Journal of Consulting and Clinical Psychology

1997. 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, child
self-reports, parent and teacher reports, cognitive assessment and behavioral observation; maintenance
was 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 were
maintained at 1-year follow-up. Client age and comorbid status did not moderate outcomes. A
preliminary examination of treatment segments suggested that the enactive exposure (when it follows
cognitive-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 from12%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 this
articlePCK
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 44042fromthe National
Institute of Mental Health. We thank the following individuals: the partic-
ipating children and their families and the referring community agencies
and practicing clinicians; Tamar Chansky, Bonnie Howard, Martha Kane,
Elizabeth Kortlander, Lynne Siqueland, and KimTreadwell; associates
Erica Brady, Serena Callahan, Brian dm, Elizabeth Gosch, Margot
Levin, Abbe Marrs, Jennifer MacDonald, and Amy Sugarman; and Peter
J. Mikulka for his artistic renderings.
Correspondence concerning this article should be addressed to Philip
C. Kendall, Department of Psychology, Temple University, 1701 North
13th 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 fromanxiety-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 childhoodal-
though not as dramatic in presentation as externalizing disor-
dersrepresent a serious mental health problemfor 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 (OADand
SP, respectively; e.g., Ambrosini, Bianchi, Rabinovich, &Elia,
366
TREATINGYOUTHS WITH ANXIETY DISORDERS 367
1993; Graee, Milner, Rizzotto, &Klein, 1994; Klein, Kople-
wicz, &Kanner, 1992). For other anxiety disorders that occur in
childhoodpanic 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 problemsolving, 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 programdid 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-
gramis 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 fromthe nosology. OADhas
been subsumed under generalized anxiety disorder (GAD), and
ADhas 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-
GADis 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-
hoodSADis characterized by an intense and chronic fear
reaction on separation fromparents 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 frommultiple community
sources served as participants (60in treatment condition, 34 in waiting-
list control condition). The 94 participants came froma total of 118
potential participants (attrition included 9 fromtreatment, 9 fromwait-
ing-list, and 6 fromtreatment after the waiting-list). Of the 60treated
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 fromother minorities. Fifty-two percent were 9-10years
old, and 48%were 11-13 years old. Family income was below $20,000
for 6.4%, $40,000for 27.7%, $60,000for 33%, $80,000for 23.5%, and
above $80,000for 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 InterviewSchedule 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 problembehaviors, and to screen out additional
disorders. The interviewhas interrater reliability (e.g., r =.98for parent
interviewand 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-itemself-
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 ChildrenRevised (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 itemcontains three statements, and children select the
one that best characterizes themduring 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 fromnot 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 NASSQincludes self-statements that children endorse on a scale
ranging fromnot 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 NASSQare 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 NASSQwas 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-itemscale
assessing behavioral problems and social competencies (Achenbach,
199la). Items are rated fromnot 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).
STAICModification 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.
TREATINGYOUTHS 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 howrespon-
dents generally feel (A-Trait) and 20items 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-iteminventory 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 CBCLTeacher Report Form(TRF) mirrors the parent version
of the CBCL and provides a picture of the child's classroomfunctioning
(Achenbach, 1991b). This measure was completed by the child's pri-
mary teacher; however, children often changed grades over the course
of the programso that die primary classroomteacher 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 systemwas 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 CPTRwas 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 PIRtaps
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 18sessions (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 fromothers 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 reviewthe 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 howto 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 20depen-
dent variables revealed 20nonsignificant therapist effects. Ex-
amining maintenance scores (posttreatment to follow-up) re-
vealed 18of 20nonsignificant 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 20instances) 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) X2 (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 meaningful
pattern.
TREATINGYOUTHS WITHANXIETY 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) X2 (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 theminto 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 XTrials 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 frompre- 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, respectivelyand
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 CQmothers' 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 fromthe diagnostic interview.
Albeit insufficient to be diagnosis-free, these analyses revealed
significant improvement frompretreatment 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 2X
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 X2 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 child
interview, some cases did not meet diagnostic criteria at pretreatment),
we found that 45.74%of those treated no longer had their primary
diagnosis as primary at the end of treatment.
