Therapeutic Alliance, Attendance, and Outcomes in Youths Receiving CBT or Client-Centered Therapy for Anxiety

OBJECTIVE

Positive associations between therapeutic alliance and outcome (e.g. youth symptom severity) have been documented in the youth anxiety literature; however, little is known about the conditions under which early alliance contributes to positive outcomes in youth. The present study examined the relations between therapeutic alliance, session attendance, and outcomes in youths (N = 135; 55.6% female) who participated in a randomized clinical trial testing the efficacy of cognitive-behavioral therapy or client-centered therapy for anxiety.

METHOD

We evaluated a conceptual model wherein: (1) early alliance indirectly contributes to positive outcomes by improving session attendance; (2) alliance-outcome associations differ by intervention type, with stronger associations in cognitive-behavioral therapy compared to client-centered therapy; and (3) alliance-outcome associations vary across outcome measurement timepoints, with the effect of early alliance on outcomes decaying over time.

RESULTS

Contrary to hypotheses, provider ratings of early alliance predicted greater youth-rated anxiety symptom severity post-treatment (i.e. worse treatment outcomes). Session attendance predicted positive youth-rated outcomes, though there was no indirect effect of early alliance on outcomes through session attendance.

CONCLUSIONS

Results show that increasing session attendance is important for enhancing outcomes and do not support early alliance as a predictor of outcomes.

Error-related brain activity in pediatric anxiety disorders remains elevated following individual therapy: a randomized clinical trial

BACKGROUND

Anxiety disorders are associated with an overactive action monitoring system as indexed by a larger error-related negativity (ERN). This study tests whether ERN magnitude changes following treatment, predicts response to treatment, and varies by treatment type.

METHODS

The sample included 130 youth (9-14 years): youth with an anxiety disorder (ANX; n = 100) and healthy control (HC; n = 30) youth with no lifetime DSM-IV disorders. ANX youth were randomized to either a manualized cognitive-behavior therapy (CBT) or a comparison child-centered therapy (CCT). The ERN was assessed before and after 16 sessions of treatment and within a comparable interval for HC. Subjective ratings about making errors on the task were obtained following each testing session. The ClinicalTrials.gov identifier is NCT00774150.

RESULTS

The ERN was larger in ANX than HC youth but ERN magnitude did not significantly change following treatment in the ANX youth, regardless of treatment type, and baseline ERN did not predict treatment response. Post-task ratings revealed that ANX youth worried more about task performance feedback than HC. Like the ERN, mean ratings did not significantly change following treatment. However, these ratings were not correlated with ERN amplitude.

CONCLUSIONS

Findings of greater ERN in pediatric anxiety disorders are replicated in a larger sample. More importantly, findings from this randomized control trial show that a larger ERN and feeling worried about performance feedback remain unchanged following treatment and are unrelated to treatment response. Such findings suggest that action monitoring systems remain overactive in anxious youth treated with psychotherapy, suggesting the need for future investigation of whether novel complimentary cognitive and emotional training programs can modify these systems would be warranted.

Placebo Response in Pediatric Anxiety Disorders: Results from the Child/Adolescent Anxiety Multimodal Study

OBJECTIVES

The aim of this study is to identify predictors of pill placebo response and to characterize the temporal course of pill placebo response in anxious youth.

METHODS

Data from placebo-treated patients (N = 76) in the Child/Adolescent Anxiety Multimodal Study (CAMS), a multisite, randomized controlled trial that examined the efficacy of cognitive-behavioral therapy, sertraline, their combination, and placebo for the treatment of separation, generalized, and social anxiety disorders, were evaluated. Multiple linear regression models identified features associated with placebo response and models were confirmed with leave-one-out cross-validation. The likelihood of improvement in patients receiving pill placebo-over time-relative to improvement associated with active treatment was determined using probabilistic Bayesian analyses.

