite TV shows) were provided, and

the diagnostician left the room.

After intake, participants who met criteria were randomly assigned

to either the 16-week cognitive-behavioral treatment or the 8-week

waiting-list control condition.2 Participants who did not meet diagnostic

criteria were provided with referrals. Waiting-list children completed an

additional assessment at the end of the 8-week period. All control-group

children and their parents were asked if they sought alternate treatment

during the waiting-list period, and participants who did not maintain

integrity were not included in the study. Following the waiting-list, chil-

dren were provided with therapy. Randomization was used in all in-

stances of clients being assigned to therapists.

Participants received an average of 18 sessions (range, 16-20), last-

ing 60 min once a week, except for illness or vacations. The self-,

parent-, and teacher-report questionnaires were administered at midtreat-

ment, and a full battery assessment including structured diagnostic inter-

views, questionnaires, and behavioral observations was conducted at

posttreatment and at 1-year follow-up. To help ensure contact with the

children after treatment, a parent (or parents) provided the names and

phone numbers of two people closest to the family.

Treatment Manual and Materials

The treatment manual (Kendall et ah, 1990) describes the goals and

strategies to be implemented for each treatment session; however, a

flexible and clinically sensitive application of the procedures was applied

(Dobson & Shaw, 1988; Kendall, Kortlander, Chansky, & Brady, 1992)

with consideration of the client's age, intellectual ability, and family

factors. Also, an addendum, Working with Potential Difficulties, detailed

the modest shifts in treatment emphasis used in cases of comorbidity

and with difficulties in compliance or denial. A workbook for use by

children, The Coping Cat (Kendall, 1990), and stimulus materials (i.e.,

age-appropriate sketches) were used to present goals and promote inter-

est and involvement in treatment. To reinforce and generalize the skills,

we assigned homework tasks for the children to complete using the

Coping Cat Notebook.

Treatment Method: Cognitive-Behavioral Therapy

Children received individual cognitive-behavioral therapy aimed at

the recognition and analysis of anxious cognition and the development

of management strategies to cope with anxiety-provoking situations

(Kendall, Chansky, et al., 1992). The focus was on four related compo-

nents: (a) recognition of anxious feelings and somatic reactions to anxi-

ety; (b) clarification of anxious cognition in anxiety-provoking situa-

tions (i.e. unrealistic or negative expectations); (c) development of a

coping plan (i.e., modifying anxious self-talk into coping self-talk, as

well as determining what coping actions might be effective); and (d)

evaluation of performance and administration of self-reinforcement as

appropriate. The therapist guides both the youngster's attributions about

prior behavior and his or her expectations for future behavior. Thus, the

youngster can acquire a cognitive structure for future events that includes

2 A 16-week (4-month) waiting-list was deemed too long for clinically

referred cases. Such a long wait period may increase attrition (and

differential attrition), with many parents seeking alternate treatment for

their children during the wait period and, thereby, reducing the represen-

tativeness of the resulting sample.

370 KENDALL ET AL.

the adaptive skills and appropriate thinking associated with adaptive

functioning (Kendall, 1993).

Behavioral training strategies with demonstrated efficacy such as

modeling, in vivo exposure, role play, relaxation training, and contingent

reinforcement were used. Throughout, therapists used social reinforce-

ment to encourage and reward the children, and children were prompted

to reinforce their own successful coping. Children were encouraged to

practice the skills in anxiety-provoking situations at home and school

and were rewarded for successfully completing weekly assignments.

The first half and the second half of the treatment addressed different

components of the program.

In each of the first eight sessions, the basic concepts were introduced,

followed by practice and reinforcement of the skill. Session 1 was de-

voted to building rapport with the child and collecting specific informa-

tion about the situations and experiences in which the child felt anxious

and his or her reactions to that anxiety. Session 2 introduced affective

education through the identification of various kinds of feelings. In

Session 3, a hierarchy of anxiety-producing situations was developed to

help distinguish anxious reactions from others and to identify his or her

own somatic reactions to anxiety. After Session 3, a parent meeting took

place to elicit more information concerning the child's anxiety, discuss

parental concerns, and review the treatment goals. Session 4 introduced

relaxation training (both progressive muscle relaxation and visualiza-

tion) and its use in controlling anxiety-related muscle tension. Children

were provided with a personalized relaxation cassette for use outside

of the session. Session 5 consisted of teaching the child to recognize

and assess anxious self-talk during anxiety-provoking situations and to

practice alternate coping self-talk. Session 6 introduced the concept

of coping strategies and verbal self-direction, as well as developing

appropriate actions to aid in coping with anxious situations. Session 7

introduced the concepts of self-evaluation and self-reward. Session 8,

the final training session, comprised a review of all concepts and skills

presented during the previous sessions.

The second eight sessions involved practicing the skills learned, using

both imaginal and in vivo exposure, beginning with low-anxiety situa-

tions and progressing to high stress and anxiety situations. Situations

were individualized for each child to specifically address his or her

anxieties. The child was encouraged to apply the newly learned skills

to these anxiety-provoking situations, and therapist modeling and role

plays were used. The final session was devoted to preparing a ' 'testimo-

nial" or "commercial" in which the child is the expert and the goal is

teaching other children how to cope with distressing anxiety. The child

was given a copy of the videotaped commercial to take home.

