Cognitive–Behavioral Therapy for Anxiety Disordered Youth: ARandomized Clinical Trial Evaluating Child and Family Modalities

Philip C. KendallTemple University

Jennifer L. HudsonMacquarie University

Elizabeth GoschPhiladelphia College of Osteopathic Medicine

Ellen Flannery-SchroederUniversity of Rhode Island

Cynthia SuvegUniversity of Georgia

This randomized clinical trial compared the relative efficacy of individual (child) cognitive–behavioraltherapy (ICBT), family cognitive–behavioral therapy (FCBT), and a family-based education/support/attention (FESA) active control for treating anxiety disordered youth ages 7–14 years (M � 10.27).Youth (N � 161; 44% female; 85% Caucasian, 9% African American, 3% Hispanic, 3% other/mixed)with a principal diagnosis of separation anxiety disorder, social phobia, or generalized anxiety disorderand their parents participated. Outcome analyses were conducted using hierarchical linear models on theintent-to-treat sample at posttreatment and 1-year follow-up using diagnostic severity, child self-reports,parent reports, and teacher reports. Chi-square analyses were also conducted on diagnostic status at postand 1-year follow-up. Children evidenced treatment gains in all conditions, although FCBT and ICBTwere superior to FESA in reducing the presence and principality of the principal anxiety disorder, andICBT outperformed FCBT and FESA on teacher reports of child anxiety. Treatment gains, when found,were maintained at 1-year follow-up. FCBT outperformed ICBT when both parents had an anxietydisorder. Implications for treatment and suggestions for research are discussed.

Keywords: anxiety, children, treatment, cognitive–behavioral therapy, family therapy

The results from randomized clinical trials (RCTs) support theefficacy of child-focused cognitive–behavioral therapy (CBT) fortreating anxious youth (e.g., Barrett, Dadds, & Rapee, 1996; Ken-dall et al., 1997). CBT for youth anxiety disorders producesmedium to large effect sizes when compared with wait-list controls(Barmish & Kendall, 2005; Compton et al., 2004). A recent reviewindicated that 56% of anxious youth no longer met criteria for theirprincipal anxiety disorder following CBT, and 63% no longer didat 6- to 12-month follow-up (Cartwright-Hatton, Roberts, Chitsa-besan, Fothergil, & Harrington, 2004). According to criteria for

empirically supported treatments (Chambless & Hollon, 1998),CBT for anxious youth is “probably efficacious” (e.g., Ollendick,King, & Chorpita, 2006).

A lingering question concerns whether increasing parent in-volvement in CBT could enhance the efficacy of CBT for anxiousyouth. Etiological models emphasize the reciprocal relationshipbetween parent and child behavior in child anxiety (e.g., Chorpita& Barlow, 1998; Ginsburg & Schlossberg, 2002; Hudson &Rapee, 2004), and anxious children are more likely to have anx-ious parents whose behavior may maintain anxiety and avoidance(e.g., Last, Hersen, Kazdin, Francis, & Grubb, 1987). Parents mayfacilitate anxiety (avoidance, cognitive biases) through reinforce-ment and modeling (e.g., Barrett, Rapee, Dadds, & Ryan, 1996),and some familial variables have been associated with child CBToutcomes. For example, higher levels of parent anxiety predictedpoorer youth outcomes after CBT (Berman, Weems, Silverman, &Kurtines, 2000; Crawford & Manassis, 2001; Southam-Gerow,Kendall, & Weersing, 2001). Increasing parent involvement intreatment may impact parents’ restriction of activity, overcontrol,and modeling of avoidance and/or cognitive bias (Ginsburg,Siqueland, Masia-Warner, & Hedtke, 2004; Wood, McLeod, Sig-man, Hwang, & Chu, 2003).

CBT combined with parent involvement, as opposed to theapproach taken with wait-list controls, has demonstrated efficacy(e.g., Barrett, 1998; Shortt, Barrett & Fox, 2001; Silverman et al.,

Philip C. Kendall, Department of Psychology, Temple University; Jen-nifer L. Hudson, Centre for Emotional Health, Department of Psychology,Macquarie University, Sydney, Australia; Elizabeth Gosch, Department ofPsychology, Philadelphia College of Osteopathic Medicine; EllenFlannery-Schroeder, Department of Psychology, University of Rhode Is-land; Cynthia Suveg, Department of Psychology, University of Georgia.

Philip C. Kendall is a coauthor of the treatment materials and receivesroyalties from their sales.

This research was supported by National Institute of Mental HealthGrant MH 59087 awarded to Philip C. Kendall.

Correspondence concerning this article should be addressed to Philip C.Kendall, Department of Psychology, Weiss Hall, Temple University, 1701North 13th Street, Philadelphia, PA 19122-6085. E-mail:pkendall@temple.edu

Journal of Consulting and Clinical Psychology Copyright 2008 by the American Psychological Association2008, Vol. 76, No. 2, 282–297 0022-006X/08/$12.00 DOI: 10.1037/0022-006X.76.2.282

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1999); however, studies comparing the relative efficacy of child-focused CBT with interventions combining child-focused CBTand increased parent involvement have yielded inconsistent find-ings (see Barmish & Kendall, 2005). In two studies, family-focused CBT produced greater improvement in anxiety than withindividual-focused CBT (Barrett, Dadds, & Rapee, 1996; Wood,Piacentini, Southam-Gerow, Chu, & Sigman, 2006). Barrett,Duffy, Dadds, and Rapee (2001) reported superior results for CBTand family anxiety management versus CBT at posttreatment andat 12-month follow-up but not at 6-month or 6-year follow-up.Findings suggested that younger children and girls benefited morefrom the combined treatment than did older children and boys.Another study found no significant differences between child-focused CBT and child-focused CBT plus a seven-session parenttraining (Nauta, Scholing, Emmelkamp, & Minderaa, 2003). Fourstudies comparing child group CBT with child group CBT plusparent interventions reported equivocal outcomes, although onestudy reported significantly more coping and parent-reported gainin the parent–child treatment (Barrett, 1998; Cobham, Dadds, &Spence, 1998; Mendlowitz et al., 1999; Spence, Donovan, &Brechman-Toussaint, 2000). Cobham et al.’s (1998) findings sug-gest that children with an anxious parent benefited more from CBTthat included parent anxiety management than from individual(ICBT), whereas children of nonanxious parents benefited fromboth treatments. Further studies are needed to clarify the incre-mental benefits of increased parent involvement in CBT and thefamily variables that moderate outcomes.

Identifying commonalities in the two studies favoring familyCBT (FCBT) over ICBT (Barrett, Dadds, & Rapee, 1996; Wood etal., 2006) provides a base from which to design further research.Both studies implemented CBT with children (ages 6–14 years)who met criteria for separation anxiety disorder (SAD), general-ized anxiety disorder (GAD), or social phobia (SP) in nongroupformats. Therapists met conjointly with parent and child for at leasta portion of each session. Both FCBT treatments implementedchild-focused CBT strategies emphasizing anxiety management(e.g., relaxation, cognitive restructuring, problem solving) andexposure tasks in concert with parent training. Therapists separatedthe delivery of child-focused components and parent-focused com-ponents through the use of a child CBT manual and a parenttreatment manual. Both treatments included therapeutic strategiesdirected toward removing reinforcement for anxious and avoidantbehavior, increasing reinforcement for adaptive behavior, teachingparents skills to manage their own anxiety, decreasing parentalmodeling of anxious and avoidant behaviors, encouraging adaptivecommunication, and increasing family problem-solving skills.Both studies compared ICBT with ICBT plus FCBT but did notinclude an alternative family treatment to control for nonspecificfamily treatment effects. Sessions in these treatments extendedbeyond the 45- to 60-min session of standard clinical practice,making the treatments less generalizable to clinical settings.

At present, we need to know about CBT in comparison toalternative treatment. Only a few studies compared CBT withsupportive treatments. Two found CBT and educational supportconditions equally effective (Last, Hansen, & Franco, 1998; Sil-verman et al., 1999). The educational support condition providedsupport and information about anxiety but neither exposure pro-cedures nor specific instruction in anxiety reduction strategies.Note that the educational support contained features of CBT such

as psychoeducation and that youth in this condition engaged intherapeutic exposures outside of treatment. Ginsburg and Drake(2002) compared an attention-support control condition with groupCBT. Anxious adolescents in group CBT attained greater benefitsthan did those in attention support. These findings provide prelim-inary support for treatments containing information about anxietyreduction techniques and cognitive–behavioral strategies (Gins-burg & Drake, 2002).