RESULTS

Based on a categorical definition of response (Clinical Global Impressions-Improvement Scale score ≤2), nonresponders (n = 48), and pill placebo responders (n = 18) did not differ in age (p = 0.217), sex (p = 0.980), race (p = 0.743), or primary diagnosis (all ps > 0.659). In terms of change in anxiety symptoms, separation anxiety disorder and treatment expectation were associated with the degree of pill placebo response. Greater probability of placebo-related anxiety symptom improvement was observed early in the course of treatment (baseline to week 4, p < 0.0001). No significant change in the probability of placebo-related improvement was observed after week 4 (weeks 4-8, p = 0.07; weeks 8-12, p = 0.85), whereas the probability of improvement, in general, significantly increased week over week with active treatment.

CONCLUSIONS

Pill placebo-related improvement occurs early in the course of treatment and both clinical factors and expectation predict this improvement. Additionally, probabilistic approaches may refine our understanding and prediction of pill placebo response.

Parental psychopathology and treatment outcome for anxious youth: roles of family functioning and caregiver strain

OBJECTIVE

Research has examined the effects of parental psychopathology, family functioning, and caregiver strain on treatment response in anxious youths. Although these variables have shown individual links to youth treatment response, theoretical models for their combined effects remain unexplored. This study tested the hypothesis that improvements in family functioning and reductions in caregiver strain explained the effects of parental psychopathology on youth treatment outcome in an anxiety treatment trial.

METHOD

A multiple mediation technique was used to test the proposed model across independent evaluator (IE), parent, and youth informants in 488 youths, aged 7-17 years (50% female; mean age = 10.7) meeting Diagnostic and Statistical Manual of Mental Disorders criteria for social phobia, separation anxiety, and/or generalized anxiety disorder. Youths were randomized to receive 12 weeks of cognitive-behavioral treatment (Coping Cat), medication (sertraline), their combination, or a pill placebo. At pre- and posttreatment, parents completed self-report measures of global psychopathology symptoms, family functioning, and caregiver strain; parents, youths, and IEs rated youths' anxiety symptom severity.

RESULTS

Changes in family functioning and caregiver strain jointly explained relations between parental psychopathology and reductions in youth anxiety. Specifically, across IE and parent informants, families with higher pretreatment parental psychopathology showed more improvement in family functioning and caregiver strain, which in turn predicted greater youth anxiety reductions. Further, higher pretreatment parental psychopathology predicted greater caregiver strain reductions and, in turn, greater youth anxiety reductions, based on youths' reports of their own anxiety.

CONCLUSIONS

Findings suggest that improvements in family functioning and reductions in caregiver strain can influence treatment outcomes for anxious youths, especially among youths with more distressed parents.

Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial

OBJECTIVE

We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS).

METHOD

Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures.

RESULTS

Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I).

DISCUSSION

Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.

The Predictive Efficacy of Three MMPI Short Forms

In order to investigate the predictive efficacy of three MMPI short forms, the standard form answer sheets of 50 inmate volunteers and 44 clinic outpatients were scored separately for Faschingbauer's, Hugo's and Mini-Mult scales. T-score correlations and t tests between the standard form and each short form, as well as comparisons using Lacks' criteria were reported. Results indicated that the Faschingbauer form was superior to the other two forms. Results were discussed in terms of the populations tested and in reference to the different methodologies used in developing each of the short forms.

Multidimensionality of the Nowicki-Strickland Locus of Control Scale for Adults

In order to investigate the dimensionality of the Adult Nowicki-Strickland Locus of Control Scale (ANS-IE), the responses of 120 undergraduate psychology majors were subjected to one principal components factor analysis using Kaiser's varimax criterion, Five meaningful factors emerged which accounted or 80.6% of the total variance. Results were discussed in terms of their similarity to other factor analyses using the children's version of this scale and to a factor analysis of the ANS-IE (chandler & Dugovics, 1977) which used a modified response format.