Treatment Integrity

All sessions were audiotaped. Randomly, 15% of tapes were selected

for each of the child-therapist combinations and were independently

rated using a treatment integrity checklist (used in Kendall, 1994) as-

sessing conformity to the procedures in the manual.

Results

Reliabilities

Diagnosticians and observers or raters were trained with writ-

ten and videotape samples. Initial discrepancies were discussed

to reach agreement. Diagnosticians met an initial reliability cri-

teria of 85% agreement. Reliability (kappa, 85% agreement)

was checked periodically, with each diagnostician rating four

child and four parent interviews. Interobserver reliability for

coding behavioral observations (six separate codes) and making

global behavioral ratings (three ratings) also met the kappa

criterion of 85% agreement.

Group Comparability

One-way analyses of variance (ANOY\s) or chi-square val-

ues (for noncontinuous data) were examined for pretreatment

differences in age, gender, race and all dependent variables:

Waiting-list and treated participants were found not to differ

significantly. Similar analyses indicated nonsignificant differ-

ences for parents' marital status, family income, mothers' and

fathers' levels of education, and mothers' and fathers' levels of

depression (BDI) and anxiety (STAI).

Regarding sample representativeness, there were nonsignifi-

cant differences (ANOVAs and chi-square values) between com-

pleters (n = 94) and dropouts (n = 24) in age, gender, race,

primary diagnosis (OAD, SAD, and AD), pretreatment scores

on dependent measures, and parents' and teachers' ratings (one

exception: Mothers' of dropouts reported less CBCL internaliz-

ing distress than mothers of completers, f (1, 115) = 2.65, p <

.01; (Ms = 66.87 and 71.53, respectively).

Therapist Comparability

Therapy was provided by 11 therapists. Analyses of 20 depen-

dent variables revealed 20 nonsignificant therapist effects. Ex-

amining maintenance scores (posttreatment to follow-up) re-

vealed 18 of 20 nonsignificant differences. Also, analyses of

CPTR scores revealed nonsignificant differences across thera-

pists. Therapist experience (i.e., third time using the protocol,

sixth time, etc.) was also nonsignificantly related to treatment

gains (in 19 of 20 instances) and maintenance scores (20 of

20 ).3

Treatment Integrity

The strategies called for in the manual were those used in

sessions. Two experienced cognitive-behavioral therapists lis-

tened to 15% of all audiotaped sessions and completed treatment

integrity checklists. All sessions were comparably represented

in the sample and all therapists, relative to the number of treated

cases, were also comparably represented. There were rro in-

stances where other forms of therapeutic intervention were used

and adherence to sessions goals was rated 100%. The treatment

manual was not implemented in a rigid fashion but in a flexible

manner that maintained programmatic strategies while permit-

ting individualization.

Treatment Outcome

Treatment effects were analyzed using 2 (treatment vs. wait-

ing-list; between groups) X 2 (assessments; within groups)

mixed factorial ANOVAs. In instances where the linear combina-

tion of dependent variables was meaningful, multivariate analy-

ses of variance (MANOV\s) were performed. Overall MANO-

VAs were conducted on the child self-report measures and on

parent-teacher reports of the child's internalizing distress.

Means and standard deviations are presented in Table 1, and

5 These results indicate that therapists were comparable. A closer in-spection of the odd, if not by chance, differences showed no meaningfulpattern.

TREATING YOUTHS WITH ANXIETY DISORDERS 371

changes over time are presented in Figures 1 and 2. Where

significant main effects and significant interactions were found,

only the interactions were interpreted. Also, treatment outcome

was examined for potential gender differences through 2 (Gen-

der) X 2 (Trials) repeated measures ANOVAs. All parent, child,

and teacher reports found that gender did not moderate outcome.

Child Diagnoses

The present report examines the percentages of cases who no

longer meet diagnostic criteria for the primary anxiety disorder

(the one that got them into the treatment program) at posttreat-

ment in two ways: (a) those who do not meet diagnostic criteria

for their initial anxiety disorder as primary (some could meet

criteria but not as the primary disorder) and (b) those who do

not meet diagnostic criteria at all.

Using the parent-structured interview for the child's primary

anxiety disorder (the criterion for child inclusion), 71.28% of

the treated children no longer had their primary diagnosis as

primary at the end of treatment, and 53.19% no longer met

diagnosis for their primary anxiety disorder at posttreatment at

all.4 Of the participants in the waiting-list condition, only 2 did

not qualify for their primary anxiety disorder diagnosis after the

waiting-list period.

Child Reports

Using MANOVA and Wilks's criterion, we found that the

combined dependent variables were significantly affected by the

interaction of treatment and trial, F(7, 75) = 2.89, p < .01.

Subsequent ANOVAs indicated that, in terms of coping with

most dreaded situations, CQ-C changes revealed a significant

Conditions X Trials interaction, F(\, 90) = 4.67, p < .04.