The present study evaluated the relative efficacy of ICBT andFCBT in comparison to family-based education, support, andattention (FESA), an active comparison treatment, for anxietydisordered youth. As with other trials (e.g., Last et al., 1998;Silverman et al., 1999), FESA was modified for use with families(to control for family factors). All conditions were matched fortherapy contact time. We hypothesized that ICBT and FCBTwould produce significant change from pre- to posttreatment com-pared with FESA on child diagnostic status (fewer principal diag-noses; reduced severity). We also hypothesized significant reduc-tions in anxious distress and improved child coping, as measuredby child self-report and parent and teacher reports on the child.Maintenance of gains at 1-year follow-up was expected. Norma-tive comparisons (Kendall, Marrs-Garcia, Nath, & Sheldrick,1999) were used to evaluate the clinical significance of any ob-served gains, and age and gender were evaluated as potentialmoderators (e.g., FCBT better for younger participants, ICBTbetter for older participants). In addition, this study diagnosedparent psychopathology to examine whether (a) treatment pro-duced changes in parental anxiety and (b) the presence of parentalanxiety moderated child outcomes. It was hypothesized that pa-rental anxiety would moderate child outcomes (less parental anx-iety, better child outcomes).

Method

Participants

Community sources referred 161 youth diagnosed with a prin-cipal anxiety disorder and their parents between 2000 and 2006.Prior to data collection, a power analysis determined that a samplesize of 44 was needed to detect moderate differences betweenconditions. Of the randomized cases, 55 were assigned to ICBT, 56to FCBT, and 50 to the FESA condition. Treated participants camefrom a total of 231 potential participants (attrition included 5, 7,and 11 participants from ICBT, FCBT, and FESA, respectively;see Figure 1). Eligible children were ages 7–14, met diagnosticcriteria, and agreed to the RCT. Exclusion criteria were few:psychotic symptoms, mental retardation, a disabling medical con-dition, the child’s participation in concurrent treatment, or thechild’s taking antianxiety or antidepressant medications. At leastone parent was required to be English speaking.

Of the 161 child participants, 44% were girls, 85% wereCaucasian, 9% were African American, 3% were Hispanic, and3% were self-identified as “other” or mixed race. Sixty-threepercent were 7–10 years old, and 37% were 11–14. Eighty-eightchildren were diagnosed with a principal diagnosis of GAD, 47with SAD, and 63 with SP, based on structured interviews.Composite diagnoses were computed using the “or” rule: Thediagnosis was assigned if the child or parent reported thediagnosis and the clinician subsequently assigned a clinician

283COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH

severity rating (CSR) of 4 or greater. Twenty-four percent ofchildren were comorbid with GAD, 32% with SAD, 37% withSP, 53% with specific phobia, 32% with attention-deficit/hyperactivity disorder, 14% with oppositional defiant disorder,6% with dysthymia, and 5% with major depressive disorder.Few participants were comorbid with other diagnoses (e.g., 1

child met criteria for conduct disorder). Participants reportedfamily income as below $20,000 (3%), up to $40,000 (13%), upto $60,000 (22%), up to $80,000 (26%), and above $80,000(36%). Fathers and mothers did not complete high school (4%and 1%, respectively), were high school graduates withoutcollege (30% and 26%), had some college education (19% and

Figure 1. Flow of participants through the clinical trial. ICBT � individual (child) cognitive–behavioraltherapy; FCBT � family cognitive–behavioral therapy; FESA � family-based education/support/attention.

284 KENDALL ET AL.

24%), completed a 4-year college education (23% and 31%),attended graduate school (23% and 16%), or self-identifiedtheir education as “other” (0% and 1%).

Setting and Personnel

All procedures were internal review board–approved and wereconducted at the Child and Adolescent Anxiety Disorders Clinic(CAADC), Temple University. Doctoral candidates in clinicalpsychology conducted structured diagnostic interviews and assess-ments. The ICBT, FCBT, and FESA conditions were implementedby master’s-level therapists with 2–3 years of experience at theCAADC and doctoral-level psychologists, with supervision bydoctoral-level psychologists with 6–7 years of experience in thecommunity. All therapists for each condition studied written ma-terials (manuals) and participated in training (typically two 3-hrworkshops) before initiating supervised pilot experience. Work-shops included didactic presentation, role plays, trainee demon-stration, videotape playback, and discussion. Following training,and continuing throughout, all therapists participated in weekly2-hr supervision groups.

Measures

Primary outcomes were evaluated via changes in principal di-agnoses and severity ratings. Other outcomes included anxiety andinternalizing symptoms (self-, parent, and teacher report) and childcoping. Clinical significance was addressed via normative com-parisons.

Child Psychopathology

Anxiety Disorders Interview Schedule for Children (ADIS-C/P;Silverman & Albano, 1996). Children’s anxiety was assessedusing the ADIS-C/P for the Diagnostic and Statistical Manual (4thed.; DSM–IV American Psychiatric Association, 1994) disorders.This is a semistructured interview with established reliability andconvergent validity. Experienced diagnosticians trained indepen-dent evaluators by observing practice administrations with clients,providing feedback/supervision, and monitoring performance withreliability assessments. Trainees were required to reach and main-tain interrater diagnostic reliability of .85 (Cohen’s �). Trainingprepared independent evaluators to provide ratings on the ADIS-C/P clinician severity rating (Silverman & Albano, 1996) regard-ing the severity of the child’s anxiety (0 � not at all, 4 � some,8 � very, very much).

Children’s Self-Report Measures

Multidimensional Anxiety Scale for Children (MASC; March,Parker, Sullivan, Stallings, & Conners, 1997). Children re-sponded to the MASC, a 39-item scale with excellent internalconsistency (� � .86) and strong convergent validity that assesseschildren’s anxiety symptoms. The scale assesses four factors:physical symptoms, social anxiety, harm avoidance, and separationanxiety. The scale has children report how they have been think-ing, feeling, or acting over the last 2 weeks on a scale of 1 (never)to 4 (often).

Coping Questionnaire–Child (CQ-C; Kendall & Marrs-Garcia,1999). The CQ-C, which assesses a child’s sense of coping withanxious distress in three challenging situations, is rated on a scale

of 1 (not at all able to help) to 7 (totally able to help myself). Thethree items are summed for a total score. For the measure to berelevant, situationally based, and individualized, three areas ofdifficulty for each child are chosen from the information in thediagnostic interview. Analyses indicate adequate internal consis-tency and strong retest reliability and document its usefulness as ameasure of improvement.

Parent and Teacher Reports of Child Functioning

Child Behavior Checklist (CBCL; Achenbach, 1991; Achenbach& Edelbrock, 1991). The CBCL is a 118-item checklist. Parentsreport whether their child displays various behaviors by circling 0(not true), 1 (somewhat/sometimes), or 2 (very/often true). Themeasure generates T scores that reflect a child’s status relative toothers of the same gender and age (e.g., internalized distress).Respondents with a T score of � 65 can be in need of treatment.Validity, internal consistency, and retest reliability have beendocumented (Achenbach & Rescorla, 2001). Kendall et al. (2007)developed a specific anxiety scale, the CBCL-A, using 19 CBCLitems. The CBCL-A distinguishes between children with and with-out anxiety disorder and in our study was sensitive to treatment.Favorable retest reliability, interrater reliability, and internal con-sistency were reported for the CBCL-A.

Teacher Report Form (TRF; Achenbach, 1991; Achenbach &Edelbrock, 1986). The primary teacher rated the child’s class-room functioning on the TRF. The TRF mirrors the parent CBCL.As with the CBCL, a TRF-A has been identified (Kendall et al.,2007) to assess specific anxiety symptoms. The TRF has highretest reliability and moderate interteacher agreement and discrim-inates between referred and nonreferred children (Achenbach,1991).

Coping Questionnaire–Parent (CQ-P; Kendall & Marrs-Garcia, 1999). The CQ-P parallels the children’s version (CQ-C)described earlier. The parent rates the child’s ability to cope withthe three most anxiety-provoking situations identified from thestructured interview on a scale from 1 (not at all able to help) to7 (totally able to help him/herself). The scale has demonstratedmoderate interrater agreement and sensitivity to treatment effects.

Parent Psychopathology

Anxiety Disorder Interview Schedule for DSM–IV, Lifetime Ver-sion (ADIS-IV-L; DiNardo, Brown, & Barlow, 1994). TheADIS-IV-L is a structured interview to diagnose current and pastepisodes of adult anxiety disorders. The instrument includes as-sessments of current and past mood, somatoform, and substanceuse disorders and provides a timeline to assess the duration andonset of current and past episodes. Evaluators rate the severity ofthe individual’s diagnosis on a scale of 0 to 8, with 4 indicating adiagnosable disorder. Respectable reliability and favorable psy-chometric properties have been reported (DiNardo, Brown, Law-ton, & Barlow, 1997; DiNardo, Moras, Barlow, Rapee, & Brown,1993).