Quantitative Difference in the Experience of State-Trait Anxiety in Emotionally Disturbed and Normal Children

In order to investigate the state-trait anxiety distinction in emotionally disturbed and normal children, the responses of 120 emotionally disturbed children and 126 normal children to the State-Trait Anxiety Inventory for Children (Spielberger, 1973) were factor analyzed separately. For the emotionally disturbed group two A-State and two A-Trait factors were found with the A-State factors accounting for significantly more of the variance than did A-Trait factors. For the normal group four A-State and two A-Trait factors were found, but there was not a significant difference between the amount of variance accounted for by A-State and A-Trait factors. Results were discussed as supporting the state-trait distinction and as having several implications for future research on anxiety.

Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods

OBJECTIVE

To present the design, methods, and rationale of the Child/Adolescent Anxiety Multimodal Study (CAMS), a recently completed federally-funded, multi-site, randomized placebo-controlled trial that examined the relative efficacy of cognitive-behavior therapy (CBT), sertraline (SRT), and their combination (COMB) against pill placebo (PBO) for the treatment of separation anxiety disorder (SAD), generalized anxiety disorder (GAD) and social phobia (SoP) in children and adolescents.

METHODS

Following a brief review of the acute outcomes of the CAMS trial, as well as the psychosocial and pharmacologic treatment literature for pediatric anxiety disorders, the design and methods of the CAMS trial are described.

RESULTS

CAMS was a six-year, six-site, randomized controlled trial. Four hundred eighty-eight (N = 488) children and adolescents (ages 7-17 years) with DSM-IV-TR diagnoses of SAD, GAD, or SoP were randomly assigned to one of four treatment conditions: CBT, SRT, COMB, or PBO. Assessments of anxiety symptoms, safety, and functional outcomes, as well as putative mediators and moderators of treatment response were completed in a multi-measure, multi-informant fashion. Manual-based therapies, trained clinicians and independent evaluators were used to ensure treatment and assessment fidelity. A multi-layered administrative structure with representation from all sites facilitated cross-site coordination of the entire trial, study protocols and quality assurance.

CONCLUSIONS

CAMS offers a model for clinical trials methods applicable to psychosocial and psychopharmacological comparative treatment trials by using state-of-the-art methods and rigorous cross-site quality controls. CAMS also provided a large-scale examination of the relative and combined efficacy and safety of the best evidenced-based psychosocial (CBT) and pharmacologic (SSRI) treatments to date for the most commonly occurring pediatric anxiety disorders. Primary and secondary results of CAMS will hold important implications for informing practice-relevant decisions regarding the initial treatment of youth with anxiety disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00052078.

Examining outcome variability: correlates of treatment response in a child and adolescent anxiety clinic

Examined correlates of treatment response in a clinic providing cognitive-behavioral therapy for children with anxiety disorders. Youth (ages 7 to 15) with a primary Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., or 4th ed.; American Psychiatric Association, 1987, 1994) anxiety-disorder diagnosis (overanxious disorder, generalized anxiety disorder, separation anxiety disorder, social phobia, or avoidant disorder) participated. After completing a full course of treatment and posttreatment (n = 135) and 1-year follow-up (n = 107) assessments, participants were classified into 1 of 2 groups--poor treatment response and good treatment response--using parent diagnostic reports. Discriminant function analyses indicated that higher levels of maternal- and teacher-reported child-internalizing psychopathology at pretreatment, higher levels of maternal self-reported depressive symptoms, and older-child age were all associated with less favorable treatment response. Other factors, such as child ethnicity, child sex, family income, family composition (i.e., dual parent vs. single parent), child-reported symptomatology, and maternal-reported level of child-externalizing behavior problems did not predict treatment response. Both practical and conceptual implications of the findings are discussed.

Screening for anxiety and depression in early adolescence

OBJECTIVE

To examine the level of diagnostic and discriminative accuracy of three dimensional rating scales for detecting anxiety and depressive disorders in a school-based survey of 9th grade youths.