Interaction effects were also significant on the NASSQ, F(l,

90) = 7.88,p < .01; and the RCMAS, F(l, 90) = 5.60,p <

.03 (see Figure 1). Analyses of the STAIC A-State and A-Trait

scales revealed significant trials effects; F(l, 89) = 40.9,p <

.001, and F(l, 87) = 52.55, p < .001, respectively. The FSSC-

R also evidenced a significant trials effect, F(l, 90) = 65.76,

p < .001. For the CDI, there was a significant trials effect, F( 1,

90) = 38.49, p < .001; and an interaction that approached

significance, p = .059. Scores on the STAIC, FSSC-R, and the

CDI decreased from pre- to posttreatment.

Parent and Teacher Reports

Using MANOVA and Wilks's criterion, we found a significant

interaction of treatment and trial, F(7, 46) = 4.87, p < .001.

Using ANOVAs, we found significant interactions for mothers'

and fathers' CBCL internalizing scale reports (T scores); F( 1,

89) = 17.18, p < .001, and F(l, 65) = 17.51, p < .001,

respectively (see Figure 2). Mothers' CBCL Anxious-De-

pressed scale scores and the empirically derived CBCL Anxiety

Scale (CBCL-A) scores (Kendall et al., 1997)' also demon-

strated significant interactions, F(l, 87) = 6.56, p < .05, and

F(l, 87) = 5.93, p < .05. Fathers' Anxious-Depressed and

CBCL-A scores yielded trials effects— F(l, 67) = 52.62, p

< .001, and F(l, 67) = 55.37, p < .001, respectively—and

nonsignificant interactions.

Parent reports using the STAIC-P evidenced significant inter-

actions, for mother and father reports: F(l, 87) = 14.00, p <

.001, and F( 1,67) = 15.86, p < .001, respectively. With regard

to the children's ability to cope with their most difficult situa-

tions, changes on the CQ mothers' reports (CQ-M) and CQ

fathers' reports (CQ-F) revealed significant interactions; F(l,

76) = 34.44, p < .001, and F(l, 69) = 14.55, p < .001,

respectively.

Recall that, although over 70% of cases no longer had their

primary anxiety diagnosis as a primary diagnosis at posttreat-

ment and over 50% no longer met criteria for their primary

diagnosis at all, not all cases were free of their entering primary

diagnosis. To examine treatment outcome for those who retained

their primary anxiety diagnosis, we used a! test to compare pre-

and posttreatment severity ratings from the diagnostic interview.

Albeit insufficient to be diagnosis-free, these analyses revealed

significant improvement from pretreatment severity levels, »(1,

23) = 3.50, p < .01.

Analyses of the TRF Internalizing scale scores revealed a

significant trials effect, F(l, 76) = 9.85, p < .003. Analyses

of the TRF Anxiety-Depressed scale demonstrated main effects

for both trial, F(l, 73) = 17.72, p < .001; and condition, F(l,

73) = 4.41, p < .05.

Behavioral Observations

Behavioral observation data were examined using 2 X

OVAs (following arcsine transformation). Because participants

differed in their presentation (e.g., some presented with gratu-

itous verbalizations, others did not) observations were analyzed

using only those participants who evidenced behavior within

the code. Two codes, trembling voice and fingers in mouth,

revealed significant interactions, F( 1 , 1 5 ) = 5.05, p < .05, and

F(l, 13) = 13.84, /> < .01, respectively. Absence of eye contact

yielded significant main effects. A total behavioral observation

score was computed, and analysis revealed a significant treat-

ment effect, F(l, 75) = 5.73, p < .02.

Developmental Differences in Treatment Outcome

A 2 X 2 MANOVA comparing treatment effects for younger

(ages 9-10) versus older (ages 11-13) children was performed

on the child self-report measures. Using Wilks's criterion, the

combined dependent variables were affected by treatment but

not significantly affected by the interaction. Similarly, parent-

teacher reports revealed a significant main effect for treatment

but a nonsignificant interaction (different-aged youths did not

evidence differential response to treatment).

4 Using the child's diagnostic interview data (on the basis of the childinterview, some cases did not meet diagnostic criteria at pretreatment),we found that 45.74% of those treated no longer had their primarydiagnosis as primary at the end of treatment.

5 The CBCL Anxiety-Depression scale and the CBCL-A are notindependent (item overlap). Also, the items on the present version ofthe CBCL-A differentiated youths with anxiety disorders from thosewithout such disorders using DSM-UI-R criteria.