5
The CBCL Anxiety-Depression scale and the CBCL-A are not
independent (itemoverlap). Also, the items on the present version of
the CBCL-A differentiated youths with anxiety disorders from those
without 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
RCMAS
M
SD
STAIC
Trait anxiety
M
SD
State anxiety
M
SD
FSSC-R
M
SD
CQ-C
M
SD
GDI
M
SD
NASSQ
M
SD
55.34
10.76
50.82
12.70
54.46
11.08
132.21
27.01
3.97
1.23
10.29
6.96
58.55
40.17
43.05
11.89
40.25
14.17
44.83
10.87
111.31
25.42
5.31
1.11
4.95
6.04
43.41
31.00
40.79
10.58
38.15
12.28
47.10
11.53
105.70
23.43
5.44
1.06
5.15
6.74
38.05
25.54
55.61
8.29
54.76
12.02
56.32
11.35
142.91
26.84
3.65
1.34
13.38
9.77
53.13
38.73
49.67
10.16
49.91
11.95
49.18
10.78
124.97
28.63
4.17
1.44
10.56
9.73
46.09
36.12
Behavioral observations
Trembling voice
M
SD
Fingers in mouth
M
SD
Absence of eye contact
M
SD
0.26
0.32
0.78
0.09
0.20
0.13
0.00
0.00
0.03
0.05
0.00
0.00
0.01
0.04
0.04
0.06
0.00
0.00
0.11
0.16
0.08
0.12
0.53
0.32
0.14
0.05
0.15
0.10
0.46
0.17
Parent reports
CBCL-Mother report
Int. T score
M
SD
Anx-Dep T score
M
SD
CBCL-A
M
SD
CBCL-Father report
Int. T score
M
SD
Anx-Dep T score
M
SD
CBCL-A
M
SD
STAIC-A-Trait-P
Mother report
M
SD
Father report
M
50
72.07
6.87
72.49
9.06
13.26
3.98
69.55
8.76
68.03
9.03
11.51
4.43
54.09
8.23
52.02
8.70
61.81
10.30
62.30
9.32
8.21
4.66
59.17
11.67
60.05
9.72
7.46
4.89
44.25
8.88
42.49
9.18
57.77
11.78
60.20
9.13
6.81
4.56
56.05
11.22
58.05
7.45
6.25
3.89
42.32
8.498
41.19
8.80
70.91
8.68
70.28
10.08
12.41
3.81
67.20
8.62
67.48
10.20
11.16
4.43
51.69
8.25
48.96
9.95
68.73
8.44
68.38
9.19
10.91
3.99
66.28
7.62
65.16
9.19
9.84
4.42
49.56
8.73
47.08
9.77
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-P
Mother report
M
SD
Father report
M
SD
TRF
Int. T score
M
SD
Anx-Dep T score
M
SD
Parent reports (continued)
2.81
0.98
3.09
1.18
64.40
11.38
64.10
10.84
4.43
1.22
4.56
1.24
Teacher reports
58.15
10.38
58.60
7.82
4.83
1.20
4.91
1.19
55.11
9.39
57.36
8.11
2.91
1.09
3.14
1.27
62.48
10.99
63.39
9.95
2.96
1.09
3.41
1.16
59.10
9.71
58.89
7.65
Note. RCMAS = Revised Children's Manifest Anxiety Scale; STAIC = State-Trait Anxiety Inventory for Children; FSSC-R - Fear Survey
Schedule for ChildrenRevised; CQ-C = Coping QuestionnaireChild version: CDI = Children's Depression Inventory; NASSQ= Negative
Affectivity 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 ChildrenModifica-
tion of Trait "Version for Parents; CQ-P = Coping QuestionnaireParent 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) X2 (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
reported
6
, 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, x
2
(l, N = 20) = 20.00,
p < .001, and x
2
(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 XTrials 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 OADonly, 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 '
,
^ \
\
\
\
\
. m
i i i
Pre- Post- Follow-
test test up
Figure 1. Changes on child self-report for treated and waiting-list participants. Closed circles represent
treatment; open circles represent waiting-list; closed squares represent 1-year follow-up. CQ-C = Coping
Questionnairechild version; RCMAS = Revised Children's Manifest Anxiety Scales; NASSQ= Chil-
dren's Negative Affectivity Self-Statement Questionnaire.