METHOD

Classroom screening instruments, the Center for Epidemiologic Studies-Depression Scale (CES-D), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Multidimensional Anxiety Scale for Children (MASC) were administered to 632 youths from three sites in 1998. On the basis of rating scale results, samples of high-scoring and non-high-scoring youths were invited to participate in a diagnostic interview conducted within 2 months of the screening sessions.

RESULTS

MASC scores were most strongly associated with individual anxiety disorders, particularly among females, whereas the CES-D composite score was associated with a diagnosis of major depression, after controlling for comorbid disorders. The RCMAS was least successful in discriminating anxiety and depression. When receiver operator characteristic curves were examined, diagnostic accuracy was moderate.

CONCLUSIONS

The ability of the MASC and CES-D to discriminate within and between categorically defined diagnostic groups has important implications for the accurate identification of youths in need of services.

Comorbidity in childhood anxiety disorders and treatment outcome

OBJECTIVE

Psychiatric comorbidity is common in anxious children. The purpose of this study was to investigate the impact of comorbidity on treatment outcome in anxious children.

METHOD

Participants were 173 children between the ages of 8 and 13 years who met primary DSM-III-R/DSM-IV diagnoses of separation anxiety disorder, overanxious disorder/generalized anxiety disorder, or avoidant disorder/social phobia assessed by the Anxiety Disorders Interview Schedule for Children (ADIS-C). The majority (79%) had at least one comorbid diagnosis. Participants were randomly assigned to cognitive-behavioral therapy or waitlist. Group differences in ADIS-C diagnoses were compared after treatment. Multiple parent and child self-report measures were used to measure symptoms as well.

RESULTS

Pretreatment comorbidity was not associated with differences in treatment outcome: 68.4% of noncomorbid participants and 70.6% of comorbid participants were free of their primary diagnosis after treatment. Regarding parent and child self-report symptoms, multivariate analyses of variance revealed significant time (treatment) main effects, but no significant main effect for group (comorbid status) or time/group interaction.

CONCLUSIONS

The cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders; both groups showed clinically significant reductions in pretreatment diagnoses and symptoms.

Conceptualizing mental disorders in children: where have we been and where are we going?

Conceptions of mental illness in children are bound by cultural and social conventions of what constitutes healthy and unhealthy development. To understand current conceptualizations of disorders in children, we review the history of these conceptualizations from three intertwined perspectives: a sociopolitical history of American children and families, the history of the mental health fields and scientific disciplines involved in diagnosing children, and the evolution of children's role in the Diagnostic and Statistical Manual of Mental Disorders. We review where the field has been in its conception of childhood mental illness throughout the past century, where we believe it is now, and raise questions about the direction in which child diagnosis may be headed as we enter the new millennium. We conclude with social policy recommendations based on theory and research regarding mental disorders in children.

Normative data for normative comparisons

Normative comparisons are a procedure for evaluating the clinical significance of therapeutic interventions. Although a step-by-step statistical methodology for conducting normative comparisons has been reported elsewhere (P. C. Kendall, A. Marrs-Garcia, S. R. Nath, & R. C. Sheldrick, 1999), questions regarding the collecting of normative data remain. For this study, all treatment outcome studies published in the Journal of Consulting and Clinical Psychology from 1988 to 1997 were examined and reviewed, and the 5 most commonly used outcome measures were identified. For these outcome measures, multiple sources of normative data were located. Although we identified a dearth of normative data on measures used for treatment outcome, results discussed here nevertheless provide information that may be of use to therapy outcome evaluators when conducting normative comparisons. In addition, equations to determine the minimum sample size needed in a normative sample for a given treatment outcome study are provided.

A preliminary study of the emotion understanding of youths referred for treatment of anxiety disorders

Examined the emotion understanding of children and adolescents referred for treatment of Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) anxiety disorders (separation anxiety disorder, generalized anxiety disorder, or social phobia). Referred youths (n = 17) and nonreferred youths (n = 21) and their parents participated by completing self-report and parent-report questionnaires and structured diagnostic interviews. We interviewed all youths by using an emotion understanding interview. Referred youths demonstrated poorer understanding of hiding emotions and changing emotions compared with nonreferred youth. The 2 groups were not significantly different regarding their understanding of emotion cues and multiple emotions, however. No statistically significant relation emerged between general intelligence and emotion understanding. Future research directions are discussed.