372 KENDALL ET AL.

Table 1

Means and Standard Deviations for the Child Self-Reports, Behavioral Observations, Parent Reports,

and Teacher Reports for the Treatment and Waiting-List Participants

Treatment Waiting-list control

Measure Pretreatment Posttreatment 1-year follow-up" Prewaiting-list Postwaiting-list

Child self-reports

RCMASMSD

STAICTrait anxiety

MSD

State anxietyMSD

FSSC-RMSD

CQ-CMSD

GDIMSD

NASSQMSD

55.3410.76

50.8212.70

54.4611.08

132.2127.01

3.971.23

10.296.96

58.5540.17

43.0511.89

40.2514.17

44.8310.87

111.3125.42

5.311.11

4.956.04

43.4131.00

40.7910.58

38.1512.28

47.1011.53

105.7023.43

5.441.06

5.156.74

38.0525.54

55.618.29

54.7612.02

56.3211.35

142.9126.84

3.651.34

13.389.77

53.1338.73

49.6710.16

49.9111.95

49.1810.78

124.9728.63

4.17

1.44

10.569.73

46.0936.12

Behavioral observations

Trembling voiceMSD

Fingers in mouthMSD

Absence of eye contactMSD

0.260.32

0.780.09

0.200.13

0.00

0.00

0.030.05

0.00

0.00

0.010.04

0.040.06

0.00

0.00

0.110.16

0.080.12

0.530.32

0.140.05

0.150.10

0.460.17

Parent reports

CBCL-Mother reportInt. T score

MSD

Anx-Dep T scoreMSD

CBCL-AMSD

CBCL-Father reportInt. T score

MSD

Anx-Dep T scoreMSD

CBCL-AMSD

STAIC-A-Trait-PMother report

MSD

Father reportM50

72.076.87

72.499.06

13.263.98

69.558.76

68.039.03

11.514.43

54.098.23

52.028.70

61.8110.30

62.309.32

8.214.66

59.1711.67

60.059.72

7.464.89

44.258.88

42.499.18

57.7711.78

60.209.13

6.814.56

56.0511.22

58.057.45

6.253.89

42.328.498

41.198.80

70.918.68

70.2810.08

12.413.81

67.208.62

67.4810.20

11.164.43

51.698.25

48.969.95

68.738.44

68.389.19

10.913.99

66.287.62

65.169.19

9.844.42

49.568.73

47.089.77

TREATING YOUTHS WITH ANXIETY DISORDERS 373

Table 1 (continued)

Treatment Waiting-list control

Measure Pretreatment Posttreatment 1-year follow-up" Prewaiting-list Postwaiting-list

CQ-PMother report

MSD

Father reportMSD

TRFInt. T score

MSD

Anx-Dep T scoreMSD

Parent reports (continued)

2.81

0.98

3.091.18

64.4011.38

64.1010.84

4.431.22

4.561.24

Teacher reports

58.1510.38

58.607.82

4.831.20

4.911.19

55.119.39

57.368.11

2.911.09

3.14

1.27

62.4810.99

63.399.95

2.961.09

3.41

1.16

59.109.71

58.897.65

Note. RCMAS = Revised Children's Manifest Anxiety Scale; STAIC = State-Trait Anxiety Inventory for Children; FSSC-R - Fear Survey

Schedule for Children—Revised; CQ-C = Coping Questionnaire—Child version: CDI = Children's Depression Inventory; NASSQ = NegativeAffectivity Self-Statement Questionnaire; CBCL = Child Behavior Checklist; Int. = Internalizing; Anx-Dep = Child Behavior Checklist Anxiety -Depression Scale; CBCL-A = Child Behavior Checklist, Anxiety Scale; STAIC-A-Trait-P = State-Trait Anxiety Inventory for Children—Modifica-tion of Trait "Version for Parents; CQ-P = Coping Questionnaire—Parent version; TRF = Teacher Report Form.

" One-year follow-up means and standard deviations are for all treated cases.

Differential Outcome by Diagnosis

Several 3 (Diagnoses) X 2 (Trials) repeated measures ANO-

VAs examined outcome by diagnosis (i.e., OAD, SAD, AD).

All child and parent report variables revealed nonsignificant

interactions with few exceptions. Although the exceptions are

reported6, the overall results suggest that the favorable out-

comes carry across diagnoses.

Clinical Significance

Clinically significant improvement, defined as changes that

return deviant participants to within nondeviant limits, can be

identified using normative comparisons (Kendall & Grove,

1988). Tb be considered "clinically significant improvement,"

specific criteria were set (e.g., CBCL < 70). It should be noted

that the normative mean for an adult sample often covers the

various ages of the participants, whereas for different-aged chil-

dren the "normative" mean changes across ages. Accordingly,

examinations of whether or not a specific child met criteria for

clinically meaningful change was conducted using the mean

appropriate for that specific child's age.

According to CBCL Internalizing scale T scores (mother and

father reports averaged)7, at posttreatment 56.12% of all treated

participants whose initial 7" scores were in the clinical range

(>70) fell below clinical levels at the end of treatment. Using

the TRF Internalizing scale T scores, fully 70% of all treated

cases were returned to within nondeviant limits at the end of

treatment. A significantly greater number of the treated com-

pared with waiting-list cases, for both parent and teacher ratings,

showed clinically meaningful change, x2( l , N = 20) = 20.00,

p < .001, and x2(l, N = 28) = 19.00, p < .001, respectively

(see Figure 3).

Maintenance: 1-Year Follow-Up

Maintenance for 85 of the 94 treated participants (9 were not

available) was examined using analyses (within participants)

across three assessment periods (pre- and posttreatment, and 1-

year follow-up). Post hoc analyses of significant F ratios used

Tukey tests. The 1 -year follow-up means for treated participants

appear as squares in Figure 1.