In-Therapy Measures

Child’s Perception of Therapeutic Relationship (CPTR; Kendallet al., 1997). This seven-item, 5-point scale assesses partici-pants’ perceptions of the quality of the therapeutic relationship

285COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH

(e.g., items relate to how much the parent or child liked, felt closeto, could talk to, and wanted to spend time with the therapist).There are 10 items, but 3 are fillers. Included to index thetherapist–child relationship across treatment conditions, this mea-sure was administered to participants after each session by adiagnostician (not by the child’s therapist).

Procedure

Cases were referred through multiple sources including clinicsand practitioners, public/nonpublic schools, media descriptions,and flyers. Parent(s) participated in a brief phone screen. Within aweek, clinic staff contacted the parent(s) to arrange an intake. Atintake, parents and children signed informed consent forms (e.g.,understanding random assignment). Independent evaluators ad-ministered diagnostic interviews separately to parent(s) and child.To determine the child’s principal (and secondary) diagnoses, weused the composite approach recommended in the ADIS-C/P (in-tegration of child and parent report). If a child met inclusioncriteria, parents completed the ADIS-IV-L within the same weekto diagnose current and past adult anxiety disorders. Parents andchildren then completed self-report forms. Parents asked teachersto complete the TRF; however, when necessary and with permis-sion, staff contacted teachers. Parents provided the names, phonenumbers, and addresses of two people closest to the family tofacilitate follow-up contact. Following assessment, the coordinatorused a predetermined schedule (random number–generated) torandomly assign eligible participants to ICBT, FCBT, or FESA.Restricted randomization was used to balance participants acrossconditions. To control for potential therapist factors, we randomlyassigned cases to therapists (who were trained in all treatments).Referrals were made for cases that did not meet study criteria.

Therapists implemented the conditions using manuals, appliedwith flexibility to address individual differences. All sessions forall conditions were videotaped. Participants participated in assess-ments including structured diagnostic interviews and question-naires at posttreatment and 1-year follow-up. Session measureswere done weekly.

Strategies were used to help ensure that posttreatment andfollow-up diagnosticians (independent evaluators) would be blindto treatment condition. The coordinator (not the primary investi-gator or a therapist or diagnostician) held the key to the blind.Therapists and diagnosticians did not overlap. Also, independentevaluators were isolated from discussions of treatment cases, anda sign was placed on the table during posttreatment and follow-upevaluations instructing participants not to talk about the servicesthey had received or about their therapists. FESA participants whomet diagnostic criteria for an anxiety disorder at posttreatmentwere offered additional services (i.e., ICBT or FCBT).

Treatment Methods

All three treatments followed manuals and included 16 weekly60-min sessions (equalizing therapist contact). ICBT was con-ducted individually with the child, whereas FCBT and FESA werecarried out with the child and both parents. ICBT and FCBT hadtwo 8-session parts. The first provided psychoeducation and taughtskills to the child/family, whereas the second provided the child/family with the chance to practice new skills in exposure tasks.

FESA provided therapeutic support and attention to the familiesand education about anxiety for 16 sessions. All treatments in-cluded education about youth anxiety, but only ICBT and FCBTtaught skills to manage anxious distress and included exposuretasks.

Individual Cognitive–Behavioral Therapy (ICBT). Therapistsfollowed a CBT for anxious children therapist manual (see Kendall& Hedtke, 2006a) and used the Coping Cat Workbook (see Kendall& Hedtke, 2006b) to facilitate child interest and involvement intreatment. ICBT taught youth skills to manage anxiety using theFEAR acronym: (a) recognizing anxious feelings and somaticreactions to anxiety (i.e., Feeling frightened?), (b) identifyinganxious cognition (i.e., Expecting bad things to happen?), (c)developing a plan to cope with the situation that included modi-fying anxious self-talk and engaging in coping behavior (i.e.,Actions and attitudes that can help), and (d) evaluating perfor-mance and self-reward (i.e., Results and rewards). ICBT usedbehavioral strategies such as modeling, imaginal and in-vivo ex-posure tasks, role play, relaxation training, and contingent rein-forcement. Homework tasks were assigned to the child. Therapistsmet individually with the child for 14 (of 16) sessions and withparents at Sessions 4 and 9. Parent sessions provided the therapistwith an opportunity to inform the parents about treatment and thechild’s progress, collect information, and answer questions. Ther-apists provided psychoeducation regarding youth anxiety andcoached parents on ways of responding to their particular child’sanxious behavior.

Family Cognitive–Behavioral Therapy (FCBT). Therapistsfollowed a family CBT for anxious children manual (Howard,Chu, Krain, Marrs-Garcia, & Kendall, 2000) and used the CopingCat Workbook as in ICBT. FCBT integrated ICBT within a familyview of child anxiety. As with ICBT, the FCBT approach taughtyouth skills to manage their anxiety using the FEAR acronym,implemented behavioral strategies (e.g., contingent reinforcement,exposure tasks), and assigned “Show-That-I-Can” tasks. In addi-tion, FCBT aimed to modify maladaptive parental beliefs andexpectations, teach parents constructive responses to their child’sanxious distress, encourage parents to support the child’s mastery,and teach parents and children effective communication skills.When parents were themselves anxious, they were encouraged toapply the skills taught in therapy to cope with their own distress.In this way, parents were active members of the treatment processand were expected to engage in all therapeutic activities. AtSessions 4 and 9 the therapist met with the parents and childseparately to provide them with a private opportunity to discussissues with the therapist.

Family Education/Support/Attention (FESA). Therapists fol-lowed a manual for family education, support, and attention foranxious children (Krain, Hudson, Choudhury, & Kendall, 2000;see also Silverman et al., 1999) and used a workbook to add childinterest/involvement. FESA controlled for “common factors” (e.g.,learning about anxiety/emotions, experience with an understandingtherapist, attention to the child’s anxiety) by providing these com-ponents in a family context. As with the FESA manual, childrenand their parents were taught about emotions in general andanxiety in particular, given various theories of anxiety (e.g., be-havioral, biological), and provided with opportunities to discussthe child’s anxiety. Although parents and children were providedwith psychoeducation regarding youth anxiety, they were not

286 KENDALL ET AL.

given directions on how to respond to or manage the child’sanxiety (e.g., not taught the FEAR plan). As with FCBT, parentswere considered active members of the treatment and were ex-pected to engage in therapeutic activities. The therapist met withparents and children separately at Sessions 4 and 9 to provide aprivate opportunity to discuss issues with the therapist.

Treatment Integrity

Raters used a checklist and rated a randomly selected 15-minvideotape segment from 30% of randomly selected cases fromeach condition. The checklist had the content/strategies called forin sessions by the manual. Raters were trained as follows: Theprimary investigator listened to eight tapes with each rater andexplained the ratings; the primary investigator and raters rated newtapes and reached a criterion of at least .85 (Cohen’s �). Fourunannounced reliability checks covering half of the total ratingswere made. All raters met the .85 criterion on reliability checks.

Using the checklist, experienced therapists rated 14% of thesessions, indicating whether appropriate content was covered. Therandomly selected tapes were representative of all sessions, con-ditions, and therapists. A ratio was computed: the number ofchecklist items covered by the therapist relative to the total numberof items that should have been included. Results showed that 91%,92%, and 85% of intended content was covered in ICBT, FCBT,and FESA, respectively. Results indicated a significant main effectfor condition, F(2, 277) � 7.88, p � .000, �2 � .04; Tukey’s HSDtest indicated that the percentage of content coverage betweenICBT and FESA and between FCBT and FESA was significantlydifferent. Twenty therapists, trained in all of the conditions, ad-ministered treatment (no differential therapist effects).

Results

Preliminary analyses involved group comparisons to determineequivalence across the three conditions and to determine equiva-lence between the intent-to-treat and treatment completer samples.Chi-squared analyses were conducted to evaluate child’s diagnos-tic outcomes across the three conditions. Hierarchical linear ormixed models containing random factors for subject, fixed effectsfor treatment condition (ICBT, FCBT, FESA), and time (pre, postand follow-up) were fitted to diagnostic severity and to child-,mother-, and father-reported symptom measures.1

Though not reported here, Condition � Time analyses of vari-ance (ANOVAs) results, to a large degree, were highly consistentwith the results reported. Mixed model analyses testing age andgender effects were also conducted (note: main effects of age andgender, and the interactions Time � Age and Time � Gender,were not of interest). Bonferroni corrections were used whenappropriate. Effect sizes were calculated as the estimated fixedeffect divided by the square root of the sum of the two variancecomponents in the mixed model. To assess clinical significance,we conducted normative comparisons on parent- and teacher-report measures. In addition to child diagnostic outcomes, parentaldiagnostic status was examined for (a) change following treatmentand (b) moderating child outcomes. Finally, an integrity check onthe FESA condition was performed. Analyses were conductedusing all randomized cases (intent-to-treat analyses); analyseswere also conducted for those cases that completed treatment.