The role of parental emotional distress in parent report of child anxiety

Evaluated the role of maternal and paternal emotional distress in parent report of anxiety in their child. Participants were 239 children (ages 7.5 to 15 years) diagnosed with a primary anxiety disorder and their parents (193 fathers, 238 mothers). Parents individually completed the State-Trait Anxiety Inventory, the Beck Depression Inventory (BDI), and the State-Trait Anxiety Inventory for Children-Parent Version (a report of the child's anxiety). Children completed the State-Trait Anxiety Inventory for Children. Mothers and fathers reported more anxiety in their children than the children reported themselves. No significant relations were found between parental anxiety and parent report of child anxiety. When we examined girls only, both maternal and paternal BDI scores were significant predictors of parent report of the child's anxiety after we controlled for parental anxiety. Separate analyses by child age revealed that parent reports of child anxiety were more correlated with the self-reports of younger children. The implications of these findings are discussed.

Retrospective self-reports of therapist flexibility in a manual-based treatment for youths with anxiety disorders

Evaluated retrospective therapist ratings of the flexibility used when applying the procedures and strategies prescribed in the treatment manual. Flexibility ratings were collected from 18 therapists who had treated 148 children with anxiety disorders (ages 9 through 13). Analyses revealed strong reliabilities for a flexibility questionnaire and that flexibility was used by therapists; however, significant relations between therapist-rated flexibility and treatment outcome were not found. Discussion focuses on the role of flexibility in manual-based psychological treatments and future directions for study.

Normative comparisons for the evaluation of clinical significance

Normative comparisons are a procedure for evaluating the clinical significance of therapeutic interventions. This procedure, consisting of comparing data on treated individuals with that of normative individuals, is described, and a step-by-step statistical methodology for conducting normative comparisons in the context of treatment-outcome research is presented. Four examples of the methodology are outlined in detail. Attention is paid to potential theoretical, statistical, and methodological challenges to the implementation of normative comparisons, as well as to the advantages of normative comparisons in providing evidence for the beneficial gains of treatment.

Clinical significance

This article initiates the special section on clinical significance. Within a brief précis and overview, the 4 methodological articles and the integrative commentary of the special section are introduced. A call for the inclusion of the assessment of clinical significance in treatment evaluations is extended.

Normative comparisons for the evaluation of clinical significance

Normative comparisons are a procedure for evaluating the clinical significance of therapeutic interventions. This procedure, consisting of comparing data on treated individuals with that of normative individuals, is described, and a step-by-step statistical methodology for conducting normative comparisons in the context of treatment-outcome research is presented. Four examples of the methodology are outlined in detail. Attention is paid to potential theoretical, statistical, and methodological challenges to the implementation of normative comparisons, as well as to the advantages of normative comparisons in providing evidence for the beneficial gains of treatment.

Differentiating anxious and depressive self-statements in youth: factor structure of the Negative Affect Self-Statement Questionnaire among youth referred to an anxiety disorders clinic

Conducted a factor analysis on the items from the Negative Affect Self-Statement Questionnaire (NASSQ; Ronan, Kendall, & Rowe, 1994). This analysis yielded 4 factors (Depressive Self-Statements, Anxiety/Somatic Self-Statements, Negative Affect Self-Statements, and Positive Affect Self-Statements) broadly consistent with both the content-specificity hypothesis (Beck & Clark, 1988) and L. A. Clark and Watson's (1991b) tripartite model of anxiety and depression. The association between children's self-talk and measures of trait anxiety and depression was also examined. Self-statements with content theoretically specific to depression were the best predictors of self-reported depressive symptoms, but the results were less clear for trait anxiety. Overall, these results provide evidence for the discriminability of anxious and depressive self-talk in youth and for the utility of the NASSQ as a cognitive assessment instrument.