Using MANOVAs, across all child self-report measures, there

was a significant trials effect, F(14, 53) = 12.60, p < .001.

For the RCMAS, STAIC A-State, STAIC A-Trait, and FSSC-R,

there were significant changes over time (due to treatment),

with statistical tests revealing that the posttreatment and 1-year

follow-up means did not differ significantly. Similarly, for the

6 Mother reports on the STAIC-P and on the CBCL Internalizing scale

yielded significant Diagnoses X Trials interactions, F(2, 84) = 6.22, p

< .01, and F(2, 85) = 3.75, p < .05, respectively. Simple effects tests

revealed significant reductions across assessment periods for both OAD,

F(l, 84) = 65.05, p < .001, and SAD, F(l, 84) = 32.26, p < .001.

A significant interaction was also found on the TRF Internalizing scale,

F(2, 71) = 5.12, p < .01. Simple effects tests revealed a significant

reduction across assessment periods for OAD only, F(l, 71) = 28.77,

p < .001.7 The same results emerged when parents' reports were averaged and

when mothers' and fathers' reports were examined separately.

374 KENDALL ET AL.

5.5,

5.0

4.5-

O 4.0 •

B 3.5-1

30

2.5

0

Pre-test

Post-test

Follow-

up

«0

55

50 •

45 •

40 •

35 •

30•i

0 '

O-.,

N. "••«

N^

•

Pie- Post- Follow-test test up

64

60

56

52 •

48 •

44 •

40 '•,

^ \

°\\

\°\

. mi i i

Pre- Post- Follow-test test up

Figure 1. Changes on child self-report for treated and waiting-list participants. Closed circles representtreatment; open circles represent waiting-list; closed squares represent 1-year follow-up. CQ-C = CopingQuestionnaire—child version; RCMAS = Revised Children's Manifest Anxiety Scales; NASSQ = Chil-dren's Negative Affectivity Self-Statement Questionnaire.

NASSQ and GDI, reductions observed at posttreatment were

maintained at 1-year follow-up. With regard to the CQ-C, the

significant improvements in coping were maintained at follow-

up. Similarly, the behavioral observation codes evidencing sig-

nificant treatment interaction effects (trembling voice; fingers

in mouth) also revealed maintenance of treatment gains at 1-

year follow-up.

A MANO\A across parent reports (e.g., CBCL) and teacher

TRF data produced a significant trials effect, F( 14, 32) = 20.27,

p < .001. Subsequent analyses indicated that these maintenance

results were consistent with the children's self-reports: Means

at follow-up were improved from pretreatment but not signifi-

cantly different from posttreatment. All other parental measures

demonstrated a significant reduction in scores from pre- to post-

treatment and maintenance of gains from posttreatment to fol-

low-up. There was one exception; Mothers' CBCL Internalizing

scale reports were significantly lowered from pre- to posttreat-

ment and again significantly decreased from posttreatment to

follow-up.

CPTR scores and scores for parental involvement were corre-

lated with treatment gains (from pre- to posttreatment) and

maintenance (posttreatment to follow-up). With Bonferroni cor-

rection, CPTR scores were not a significant predictor of change.

CPTR scores and maintenance also yielded nonsignificant rela-

tionships. CPTR scores were generally very high (M - 23.4),

indicating a favorable therapeutic relationship but also truncat-

ing the range of scores and reducing potential predictiveness.

Although most children gave a high rating for a positive therapist

TREATING YOUTHS WITH ANXIETY DISORDERS 375

5.0

4.5

4.0

3.0

2.5

0

75'

70 '

65

60

55-

60 '

55"

50"

40- -

35-

0

Pre-

testPost-test

Follow-

up

50-

o:

Pre-test

Post-test

Follow-

up

Pre-test

Post-test

Follow-

up

Figure 2. Changes on parent reports for treated and waiting-list partici-pants. Closed circles represent treatment, mother report; closed triangles

represent treatment, father report; open circles indicate waiting-list,mother report; open triangles indicate waiting-list, father report. CQ-P= Coping Questionnaire—Parent version; CBCL-INT = Child Behavior

Checklist-Internalizing Scale; STAIC-P = State-Trait Anxiety Inven-tory for Children—Modification of Trait Version for Parents.

relationship, it was possible to select 13 cases in which the

CPTR score was >1 SD below the mean (i.e., <18). There

were nonsignificant differences for all parent, child, or teacher

variables when the outcomes for these cases were compared

with those with higher CPTR scores.

Parental Involvement

Three therapist ratings of parental involvement were exam-

ined: parental contact, parental interference, and beneficial

involvement. The means were 3.65, 4.48, and 2.89, and the

standard deviations and ranges indicated that the full range of

ratings was used. Bonferroni correction was used and the corre-

lations between amount of parental contact and gain scores

yielded nonsignificant findings. Correlations of amount of con-

tact and maintenance scores revealed nonsignificant relation-

ships, and therapist ratings of parents beneficial involvement

were not significantly related to any gain or maintenance scores.