NASSQand 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 fromposttreatment. All other parental measures
demonstrated a significant reduction in scores from pre- to post-
treatment and maintenance of gains fromposttreatment to fol-
low-up. There was one exception; Mothers' CBCL Internalizing
scale reports were significantly lowered frompre- 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 WITHANXIETYDISORDERS 375
5.0
4.5
4.0
3.0
2.5
0
75'
70 '
65
60
55-
60 '
55"
50"
40--
35-
0
Pre-
test
Post-
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 QuestionnaireParent version; CBCL-INT = Child Behavior
Checklist-Internalizing Scale; STAIC-P = State-Trait Anxiety Inven-
tory for ChildrenModification of Trait Version for Parents.
relationship, it was possible to select 13 cases in which the
CPTR score was >1 SDbelow 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 8weeks of waiting-
list were compared with changes over the 8weeks of the first
half of treatment. Separate 2 (treatment vs. waitlist) X2 (assess-
ments: pre- and postwaiting-list vs. pretreatment and midtreat-
ment) MANO\As for parent and child reports were nonsignifi-
VParent-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) X3
(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 (8weeks be-
tween assessments), this analysis permits a preliminary consid-
eration of the second segment of treatment: Changes over the 8
weeks frommidtreatment to posttreatment (treatment condition)
were compared with changes over the 8weeks frommidtreat-
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 frompre- to posttreat-
ment scores, as well as frommid- 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
RCMAS
M
SD
STAIC
State anxiety
M
SD
Trait anxiety
M
SD
FSSC-R
M
SD
CQ-C
M
SD
GDI
M
SD
NASSQ
M
SD
CBCL -mother report
Int. T score
M
SD
Anx-Dep Scale T
M
SD
CBCL-A scale
M
SD
Treatment
Child reports
49.19
12.54
46.72
10.55
46.48
12.66
124.93
28.17
4.54
1.16
7.09
7.10
50.03
37.27
Parent reports
67.23
8.71
core
68.05
9.97
11.49
4.48
Waiting-list
47.27
12.39
49.77
12.09
44.30
12.91
116.62
26.22
4.37
1.38
6.65
6.24
41.27
36.64
66.69
9.10
67.41
9.16
10.70
4.25
Measure Treatment Waiting-list
Parent reports (continued)
CBCL-father report
Int. T score
M
SD
Anx-Dep Scale T score
M
SD
CBCL-A Scale
M
SD
STAIC-A-Trait-P
Mother report
M
SD
Father report
M
SD
CQ-P
Mother report
M
SD
Father report
M
SD
65.95
9.46
65.41
9.28
10.28
4.77
52.54
6.79
48.62
7.60
3.59
1.21
3 91
1.21
65.44
9.24
66.12
10.19
10.24
4.79
50.97
7.27
49.73
7.32
3.93
1.15
3 95
1.05
Teacher reports
TRF
Int. T score
M
SD
Anx-Dep Scale r score
M
SD
56.74
12.91
59.55
10.24
57.42
10.61
59.08
7.66
Note. These data were used for the analyses of treatment segments. RCMAS = Revised Children's Manifest Anxiety Scale; STAIC = State-Trail
Anxiety Inventory for Children; FSSC-R= Fear Survey Schedule for ChildrenRevised; CQ-C = Coping QuestionnaireChild 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 ChildrenModification of Trait Version for Parents; CQ-P = Coping QuestionnaireParent Version; TRF =
Teacher Report Form.
TREATING YOUTHS WITHANXIETY 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 fromeach 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 fromeach 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 fromeach
assessment period to the next (p < .01).
Mothers' CQreports 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 fromone 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 froma 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 outcomesincluding over 50%of treated cases being
free of their primary anxiety disorder at posttreatmentwere
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 fromDSM-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 narrowfocus 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 treatmentthe 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
problemwas going to be addressed. Nevertheless, the next step
is to compare the present treatment with alternate treatment
approaches.
Using the criteria fromthe 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