Perhaps due to the low attrition, comparable results were consis-tently found for both sets of analyses; thus, only the intent-to-treatanalyses are reported.

Group Comparability

Analyses revealed no significant pretreatment differences acrossconditions (i.e., ICBT, FCBT, FESA) on key demographic and out-come variables (see Table 1).2 Analyses of demographic and depen-dent variables examined pretreatment differences between treatmentcompleters and noncompleters. The only significant difference be-tween these groups was the number of diagnoses. ANOVA indicatedthat noncompleting children had more diagnoses at pretreatment(M � 4.17, SD � 1.95) than did completers (M � 3.36, SD � 1.63),F(1, 159) � 4.68, p � .05, �2 � .03. ANOVA on CPTR scoresindicated no significant differences among children’s perceptions ofthe therapeutic relationship across conditions.

Child Diagnostic Status

Diagnostic outcomes were analyzed by examining the numberof pretreatment principal diagnoses by condition that were (a) nolonger principal at posttreatment or (b) no longer present at post-treatment (i.e., CSR � 4).3 Using chi-squares, we found that 64%,64%, and 42% of principal diagnoses in ICBT, FCBT, and FESA,respectively, were no longer principal at posttreatment. Furtheranalyses indicated that the differences between the ICBT andFESA, �2(1, N � 129) � 6.08, p � .02, and between FCBT andFESA, �2(1, N � 126) � 5.90, p � .02, were significant. Analysesalso indicated that 57%, 55%, and 37% of pretreatment principaldiagnoses (ICBT, FCBT, FESA, respectively) were no longerpresent at posttreatment. ICBT–FESA differences and FCBT–FESA differences were significant. No significant differences indiagnostic outcomes were found for gender or age (with youthcategorized developmentally as 7–10 years and 11–14 years).

Maintenance analyses included those cases that completed theevaluations. Data interpretations focus on changes from pretreat-ment to follow-up and not the absence of change from posttreat-ment to follow-up (i.e., null hypothesis). To examine for mainte-nance of outcomes, we checked the number of child pretreatmentprincipal disorders that were no longer principal at follow-up.Results indicated that 67%, 64%, and 46% of principal diagnoses

1 The data were analyzed with a random-intercept model of the form:Yij � B0ij � B1time2ij � B2time3ij � B3condition2j � B4condition3j �B5time2.condition2ij � B6time2.condition3ij � B7time3.condition2ij �B5time3.condition3i where time2 and time3 are indicator variables repre-senting time, condition2 and condition3 are indicator variables representingcondition, and the time.condition terms represent interactions. The inter-cept term B0ij is made up of the fixed term, B0, and random variation dueto subjects, 0j, and observations over time, ε0ij, so B0i � B0 � 0j � ε0ij.The subscript j indexes subjects, and i indexes observations within sub-jects. Terms with the subscript ij are at Level 1 of the multilevel model,while those with subscript j are at Level 2 of the model.

2 For 58% and 61% of FCBT and FESA sessions, respectively, bothparents were in attendance; the difference was not significant.

3 Note that for these analyses, the N is larger than the number ofparticipants, given that several children had more than one principaldiagnosis (i.e., some diagnoses had equal CSR ratings and thus wereconsidered “coprincipal”).

287COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH

in ICBT, FCBT, and FESA, respectively, continued to not beprincipal disorders at follow-up. This difference was significant,�2 (2, N � 198) � 6.62, p � .05. Analyses revealed that 61%,58%, and 44% of principal diagnoses in ICBT, FCBT, and FESA,respectively, remained “not present” at follow-up. The differenceacross conditions was not significant. FESA participants whocontinued to meet diagnostic criteria at posttreatment were offeredother services, reducing the number of FESA participants atfollow-up. Follow-up data for all participants include the lastobservation carried forward (see Table 2).

A mixed model was fitted to anxiety diagnosis CSRs at pre,post, and follow-up showing a significant effect for time, F(2,256) � 220.47, p � .00, and a nonsignificant condition effect, F(2,164) � 0.68, p � .51. The Condition � Time interaction wassignificant, F(4, 255) � 2.41, p � .05. Tables 3 and 4 provide theslopes and intercepts for the model and the means for the variable,respectively. FESA children showed significantly less reductionsin CSRs from pre to post compared with ICBT children and FCBTchildren. There were no significant differences between ICBT andFCBT, and no significant differences between pre and follow-up orbetween post and follow-up for any of the three conditions.

Child Self-Reports

Mixed models were fitted to child-reported anxiety (MASC totalscore) and child-reported coping (CQ-C). Both models showed asignificant time effect whereby children reported significant reduc-

tions in anxiety from pre to post, pre to follow-up, and post tofollow-up. The condition effect and the Time � Condition interactionwere not significant, nor were the effects for age and gender.Children reported significant reductions in self-reported anxiety(MASC) from pre to post, t(233) � 6.48, p � .00, from pre tofollow-up, t(247) � 8.09, p � .00, and from post to follow-up,t(246) � 2.69, p � .008. Similarly, children reported significantgains in coping from pre to post, t(233) � 8.43, p � .00, frompre to follow-up, t(259) �10.59, p � .00, and from post tofollow-up, t(260) � 3.41, p � .001. See Tables 3 and 4 for theslopes and intercepts for the model and means for the variable,respectively.

Parent and Teacher Reports on Child

Mixed models fitted to mother-reported CBCL-Internalizing Tscore (CBCL-Int), anxiety symptoms (CBCL-A), and coping(CQ-P) showed a significant time effect with significant improve-ments in symptoms from pre to post, pre to follow-up, and post tofollow-up (see Tables 4 and 5). More specifically, mothers re-ported significant decreases in internalizing symptoms from pre topost, t(232) � 8.01, p � .00, from pre to follow-up, t(243) �11.76, p � .00, and from post to follow-up, t(243) � 5.22, p � .00.Mothers also reported significant reductions in anxiety symptomsfrom pre to post, t(215) � 9.07, p � .00, from pre to follow-up,t(226) � 12.3, p � .00, and from post to follow-up, t(225) � 4.75,p � .00. Similarly, mothers reported a significant change in child

Table 1Demographic and Descriptive Information by Group

Variable

Treatment conditions

Significance test pICBT FCBT FESA

Child age in years (SD) 10.37 (1.88) 10.41(1.73) 10.03 (1.70) F(2, 158) � 0.73 .48Number of children by race

Caucasian 46 45 44 �2(2, N � 159) � 0.55 .76Black, Hispanic, Asian, Other 9 9 6

Number of families by annual householdincome

�2(8, N � 148) � 5.69 .68

$0–$19,999 2 1 2$20,000–$39,999 9 7 3$40,000–$59,999 9 13 10$60,000–$80,000 10 13 15Over $80,000 21 18 15

Number of children by referral source �2(8, N � 143) � 6.42 .60Professional 14 10 14School 8 12 12Friend 4 4 6Advertisement 16 15 7Other 7 8 6

Percentage of children with principaldiagnosis

�2(4, N� 198) � 4.11 .39

GAD 47 65 52SAD 38 25 24SP 45 35 38

Total number of child diagnoses (SD) 3.56 (1.74) 3.66 (1.68) 3.16 (1.67) F(2, 158) � 1.27 .28Number of attritions 5 7 11 �2(2, N � 161) � 3.79 .15Mean scores of children’s perceptions of

the therapeutic relationship (SD) 3.45 (0.77) 3.41 (0.74) 3.20 (0.90) F(2,104) � 0.82 .46

Note. ICBT � individual (child) cognitive–behavioral therapy; FCBT � family cognitive–behavioral therapy; FESA � family-based education/support/attention; GAD � generalized anxiety disorder; SAD � separation anxiety disorder; SP � social phobia.

288 KENDALL ET AL.

coping from pre to post, t(217) � 8.69, p � .00, from pre tofollow-up, t(240) � 11.82, p � .00, and from post to follow-up,t(242) �4.27, p � .00. The condition effect and the Condition �Time interaction were not significant for mother-reported symp-toms, nor were the effects of age and gender.

Mixed models were fitted to father-reported internalizing symp-toms (CBCL-Int), anxiety symptoms (CBCL-A), and coping(CQ-P; see Table 5). Consistent with mother-reported symptoms,all three models produced a time effect (see Table 4) but nosignificant effects for condition and Condition � Time. Therewere no other significant gender or age effects.