Comorbidity

Does the presence of comorbidity influence treatment out-

come? Sample sizes for specific comorbid conditions did not

permit separate comparisons. However, sample sizes did permit

one global comparison: all treated participants were classified

as either (a) comorbid only with another anxiety diagnosis (n

= 24) or (b) comorbid with any nonanxiety disorder (n = 64;

note that some participants comorbid with nonanxiety disorders

were also comorbid with another anxiety disorder; 6 participants

were not comorbid). On the basis of this distinction, no signifi-

cant differential outcome effects were found on dependent vari-

ables assessing internalizing symptomatology and distress.

Analyses of Treatment Segments

The treatment has two segments: (a) cognitive-educational

and (b) enactive exposure. To provide a preliminary comparison

of the effects of separate segments, assessments gathered at

midtreatment were conducted and analyzed. To examine the

effects of the first segment, changes over 8 weeks of waiting-

list were compared with changes over the 8 weeks of the first

half of treatment. Separate 2 (treatment vs. waitlist) X 2 (assess-

ments: pre- and postwaiting-list vs. pretreatment and midtreat-

ment) MANO\As for parent and child reports were nonsignifi-

•V Parent-report

I—' Teacher-report

Treatment Waitlist

Treatment Condition

Figure 3. Comparison of percentages of participants returning to non-clinical levels on parent report (on the Child'Behavior Checklist) and

teacher report (on the Teacher Report Form).

376 KENDALL ET AL.

cant. When changes due to waiting-list and due to the first half

of treatment were compared, the results were nonsignificant,

indicating that the first half of the treatment, by itself, was not

responsible for the beneficial gains that were produced by the

entire treatment.

To provide a preliminary evaluation of the effects of the sec-

ond segment, the midpoint assessments were again used. How-

ever, these MANCAAs were 2 (treatment vs. waiting-list) X 3

(assessments; see Table 2 for the midpoint means). For these

analyses, the three assessments for the treatment condition were

at pre-, mid- and posttreatment whereas the assessments for

the waitlist condition were prewaiting-list, postwaiting-list, and

midtreatment. Thus, across comparable durations (8 weeks be-

tween assessments), this analysis permits a preliminary consid-

eration of the second segment of treatment: Changes over the 8

weeks from midtreatment to posttreatment (treatment condition)

were compared with changes over the 8 weeks from midtreat-

ment to posttreatment (treatment condition). It must be noted,

however, that this comparison addresses the relative effects of

the first half of treatment versus the combined effects of the

first and second half of treatment. Thus, it is not a test of the

second half of treatment alone.

Using MANO\A, we found a significant interaction for child

self-report measures, F(}4, 63) = 2.81,p < .005. Using ANO-

VAs, we found significant interactions for both mother and father

reports on the STAIC-P; F(2, 172) = 42.07, p < .001, and

F(2, 126) = 30.23, p < .001, respectively. Simple effects tests

revealed significant effects for assessment periods within the

treated group, F(2, 172) = 42.07, p < .001, and F(2, 126) =

30.23, p < .01, for mother and father reports, respectively. Post

hoc tests revealed a significant reduction from pre- to posttreat-

ment scores, as well as from mid- to posttreatment scores, p <

.01; see Table 2).

Significant interactions were found for mother and father

Table 2

Means and Standard Deviations for the Treatment and Waiting-List Participants at Midpoint in Treatment

Measure

RCMASMSD

STAICState anxiety

MSD

Trait anxietyMSD

FSSC-RMSD

CQ-CMSD

GDIMSD

NASSQMSD

CBCL -mother reportInt. T score

MSD

Anx-Dep Scale TM

SDCBCL-A scale

MSD

Treatment

Child reports

49.1912.54

46.7210.55

46.4812.66

124.9328.17

4.541.16

7.097.10

50.0337.27

Parent reports

67.238.71

core68.059.97

11.494.48

Waiting-list

47.2712.39

49.7712.09

44.3012.91

116.6226.22

4.371.38

6.656.24

41.2736.64

66.699.10

67.419.16

10.70

4.25

Measure Treatment Waiting-list

Parent reports (continued)

CBCL-father reportInt. T score

MSD

Anx-Dep Scale T scoreMSD

CBCL-A ScaleMSD

STAIC-A-Trait-PMother report

MSD

Father reportMSD

CQ-PMother report

MSD

Father reportM

SD

65.959.46

65.41

9.28

10.284.77

52.546.79

48.627.60

3.591.21

3 911.21

65.449.24

66.12

10.19

10.244.79

50.977.27

49.737.32

3.931.15

3 951.05

Teacher reportsTRF

Int. T scoreMSD

Anx-Dep Scale r scoreMSD

56.7412.91

59.5510.24

57.4210.61

59.087.66

Note. These data were used for the analyses of treatment segments. RCMAS = Revised Children's Manifest Anxiety Scale; STAIC = State-TrailAnxiety Inventory for Children; FSSC-R = Fear Survey Schedule for Children—Revised; CQ-C = Coping Questionnaire—Child version; CDI =Children's Depression Inventory; NASSQ = Negative Affectivity Self-Statement Questionnaire; CBCL = Child Behavior Checklist; Int = Internaliz-ing; Anx-Dep = Child Behavior Checklist Anxiety-Depression Scale; CBCL-A = Child Behavior Checklist, Anxiety Scale; STAIC-A-Trait-P =State-Trait Anxiety Inventory for Children—Modification of Trait Version for Parents; CQ-P = Coping Questionnaire—Parent Version; TRF =Teacher Report Form.