Current progress and future plans for developing effective treatments: comments and perspectives

Examined the conclusions and implications of articles in this special issue. Treatments can be differentiated on their empirical basis and, for the problems reviewed, one can identify treatments of choice. To build on the documented advances, we provide a blueprint for progress in treatment research. The blueprint focuses on a series of steps that involve conceptualization of clinical dysfunction and treatment, supportive research on these conceptual views, careful specification of treatment, evaluation of treatment outcome, and tests of mediators and moderators of treatment. To improve research, we recommend expanding assessment, addressing a broad range of questions about treatment, attending to measures of clinical significance, replicating key findings, and investigating the transportability of the findings to service-oriented clinical settings.

Empirically supported psychological therapies

This article introduces the special section of the Journal of Consulting and Clinical Psychology on empirically supported psychological therapies. After a discussion of the rationale for the selection of the specific terms in the label, several justifications are considered for conducting and learning from empirical evaluations of psychological therapies. Finally, the process that guided the special section is described.

Methodological issues in treatment research for anxiety disorders in youth

This article identifies and addresses three methodological domains relevant to the treatment of anxiety disorders in youth: (a) procedural matters, (b) the assessment of anxious distress, and (c) the analysis of treatment-produced change. Procedural topics include the need to manualize treatment, have diversity among participants and comparability of the duration of treatment and control conditions, and control for medication status. Multiple-method measurement issues include child and parent reports, observations, and structured interviewing. Our examination of change issues considers comorbidity, analyzing the intent-to-treat sample, treatment "spillover," and clinical as well as statistical significance. Problems are identified and potential ameliorative strategies are offered.

Empirically supported psychological therapies

This article introduces the special section of the Journal of Consulting and Clinical Psychology on empirically supported psychological therapies. After a discussion of the rationale for the selection of the specific terms in the label, several justifications are considered for conducting and learning from empirical evaluations of psychological therapies. Finally, the process that guided the special section is described.

Self-talk in distressed youth: states-of-mind and content specificity

Tested hypotheses derived from a States-of-Mind (SOM) model in a sample of 542 children ages 7 to 15. SOM ratios were computed using empirically determined items. Support was found for the SOM model. Negative self-talk (but not positive) was consistently related to increasing levels of affective distress. Thus, children comorbid for anxiety and depression demonstrated the highest levels of negative self-talk (and most dysfunctional SOM ratios). Support for content specificity (specific cognitive content relating uniquely to affective conditions) was mixed. However, specificity was increased when attention was paid to more rationally derived content. Age was not a predictor of positive or negative self-talk. Discussion considers the use of the SOM model in child psychopathology and psychotherapy research.

Attrition in the treatment of childhood anxiety disorders

The present study explored the differences between completers and terminators (including both refusers and dropouts) of an individual cognitive-behavioral treatment for childhood anxiety. Participants were 190 children with anxiety disorders and their parents: 146 completed treatment and 44 terminated. Terminators were more likely to live in a single-parent household, be ethnic minorities, and self-report less anxious symptomatology. Follow-up interviews indicated that identifiable child factors were influential in terminators' decisions to discontinue treatment. Among terminators, differences between refusers and dropouts were also investigated.

Attrition in the treatment of childhood anxiety disorders

The present study explored the differences between completers and terminators (including both refusers and dropouts) of an individual cognitive-behavioral treatment for childhood anxiety. Participants were 190 children with anxiety disorders and their parents: 146 completed treatment and 44 terminated. Terminators were more likely to live in a single-parent household, be ethnic minorities, and self-report less anxious symptomatology. Follow-up interviews indicated that identifiable child factors were influential in terminators' decisions to discontinue treatment. Among terminators, differences between refusers and dropouts were also investigated.