Mixed models were fitted to teacher-reported internalizingsymptoms (TRF-Int) and anxiety symptoms (TRF-A; see Table 3).Both models yielded a significant Time � Condition interaction(see Table 4). Analyses from both dependent variables showed thatICBT resulted in greater symptom reduction compared with FCBTbetween pre and post but not between pre and follow-up or postand follow-up. ICBT and FCBT both outperformed FESA whencomparing teacher reported symptoms between pre and follow-up.Also, only FCBT children showed significantly greater gains frompost to follow-up compared with FESA children. There were nosignificant age or gender effects.

More specifically, ICBT children showed a greater reduction inteacher-rated internalizing (TRF-Int) from pre to post compared withFCBT children (see Figure 2). There were no significant differencesin the change of teacher-reported internalizing symptoms (TRF-Int)from pre to post between ICBT and FESA or between FCBT andFESA. FESA children showed less change from pre to follow-up ininternalizing symptoms compared with ICBT children and FCBTchildren. There was no significant difference in the change of inter-nalizing symptoms from pre to follow-up between FCBT and ICBT.Post to follow-up contrasts showed no significant differences in thechange in internalizing symptoms between ICBT and FCBT childrenor between ICBT and FESA children. However, children in the FCBTcondition showed significantly greater improvements from post tofollow-up compared with children in the FESA condition (see Tables3 and 4).

Regarding the time effect for teacher-reported anxiety symp-toms (TRF-A), ICBT children showed a greater reduction inteacher-reported anxiety from pre to post compared with both

FCBT and FESA children (see Figure 2). There was no significantdifference in the change in anxiety symptoms from pre to postbetween FCBT and FESA (see Table 3). Pre to follow-up contrastsrevealed that FESA children showed less change in anxiety symp-toms compared with ICBT children. There was no significantdifference between pre and follow-up between FCBT and ICBT orbetween FCBT and FESA. Post to follow-up contrasts showed nosignificant differences in the change in anxiety symptoms betweenICBT and FCBT or between ICBT and FESA children. FCBTchildren showed significantly greater gains from post to follow-upcompared with FESA children (see Tables 3 and 4).

Normative Comparisons

To assess clinical significance, defined as changes that returnparticipants’ deviant scores to within nondeviant limits, we rannormative comparisons (Kendall et al., 1999) using the CBCL andTRF clinical cutoff (T � 65). As seen in Table 6, there were nosignificant differences in the proportions of children exceeding thenormative limit versus returning to within the normative limit atposttreatment for participants whose mothers reported a pretreat-ment CBCL-Int T � 65 (N � 91). A chi-square analysis of thoseparticipants whose teachers reported a pretreatment TRF-Int T �65 (N � 45) revealed no significant differences among conditions.However, a chi-square analysis of participants whose fathers re-ported a pretreatment CBCL-Int T � 65 (N � 47) revealedsignificant differences among treatment conditions, �2(2, N �47) � 6.94, p � .05. Further analysis revealed that the percentageof FESA participants remaining above the cutoff was significantlyhigher than for either ICBT, �2(1, N � 31) � 5.55, p � .05, orFCBT, �2(1, N � 28) � 5.25, p � .05.

Parental Diagnostic Status

The number of anxiety disorders present at pretreatment butabsent (i.e., CSR � 4) at post were examined for mothers andfathers. Analyses examined the number of diagnoses, not partici-pants, across conditions because inclusion criteria did not specifyspecific disorders for parents and several parents met criteria formore than one anxiety disorder.

Table 2Diagnostic Information at Pre- and Posttreatment and Follow-Up

Measure

Treatment conditions

Significance test

ICBT FCBT FESA

Pre Post Follow-up Pre Post Follow-up Pre Post Follow-up

Percentage of principal diagnoses nolonger principal

64 67 64 64 42 46 �2(2, N� 198) � 7.84*a

�2(2, N � 198) � 6.62* b

Percentage of principal diagnoses nolonger present 57 61 55 58 37 44 �2 (2, N� 198) � 6.03*a

Estimated marginal means for totalCSR (SD)

14.05(0.93)

6.89(0.93)

5.05(1.06)

15.46(0.92)

7.68(0.92)

5.78(1.07)

12.10(0.98)

8.10(0.98)

4.88(1.39)

Time � Condition:F(4, 255) � 2.41*

Note. ICBT � individual cognitive–behavioral therapy; FCBT � family cognitive–behavioral therapy; FESA � family-based education/support/attention; Pre � pretreatment; Post � posttreatment; Follow � 1-year follow-up; CSR � clinician severity rating.a Significant differences at posttreatment.* p � .05.

289COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH

Mothers’ Anxiety Disorder

Mothers (N � 161) participated (55, 56, and 50 in ICBT, FBCT,and FESA, respectively) in the study. Sixty-one mothers (37.9 %)had at least one anxiety disorder, and collectively they werediagnosed with a total of 85 anxiety disorders (37 in ICBT, 24 inFCBT, and 24 in FESA). The number of mothers having at leastone anxiety disorder was 25 in ICBT, 21 in FBCT, and 15 inFESA. Of the pretreatment maternal anxiety disorders, 43.2%(16/37) were absent (i.e., CSR � 4) at post in ICBT, 45.8% (11/24)in FCBT, and 20.8% (5/24) in FESA. Chi-square analyses foundno significant differences among the conditions. Eight new mater-nal anxiety disorders were evident at posttreatment (2, 4, and 2 inICBT, FCBT, and FESA, respectively).

In an examination of maternal anxiety disorders present at post-treatment, 28.6% (4/14, with 9 missing at follow-up) of these wereabsent at follow-up in ICBT, 33.3% (2/6, with 11 missing at follow-up) in FCBT, and 62.5% (5/8, with 13 missing at follow-up) in FESA.

Chi-square analyses determined no significant differences. One newmaternal anxiety disorder was seen at follow-up.

These results suggest that the three treatment conditions hadsome, but minimal, impact on maternal anxiety status, with 62% ofmaternal anxiety disorders still present at post and 61% at follow-up. The three treatments were equivalent in their impact.

Fathers’ Anxiety Disorders

Of 129 fathers (44, 41, and 44 in ICBT, FCBT, and FESA,respectively), 24 (18.6%) had at least one anxiety disorder, andtogether they were diagnosed with 34 anxiety disorders (8 in ICBT,12 in FCBT, and 14 in FESA). In an examination of fathers’ anxietydisorders at pretreatment, 66.7% (4/6, with 2 missing at post) of thesewere absent at post in ICBT, 27.3% (3/11, with 1 missing at post) inFCBT, and 36.4% (4/11, with 3 missing at post) in FESA. Three newpaternal anxiety disorders were evident at post (0, 1, and 2 in ICBT,FCBT, and FESA, respectively). Chi-square analyses could not be

Table 3Effects of ICBT, FCBT, and FESA for Clinical-Severity, Child-Report, and Teacher-Report Measures (for Pre to Post, Pre to Follow-Up, and Post to Follow-Up)

Variable

CSR MASC-child CQ-C TRF-Int TRF-A

B (SE) d B (SE) d B (SE) d B (SE) d B (SE) d

Intercept 1Intercept: FESA at

pre 12.10 (0.98)*** 47.32 (2.89)*** 4.11 (0.20)*** 59.60 (1.60)*** 8.59 (0.97)***

FESA-ICBT at pre 1.96 (1.35) 2.99 (4.0) 0.46 (0.27)† 4.95 (2.21)* 1.28 (1.36)FESA-FCBT at pre 3.36 (1.34)* 0.46 (3.98) 0.21 (0.27) 0.49 (2.20) 0.87 (1.32)

Pre- to posttreatmentslope

Control slope:FESA 4.00 (0.95)*** 0.58 7.41 (2.82)** 0.36 0.60 (0.24)* 0.44 1.78 (1.57) 0.16 1.16 (0.93) 0.18

FESA vs. ICBT 3.16 (1.31)* 0.46 3.83 (3.89) 0.19 0.69 (0.33)* 0.51 3.84 (2.23)† 0.35 2.55 (1.30)* 0.40FESA vs. FCBT 3.79 (1.31)** 0.55 4.10 (3.88) 0.20 0.75 (0.32)* 0.55 1.54 (2.24) 0.14 2.23 (1.35) 0.35

Pre to follow-up slopeControl slope:

FESA 7.22 (1.37)*** 1.05 15.81 (4.04)*** 0.77 1.63 (0.33)*** 1.12 2.35 (2.48) 0.21 0.46 (1.48) 0.07FESA vs. ICBT 1.79 (1.72) 0.26 0.96 (5.03) 0.05 0.10 (0.41) 0.07 8.04 (3.23)* 0.72 4.79 (1.89)* 0.75FESA vs. FCBT 2.46 (1.73) 0.36 0.43 (5.13) 0.02 0.02 (0.41) 0.02 6.41 (3.13)* 0.58 3.04 (1.83)† 0.48

[Pre to posttreatmentslope]

ICBT vs. FCBT 0.62 (1.28) 0.09 0.27 (3.78) 0.01 0.06 (0.31) 0.04 5.38 (2.25)* 0.49 4.78 (1.33)*** 0.75[Pre to follow-up

slope]ICBT vs. FCBT 0.68 (1.47) 0.10 1.39 (4.34) 0.07 0.09 (0.35) 0.07 1.63 (2.81) 0.15 1.74 (1.60) 0.27

[Post to follow-upslope]

Control slope:FESA 3.22 (1.37)* 0.47 8.40 (4.12)* 0.41 1.03 (0.34)** 0.76 4.13 (2.52) 0.37 1.62 (1.49) 0.26

FESA vs. ICBT 1.38 (1.72) 0.20 4.79 (5.11) 0.23 0.59 (0.42) 0.43 4.20 (3.29) 0.38 2.23 (1.89) 0.35FESA vs. FCBT 1.32 (1.73) 0.19 3.67 (5.22) 0.18 0.74 (0.42)† 0.54 7.96 (3.23)* 0.72 5.27 (1.93)** 0.83ICBT vs. FCBT 0.05 (1.47) 0.01 1.12 (4.43) 0.05 0.15 (0.36) 0.11 3.76 (2.93) 0.34 3.04 (1.69)† 0.48

Level 1: Residualvariance 22.53*** 183.42*** 1.26*** 51.50*** 14.95***

Level 2: Interceptvariance 25.06*** 234.92*** 0.60*** 71.54*** 25.45***

Note. Analyses reported within brackets indicate additional mixed models conducted to enable all comparisons to be reported. These analyses resultedin different intercepts. CSR � clinician severity rating; ICBT � individual cognitive–behavioral therapy; FCBT � family cognitive–behavioral therapy;FESA � family-based education/support/attention; Pre � pretreatment; Post � posttreatment; MASC � Multidimensional Anxiety Scale for Children;CQ-C � Coping Questionnaire-Child; TRF-Int � Teacher Report Form-Internalizing; TRF-A � Teacher Report Form-Anxiety.† p � .10. * p � .05. ** p � .01. *** p � .001.

290 KENDALL ET AL.

conducted due to sample size limitations. Missing data on fathers atfollow-up precluded testing paternal anxiety disorders at the follow-up. Similar to maternal anxiety disorders, the three treatments hadminimal impact on paternal anxiety disorders, with 61% of paternalanxiety disorders still present at post.

Influence of Parents’ Diagnostic Status on ChildOutcomes

Do parental anxiety disorders moderate child treatment outcomes?Analyses were conducted separately comparing mothers with andwithout anxiety disorders, fathers with and without anxiety disorders,and both parents with and without anxiety disorders.4

Child Diagnostic Status

Chi-square analyses revealed no significant differences be-tween the proportion of children retaining their principal dis-order at posttreatment in the following comparisons: anxietydisordered (AD) mothers versus anxiety-free mothers; AD fa-thers versus anxiety-free fathers; or AD fathers and mothers

4 Analyses examined the influence of parent psychopathology on childoutcomes for each of the treatment conditions. The results are consistentwith those reported herein, but the specifics of these analyses are notreported here due to the small cell sizes.

Table 4Means and Standard Deviations for Child, Parent, and Teacher Reports

Measure

Treatment conditions

F

ICBT FCBT FESA

Pre Post Follow-up Pre Post Follow-up Pre Post Follow-up

Child reportMASC Time: F(2, 238) � 38.1

M 48.46 36.65 32.23 48.77 36.93 35.13 45.64 39.13 30.25SD 21.17 19.20 18.39 20.13 22.04 21.61 20.27 19.37 12.00

CQ-C Time: F(2, 249) � 64.5**

M 3.65 4.97 5.53 3.92 5.25 5.54 4.03 4.67 5.69SD 1.29 1.44 1.31 1.44 1.63 1.24 1.10 1.30 1.07

Mother reportCBLC-Int Time: F(2, 235) � 74.5**

M 67.92 62.17 57.19 68.10 60.06 56.14 65.06 61.17 55.05SD 8.25 8.30 11.55 9.03 9.51 10.04 9.74 9.68 11.42

CBCL-A Time: F(2, 216) � 84.59**

M 15.35 11.35 8.35 14.40 9.23 7.48 12.68 10.11 7.39SD 5.86 5.96 6.01 5.35 5.25 4.79 5.93 5.18 5.47

CQ-P Time: F(2, 227) � 76.36**

M 3.47 4.79 5.32 3.57 4.64 5.23 3.66 4.25 4.90SD 1.00 1.15 0.94 1.07 1.23 1.15 1.56 1.02 1.14

Father reportCBCL-Int Time: F(2, 182) � 34.67**

M 63.34 58.37 54.92 63.54 56.57 52.50 61.87 59.32 49.79SD 8.54 10.48 10.97 8.11 10.63 9.37 8.84 9.63 9.05

CBCL-A Time: F(2, 167) � 36.8**

M 12.34 9.14 6.10 11.52 8.10 6.05 10.75 9.08 4.08SD 4.93 4.85 4.03 4.90 5.37 4.61 4.75 5.27 2.78

CQ-P Time: F(2, 174) � 49.99**

M 3.61 4.60 5.30 3.41 4.39 5.15 3.57 4.35 4.62SD 1.14 1.13 1.02 1.01 1.21 0.91 1.39 1.32 0.99

Teacher reportTRF-Int Time � Condition:F(4, 187) � 3.04*

M 65.11 58.65 57.20 61.51 60.97 56.67 58.70 57.08 57.75SD 11.76 9.91 6.60 11.61 10.75 11.17 12.57 10.25 7.86

TRF-A Time � Condition:F(4, 162) � 4.51*

M 10.27 6.55 5.07 8.11 9.11 4.73 7.75 6.56 7.22SD 7.33 5.80 3.54 7.67 6.81 5.31 7.22 5.58 4.92

Note. CBCL-Int and TRF-Int data are reported in T scores. ICBT � individual cognitive–behavioral therapy; FCBT � family cognitive–behavioraltherapy; FESA � family-based education/support/attention; Pre � pretreatment; Post � posttreatment; Follow � 1-year follow-up. MASC � Multidi-mensional Anxiety Scale for Children; CQ-C � Coping Questionnaire-Child; CBCL-Int � Child Behavior Checklist-Internalizing; CBCL-A � ChildBehavior Checklist-Anxiety; CQ-P � Coping Questionnaire-Parent; TRF-Int � Teacher Report Form-Internalizing; TRF-A � Teacher Report Form-Anxiety.* p � .05. ** p � .01.

291COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH

Tab

le5

Eff

ects

ofIC

BT

,F

CB

T,

and

FE

SAfo

rM

othe

r-an

dF

athe

r-R

epor

tM

easu

res

Acr

oss

Tim

e

Var

iabl

e

Mot

her

repo

rts

Fath

erre

port

s

CB

CL

-Int

CB

CL

-AC

Q-P

CB

CL

-Int

CB

CL

-AC

Q-P

B(S

E)

dB

(SE

)d

B(S

E)

dB

(SE

)d

B(S

E)

dB

(SE

)d

Fixe

def

fect

s

Inte

rcep

t1

Inte

rcep

t:FE

SAat

pre

65.0

6(1

.33)

***

13.1

0(0

.80)

***

3.71

(0.1

6)***

61.4

0(1

.49)

***

10.4

0(0

.78)

***

3.56

(0.1

9)***

FESA

-IC

BT

atpr

e2.

40(1

.86)

1.62

(1.1

3)

0.21

(.23

)1.

60(2

.09)

1.02

(1.1

0)0.

16(0

.26)

FESA

-FC

BT

atpr

e3.

28(1

.87)

†1.

96(1

.13)

†

0.17

(0.2

2)2.

63(2

.11)

1.60

(1.1

3)

0.10

(0.2

6)Pr

eto

post

slop

eC

ontr

olsl

ope:

FESA

3.

89(1

.29)

**

0.41

2.

74(0

.75)

***

0.49

0.57

(0.2

0)**

0.51

2.

06(1

.54)

0.21

1.

40(0

.79)

†0.

280.

75(0

.21)

***

0.65

FESA

vs.

ICB

T

1.59

(1.8

1)0.