TREATING YOUTHS WITH ANXIETY DISORDERS 377

CBCL reports of internalized distress, F(2, 172) = 47.04, p <

.001, and F(2, 124) = 32.24, p < .001, respectively. Simple

effects tests revealed significant effects for assessment period

within the treated group, F(2, 172) = 47.04, p < .001, and

F(2, 124) = 32.24, p < .001, respectively. Follow-up tests

revealed significant reductions from each assessment period to

the next (p < .05). Using the CBCL Anxiety-Depressed scale,

we found that both mother' and father reports demonstrated sig-

nificant interactions, F(2, 174) = 8.45, p < .001, and F(2,

124) = 6.30, p < .01, respectively. Simple effects tests revealed

significant effects for assessment period within the treated

group, F(2, 174) = MM, p < .001, and F(2, 124) = 19.09,

p < .001. Follow-up tests revealed significant reductions from

each assessment period to the next (p < .05). Similarly, mother

and father reports on the CBCL-A scale demonstrated signifi-

cant interactions, F(2, 174) = 11.84, p < .001 andF(2, 124)

= 6.83, p < .01, respectively. Simple effects tests on mothers'

reports revealed significant effects for assessment period within

both the treated group, F(2, 174) = 53.35, p < .001 and the

waiting-list group, F(2, 174) = 3.28, p < .05. Follow-up tests

revealed significant reductions from each assessment period to

the next within the treated group (p < .01). Simple effects tests

on fathers' reports revealed significant effects for assessment

period within the treated group, F(2, 124) = 22.43, p < .001,

with follow-up tests revealing significant reductions from each

assessment period to the next (p < .01).

Mothers' CQ reports demonstrated a significant interaction,

F(2, 166) = 3.9, p < .01. Simple effects tests revealed a sig-

nificant effect for assessment period within the treated group,

F(2,166) = 11.31,p < .001. Follow-up tests showed significant

reductions from one assessment to the next (p < .05).

On the FSSC-R, a significant interaction was found, F(2,

180) = 3.03, p - .05. Simple effects tests demonstrated a

significant assessment period within treatment condition effect,

F(2, 180) = 32.10, p < .001. For participants in the treatment

condition, post hoc tests revealed significant reductions from

pre- to midtreatment and mid- to posttreatment (p < .05).

Discussion

Clinically referred and diagnosed youths with anxiety disor-

ders were found to benefit from a cognitive-behavioral therapy,

compared with waiting-list. There was very low attrition, the

treatment was found to have integrity, and the treatment and

waiting-list participants and their parents were found not to

differ meaningfully on important factors.

The outcomes—including over 50% of treated cases being

free of their primary anxiety disorder at posttreatment—were

quite favorable. For those cases in which the primary diagnosis

remained at posttreatment, analyses showed significant reduc-

tions on severity scores. Mothers', fathers', and children's CQ

reports indicated that the treated children were significantly bet-

ter prepared than control participants to face and handle their

most dreaded situations. Mothers' and fathers' reports across

multiple dependent measures were consistent and indicated that

the changes in the treated children were significantly greater than

those in control participants. Child-report measures consistently

supported a favorable outcome from treatment, with several

anxiety scales and a depression inventory indicating differential

gains over time across conditions. Using normative comparisons

(Kendall & Grove, 1988), the treatment was found to have

returned a significantly greater percentage of cases than controls

to within the normal range of scores on numerous psychopathol-

ogy indices. Maintenance of gains, on numerous measures and

observations, was evident at 1-year follow-up. Furthermore, al-

though there were 11 therapists, there were no differential thera-

pist outcomes and the absence of a correlation between scores

on the measures of the child's perception of the therapeutic

relationship and outcome also supports the interpretation that

therapist differences did not account for treatment gains. The

treatment-produced outcomes were comparable across age

groups and across three different DSM-III-R diagnostic cate-

gories (OAD, SAD, AD; and these cases are not meaningfully

different from DSM-IV categories GAD, SAD, and SP; Ken-

dall & Warman, 1996). Also, earlier research suggested compa-

rable effectiveness across gender and ethnicity (Tteadwell, Flan-

nery, & Kendall, 1995), findings that were replicated herein.

Although the waiting-list cases showed some change on some

measures, there was more consistent and greater change associ-

ated with the treatment condition. These findings add to the

growing body of data indicating effective psychosocial interven-

tion for anxiety disorders in childhood (e.g., Barrett et al., 1996;

Kendall, 1994) and, given the otherwise chronic course of anxi-

ety (Last et al., 1987; Weissman et al., 1984), may offer promise

as an intervention to prevent a lifetime of anxious distress.

With regard to comorbidity, herein operationalized in a pre-

liminary manner, there were no differential effects for our one

method of comparison of comorbid status. In general, as in work

with adults (Brown, Anthony, & Barlow, 1995), comorbidity

was not found to be a moderator of treatment gains. Self-re-

ported depression, a nontarget problem, changed with treatment

(see also Borkovec, Abel, & Newman, 1995). Possible explana-

tions include (a) client generalization of coping skills to prob-

lems other than treatment targets, and (b) presence of functional

relationships between anxiety and depression (overlap of nega-

tive emotions consistent with notions of negative affectivity,

Watson & Clark, 1984). In either case, the findings encourage

broad measurement of child problems (Kendall & Flannery-

Schroeder, 1997)—not a narrow focus on treatment-targeted

problems. Work is underway, using a larger set of cases, to

evaluate comorbidity more closely and to examine changes on

child behavior problems not usually associated with anxiety.

Although not designed specifically to test effects of the two

segments of treatment (educational first half; exposure second

half), the gathering of midtreatment assessments permitted pre-

liminary examinations of the effects of the first segment and

the additive contribution of the second segment of treatment.

The present findings suggest that the first segment alone was not

sufficient to produce meaningful changes. The second segment

(considered herein only when it followed the first segment)

was an active force in the overall outcomes. These results are

consistent with our conceptualization of the treatment—the pre-

paratory segment is necessary to accomplish and facilitate

change during the enactive exposure but itself is not likely to

be sufficient to produce meaningful change without the enactive

exposure.

A different study would need to be designed specifically to

dismantle the treatment (e.g., cognitive training vs. behavioral

378 KENDALL ET AL.

exposure). More specifically, given favorable outcomes, re-

search is needed to determine what the central active ingredients

were within treatment. Was it, consistent with treatment of adult

anxiety disorders, the exposure that was provided? Certainly,

preliminary analyses of the segments of the treatment suggest

that exposure is one significant factor. Was it the developmen-

tally sensitive and tailored treatment materials (workbook) that

facilitate the child's active involvement in the treatment process?

Involvement has been identified as a predictor of treatment out-

come and maintenance gains in related cognitive-behavioral

therapy of children (Braswell, Kendall, Braith, Carey, & Vye,

1985). What about the role of the therapist-child relationship?

Relationship factors may be necessary, but are they sufficient

for therapeutic change? Although improvements were not mean-

ingfully associated with our measure of the child-therapist rela-

tionship, ceiling effects (therapists received high CPTR ratings)

reduce variability and preclude identifying meaningful correla-

tions. Were parental factors active? All therapist ratings of paren-

tal involvement did not predict treatment gains. The present

study does not identify specific active ingredients within an

effective treatment but offers suggestions worthy of future re-

search pursuits.

Although there were significant gains, some measures did

not reflect differential changes. For example, only some of the

behavioral observations reflected treatment effects. It should be

noted, however, that in another study (Gosch, Kendall, Panas, &

Bross, 1991), the behavioral codes did not discriminate between

youths diagnosed with anxiety disorders and those who did not

meet the criteria for a diagnosis (e.g., normal youths). Also,

some codes evidenced very low frequencies. As a result, it may

not be meaningful to use some codes to examine treated cases.

Also, teacher reports did not indicate differential effects; it

should be recalled that children were not referred by teachers,

nor were they necessarily seen by teachers as difficult in class.

Indeed, a substantial number of children with anxiety disorders

are not seen by teachers as troublesome in the classroom.

The waiting-list comparison condition provided necessary

controls for several sources of internal invalidity but was not

without limitations. For example, use of waiting-list controls

limit conclusions that can be drawn because the outcomes indi-

cate that something (treatment) was superior to nothing (wait-

ing-list), without providing information regarding differential

efficacy or effectiveness for different types of therapy. Also, as

in the present study, the waiting-list duration was not identical

to the duration of treatment. Use of a midpoint assessment,

where durations were the same, buttressed the conclusion that

treatment was effective beyond effects of the passage of time,

repeated assessments, and parent-child knowledge that the

problem was going to be addressed. Nevertheless, the next step

is to compare the present treatment with alternate treatment

approaches.

Using the criteria from the APA Task Force on Promotion and

Dissemination of Psychological Procedures (1995), the present

cognitive-behavioral therapy qualifies as "probably effica-

cious" (i.e., three published studies, conducted by different

investigators, including one in another country, provide support-

ive evidence) and should now be compared with an alternate

therapy such as family treatment, group treatment, or, once effec-

tive medications are identified, psychopharmacologic medica-

tions. The model includes the relationships of cognition and

behavior to the child's affective state and the functioning of the

child in the larger social context. In light of this, cognitive-

behavioral therapy has moved beyond the sole focus on the

child client and has incorporated strategies that involve parents

(Howard & Kendall, 1996), peers, and school personnel. Our

experience supports the movement to include interpersonal and

social contexts and parents as collaborators or coclients, but

treatment evaluation studies have not yet kept pace with these

expanded clinical applications. Research is also needed to exam-

ine the degree to which research and clinical procedures and

outcomes can be transported to service-oriented clinics (Hoag-

wood, Hibbs, Brent, & Jensen, 1995; Kendall & Southam-

Gerow, 1996).

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Received June 27, 1996

Revision received September 24, 1996

Accepted September 30, 1996 •