17

0.94

(1.0

6)0.

170.

70(0

.28)

*0.

64

2.66

(2.2

1)0.

27

1.52

(1.1

6)0.

300.

22(0

.30)

0.19

FESA

vs.

FCB

T

4.4

(1.8

1)*

0.47

2.

85(1

.07)

**

0.51

0.57

(0.2

7)*

0.51

5.

14(2

.22)

*0.

52

2.14

(1.1

8)†

0.42

0.20

(0.2

9)0.

17Pr

eto

follo

w-u

psl

ope

Con

trol

slop

e:FE

SA

9.55

(1.7

9)***

1.01

5.

01(1

.04)

***

0.90

1.26

(0.2

7)***

1.14

8.

99(2

.16)

***

0.92

4.

59(1

.12)

***

0.91

0.89

(0.2

8)**

0.77

FESA

vs.

ICB

T

0.86

(2.3

1)0.

09

1.50

(1.3

5)0.

270.

45(0

.34)

0.41

1.26

(2.7

6)0.

130.

10(1

.43)

0.02

0.56

(0.3

6)0.

48FE

SAvs

.FC

BT

2.

65(2

.36)

0.28

2.

82(1

.36)

*0.

500.

42(0

.34)

0.38

0.

83(2

.83)

0.08

0.

55(1

.47)

0.11

0.68

(0.3

6)†

0.59

[Pre

topo

stsl

ope]

ICB

Tvs

.FC

BT

2.

82(1

.80)

0.30

1.

90(1

.07)

†0.

34

0.14

(0.2

8)0.

13

2.49

(2.2

5)0.

25

0.62

(1.2

2)0.

12

0.02

(0.3

0)0.

02[P

reto

follo

w-u

psl

ope]

ICB

Tvs

.FC

BT

1.

79(2

.12)

0.19

1.

31(1

.22)

0.23

0.

04(0

.31)

0.04

2.

09(2

.51)

0.21

0.

65(1

.31)

0.13

0.12

(0.3

3)0.

10[P

ost

tofo

llow

-up

slop

e]C

ontr

olsl

ope:

FESA

5.

66(1

.80)

**

0.60

2.

27(1

.05)

*0.

410.

69(0

.27)

*0.

62

6.93

(2.2

0)**

0.71

3.

19(1

.12)

**

0.63

0.13

(0.2

8)0.

11FE

SAvs

.IC

BT

0.73

(2.3

3)0.

08

0.56

(1.3

6)0.

10

0.25

(0.3

5)0.

233.

92(2

.84)

0.40

1.62

(1.4

5)0.

320.

34(0

.37)

0.29

FESA

vs.

FCB

T1.

76(2

.37)

0.19

0.03

(1.3

7)0.

02

0.15

(0.3

5)0.

144.

32(2

.89)

0.44

1.59

(1.4

9)0.

310.

48(0

.37)

0.41

ICB

Tvs

.FC

BT

1.03

(2.1

4)0.

110.

59(1

.24)

0.11

0.10

(0.3

2)0.

090.

40(2

.59)

0.04

0.

03(1

.35)

0.01

0.13

(0.3

5)0.

11

Ran

dom

effe

cts

Lev

el1:

Res

idua

lva

rian

ce39

.65*

**

12.5

6***

0.86

***

46.6

7***

11.9

7***

0.76

***

Lev

el2:

Inte

rcep

tva

rian

ce49

.98*

**

18.7

1***

0.38

***

49.6

2***

13.7

5***

0.58

***

Not

e.A

naly

ses

repo

rted

with

inbr

acke

tsin

dica

tead

ditio

nal

mix

edm

odel

sco

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292 KENDALL ET AL.

versus anxiety-free fathers and mothers. At follow-up, a signif-icantly higher percentage of children with AD mothers (43.2%)versus children with anxiety-free mothers (20.8%) retainedtheir principal diagnosis, �2(1, N � 116) � 6.58, p � .01.Analyses of (a) children with AD fathers versus anxiety-freefathers and (b) anxiety disorders in both parents versus neitherparent revealed no significant differences.

Child, Parent, and Teacher Reports

When maternal anxiety status was fitted to mixed models for theMASC, there was a nonsignificant main effect and no significanttwo- or three-way interactions between maternal anxiety status andtime and condition. When paternal anxiety status was fitted to theMASC, there was a significant three-way interaction, F(6, 190) �2.88, p � .01. For children with a nonanxious father, there were nosignificant differences between any of the three conditions acrosstime: test of overall interaction contrasts, F(4, 161) � 0.57, p �.68. However, ICBT children with an anxious father showedsignificantly less change from pre to follow-up than did children inthe FCBT condition, t(25) � 5.4, p � .000, and the FESAcondition, t(25) � 3.65, p � .001 (change: ICBT: M � –9.47,

SE � 4.94; FCBT: M � 34.75, SE � 6.53; FESA: M � 20.06,SE � 6.4). Similarly, children with an anxious father who receivedICBT showed significantly less change from post to follow-upcompared with FCBT children, t(25) � 4.36, p � .00, and FESAchildren, t(24) � 2.79, p � .01 (change: ICBT: M � –9.0, SE �4.98; FCBT: M � 28.33, SE � 6.96; FESA: M � 13.75, SE �6.46). There were no significant differences between the threeconditions between pre and post, and no significant differencesbetween FCBT and FESA between pre and follow-up and post andfollow-up ( ps � .14).

Does having two anxious parents impact the child’s treatment?When both parents’ anxiety status was included in the model forchild-reported anxiety (i.e., MASC) the result approached signif-icance: interaction of Parental Anxiety � Time � Condition, F(6,226) � 2.02, p � .06.

There was a significant interaction of Time � Maternal Anxiety,F(2, 232) � 3.17, p � .05, when a mixed model was fitted toCBCL-Int. Follow-up interaction contrasts indicated that childrenwith an anxious mother showed less CBCL-Int improvement frompre to follow-up compared with children with nonanxious mothers,t(239) � 2.46, p � .015. There was no significant difference in

Figure 2. Teacher report (TRF) of children’s internalizing (TRF-Int) and anxious (TRF-A) symptomatology atpretreatment, posttreatment, and follow-up for the treatment conditions. ICBT � individual (child) cognitive–behavioral therapy; FCBT � family cognitive–behavioral therapy; FESA � family-based education/support/attention; Pre � pretreatment; Post � posttreatment.

293COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH

improvement between children with and without anxious mothersbetween pre and post or between post and follow-up ( p � .14).The interaction of Condition � Time � Maternal Anxiety was notsignificant.

There were nonsignificant effects for maternal anxiety onfather-reported CBCL-Int and for paternal anxiety on the CBCL-Int (mother or father report). When both parents’ anxiety statuswas examined, there was a nonsignificant interaction of Time �Condition � Parent Anxiety Status for mother-reported CBCL-Int.There were nonsignificant effects for maternal and paternal anxi-ety status on the TRF-Int.

FESA Integrity Check

Two independent procedures examined the degree to which theFESA condition consisted of CBT. In the first, two externalexperts independently rated, on a 5-point scale (1 � no CBT at all,5 � a lot of CBT), that the FESA treatment manual contained“some” CBT content (M � 3.5) and procedures (M � 3.0). Theseraters further indicated that 65% of the FESA program includedCBT content and procedures.

In the second check, three experienced CBT therapists viewedone of three randomly selected videotaped sessions for each 16-session FESA case and rated how much CBT bleeding (presenceof CBT seen in the FESA session but not in the FESA therapistmanual) occurred on a 5-point scale (1 � none, 5 � a lot). Next,raters indicated how much CBT (total) was included in the FESAsession considering (a) content in the therapist manual and (b)CBT bleeding.5 ANOVA revealed no significant differences inCBT bleeding across the 16 sessions. However, an ANOVA indi-cated a significant difference in CBT total by FESA session, F(15,

106) � 3.96, p � .000, �2 � .30; Tukey’s HSD tests indicated thatSession 7 was rated significantly higher in CBT total than wereSessions 3 and 4.

To examine whether diagnostic outcomes differed as a functionof CBT bleeding or CBT total, we dichotomized these variablesinto two groups: low (ratings of 0 or 1) and high (ratings of 3, 4,or 5) and conducted chi-square analyses. We found no significantdifferences between the groups on the number of pretreatmentprincipal diagnoses that were either (a) no longer principal atposttreatment or (b) no longer present at posttreatment (i.e.,CSR � 4). In separate univariate ANOVAs between groups onoutcome measures, only one significant difference was found:Mothers in the high CBT total group rated their children assignificantly less anxious at posttreatment than did mothers in thelow CBT total group, F(1, 37) � 4.04, p � .05, �2 � .10.

Discussion

Research reviews and practitioner discussions have consideredthe merits of including parents in treatment for anxiety disorders inyouth. In general, ICBT and FCBT resulted in posttreatmentoutcomes that were superior to those for FESA, indicating that the

5 ANOVAs indicated a significant difference between raters for CBTbleeding, F(2, 119) � 5.70, p � .01, �2 � .09, and CBT total, F(2, 119) �3.20, p � .05, �2 � .05. Tukey’s HSD tests indicated that for CBTbleeding, one rater gave higher scores than did the other two raters. ForCBT total, the same rater gave higher CBT total scores than did one of theother therapists. The other two raters did not differ significantly from oneanother.

Table 6Percentages of Participants Exceeding Normative Limits (T � 65) at Pretreatment and Exceeding (T � 65) or Returning to WithinNormative Limits (T � 65) at Posttreatment With Chi-Square Value and N of Normative Comparison Analyses

Measure

Treatment conditions

�2 Total N

ICBT FCBT FESA

Exceeds limitat post

Within limitat post

Exceeds limitat post

Within limitat post

Exceeds limitat post

Within limitat post

Mother report

CBCL-Int% 18.68 15.39 17.58 21.98 13.19 13.19 0.72 91N 17 14 16 20 12 12

Father reportCBCL-Int

% 12.77 27.66 10.64 23.40 19.15 6.38 6.94* 47N 6 13 5 11 9 3

Teacher reportTRF-Int

% 22.20 15.56 20.00 1.11 15.56 15.56 0.60 45N 10 7 9 5 7 7

Note. Total N refers to the number of participants greater than or equal to a standardized T score of 65 at pretreatment. ICBT � individualcognitive–behavioral therapy; FCBT � family cognitive–behavioral therapy; FESA � family-based education/support/attention. CBCL-Int � ChildBehavior Checklist–Internalizing; TRF-Int � Teacher Report Form–Internalizing.* p � .05.

294 KENDALL ET AL.

two versions of CBT were comparable. These findings suggest thatFCBT is not superior to ICBT and that including parents in thechild’s treatment sessions is not essential to positive gains. Note,however, that parents are involved, albeit to a lesser degree and ina different way, in ICBT (as collaborators, not as co-clients), sothat it would be incorrect to conclude that parents need not beinvolved with their child’s treatment (see also Barmish & Kendall,2005; Nauta et al., 2003).

We examined treatment gains using the diagnostic data in twoways: (1) the child’s principal anxiety disorder was no longerpresent after treatment and (2) the child’s principal anxiety disor-der was no longer the principal diagnosis after treatment. Usingboth approaches to define responder status, we found that ICBTand FCBT outperformed FESA.

Children, as reporters of their own symptomatology, did notdifferentiate the treatment conditions. That is, although indepen-dent diagnostic evaluations evidenced differential improvements,child self-reports indicated that all participants improved. Perhapsthe social desirability frequently observed in anxious youthprompted them to report fewer symptoms. It is also possible thatall treatments were successful in reducing self-reported anxiety.Finally, it could be that all children improved in self-reportedsymptoms, but the magnitude of gains were not as great as thosefound based on diagnostics.

Regardless of treatment condition, separate mother and fatherCBCL reports evidenced general improvements, and the CQ-Pevidenced gains in particular situations that are difficult for eachchild—but parents knew about the treatment conditions. Teachersknew little about the treatments and nothing about the condition towhich the child was randomized. Thus, teacher reports providevaluable evaluative information that is less likely to be biased. Onthe basis of teacher reports, ICBT was associated with posttreat-ment improvements significantly greater than those for FCBT andFESA. This relative differential outcome may be a reflection of thenature of treatment-produced change. That is, ICBT-producedchanges may be those visible in the school/peer environment.

Many dependent measures evidenced time effects but no signif-icant interactions. Previous studies using wait-lists report remis-sion rates of 6%–8% (e.g., Flannery-Schroeder & Kendall, 2000;Kendall et al., 1997). Diagnostic changes evident herein (i.e.,FESA 37%) are of a magnitude suggesting that changes were notdue to spontaneous remission. The limited differential effects ofconditions merit consideration within the context of FESA integ-rity. Experts rated the FESA manual as having two thirds CBTcontent, and observations of FESA tapes identified CBT bleeding.Apparently, despite efforts to have distinct conditions, there wasoverlap. To control for therapist characteristics, each therapisttreated cases in all conditions. Thus, the FESA condition wasadministered by therapists trained in CBT. Perhaps future studiesshould employ others (therapists not trained in CBT) to providenon-CBT treatment? The absence of differences across conditionsmay be linked to the bleeding of the CBT content into the FESAcondition. However, it also remains a possibility that the FESAcondition (and “common factors”), though less on some measures,produced desirable gains.

The present findings are not likely explained by preexistingclient factors. No age or gender differences were found acrossconditions. Also, although not a moderator of treatment response,participants who were assigned more diagnoses at pretreatment

were less likely to complete treatment (greater attrition; Kendall &Sugarman, 1997).

How did the treated youth fare in terms of returning to withinthe normal range (clinical significance via normative comparisons;Kendall et al., 1999)? Participants showed improvement, withmany who were in the CBCL clinical range at pretreatment im-proving to within the normal range (no longer above the clinicalcutoff) following treatment. Some differential treatment responsewas identified: For father-reported CBCL data, those children inthe ICBT and FCBT conditions were more likely than those inFESA to return to within the normative range on the CBCL.

Not all the treated youth showed meaningful benefits, andhaving parents as co-clients did not account for differential out-comes. Investigations are needed to understand the limited gainsseen in some participants and to better determine the optimalinvolvement for parents (e.g., consultants, collaborators, co-clients). Indeed, not all “family” CBT is alike (Barmish & Kendall,2005; Wood et al., 2006). Future research would benefit fromexamination of variables associated with in-session processes re-lated to parenting. For example, in one set of analyses (Khanna &Kendall, 2007), coded instances of transfer of control (Ginsburg,Silverman, & Kurtines, 1995) and contingency management weresignificantly linked to child improvement.

What role did parental anxiety play? We addressed two ques-tions: (1) Did treatment for child anxiety impact parental anxiety(spillover)? and (2) Did parental anxiety moderate child outcomes(e.g., Cobham et al., 1998)? Although the present data suggest thatsome parental anxiety improved (e.g., 40% of mother diagnoseswere not present at posttreatment), there were no significant dif-ferences across conditions. In the present study, mothers’ anxietydisorder moderated some child outcomes (cf. Cobham et al.,1998): Children with nonanxious mothers were significantly morelikely to be free of their principal anxiety diagnosis at follow-upcompared with children with anxious mothers. The presence orpersistence of a parental anxiety disorder seems to detract fromtreatment of a youth anxiety disorder.

At 1-year follow-up, some gains showed further improvementfrom posttreatment (e.g., child self-reports; mother CQ-P; fatherCBCL). Some parent self-reports reflected improvement over thefollow-up period. Indeed, the present results are consistent withother findings that anxiety disorders in youth can be treated suc-cessfully with maintenance into a follow-up period (e.g., Barrett etal., 2001; Kendall, Safford, Flannery-Schroeder, & Webb, 2004).However, not all participants showed the same degree of mean-ingful change, indicating that research now needs to evaluateinterventions for those who are nonresponders. Similarly, researchis needed to examine the relative merits of psychopharmacologictreatment and psychological treatment for anxiety disorders inyouth. Because the present study (as with several before it) in-cluded real clinical cases, one can be relatively confident in thegeneralizability of the findings to other clinic settings. However,generalizability is limited due to the relatively homogenous samplethat was studied. The present findings are based on complex andcomorbid cases. Future research will need to examine the potentialrole of complexities of comorbidities in the treatment-producedgains.

Potential limitations merit consideration. For example, FCBT,as operationalized in this study, is but one format for additionalparental involvement. Relatedly, the individual skills taught in

295COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH

ICBT may not have received optimal focus for a child whenpresented in FCBT. Other evaluations of treatments with varyingformats for parental inclusion are needed. Also, evaluations ofoutcomes need to expand beyond symptom reduction and includeassessments of the quality of life that follows intervention (e.g.,Does treatment result in gains in social activities or in schoolperformance?). Therapists were not blind to the comparison treat-ments, and future work should evaluate outcomes when therapistsare unaware of the alternate treatment conditions. Research needsto consider these issues as well as to address the optimal methodsfor dissemination.

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Received March 8, 2007Revision received December 13, 2007

Accepted December 21, 2007 �

297COGNITIVE–BEHAVIORAL THERAPY FOR ANXIETY IN YOUTH