Social expectancies and self-perceptions in anxiety-disordered children

The link between anxiety and negative social expectancies was examined by comparing 47 anxiety-disordered children with 31 nonanxiety-disordered controls on social expectancies, social anxiety, and self-perceived social competence. Participants were exposed to a videotape of confederate children playing a game, being told the children were next door. In anticipation of joining the play, social expectations were assessed via thought-listing and a questionnaire. Parent, teacher, and child measures of sociability were completed prior to the experimental session. Results indicated that anxiety-disordered children reported significantly more negative social expectations, lower social self-competence, and higher levels of social anxiety than controls. Parents and teachers each rated the anxiety-disordered children as significantly more socially maladjusted than controls. Social anxiety was the best predictor of social expectancies. Given the importance of healthy peer relations, treatment implications for anxiety-disordered children are highlighted.

Therapy for youths with anxiety disorders: a second randomized clinical trial

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 suggestions for future research.

Therapy for youths with anxiety disorders: a second randomized clinical trial

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 suggestions for future research.

Maternal expectations and attributions about coping in anxious children

This study examined maternal expectations and attributions regarding their child's ability to cope with a stressful situation. Children either met DSM III-R criteria for an Anxiety Disorder or were normal. Results indicated that it was not the perception of threat that differentiated the expectations of mothers in both groups, but rather their expectations for coping, both generally and in terms of specific behavior. Mothers of anxiety-disorder (AD) children expected their children to be more upset, less able to make themselves feel comfortable, and were less confident in their children's abilities to perform task related behavior. In general, maternal expectations for coping appear to reflect the actual lower coping ability of anxious children. Concerning attributions, mothers of AD children made fewer causal distinctions between high and low coping than did mothers of normal control (NC) children. Discussion considers how lowered expectations for coping may relate to protective parenting and how such patterns may unwittingly maintain anxious behavior in children.

Self-talk in youth with anxiety disorders: states of mind, content specificity, and treatment outcome

This study investigated the relationship between childhood anxiety disorders, the valence and content of self-statements, and the impact of treatment on the internal dialogue. Participants (151 8- to 13-year-olds) included 71 youth with anxiety disorders and 80 control participants. Positive and negative self-statements and a states-of-mind (SOM) ratio were examined. Results indicated that the negative self-statements and SOM ratio (but not positive self-statements) of children with anxiety disorders significantly predicted anxiety. Results also indicated that negative (but not positive cognition) and SOM ratio predicted improvement in anxiety after treatment and mediated treatment gains. Results of analyses to explore the content specificity hypothesis were mixed. The impact of negative self-talk on children's anxious symptomatology and favorable treatment outcome is discussed.

Psychological effects of weight loss and regain: a prospective evaluation

This study prospectively assessed the psychological effects of weight loss and regain (i.e., weight cycling) in obese women. Measures of mood, binge eating, restraint, disinhibition, and hunger were obtained from 55 participants at baseline, after 6 months of treatment, and 58 months posttreatment. Women lost 21.1 +/- 8.4 kg after 6 months of treatment but were 3.6 +/- 10.9 kg above baseline weight at the time of the follow-up. Contrary to expectations, after this 21-kg cycle of weight loss and regain, women reported significant improvements in mood and binge eating, as well as reductions in hunger and disinhibition. Restraint was unchanged from baseline to follow-up. These data suggest that weight loss and regain are not associated with long-term adverse psychological effects. The findings also confirm earlier reports of significant weight regain after treatment and underscore the need for research to improve the maintenance of weight loss.

Long-term follow-up of a cognitive-behavioral therapy for anxiety-disordered youth

This study examined the long-term effects of a psychosocial treatment for anxiety-disordered youth. Clients (N = 36) who had completed treatment 3.35 years earlier (on average) were reassessed using self- and parent-report instruments as well as structured diagnostic interviews. Results indicated that previously documented treatment gains were maintained. An examination of participants' recalled events within therapy suggested that the therapeutic relationship, games and activities, and discussion of problems were salient treatment components. Theoretically important components of treatment were also recalled by clients, and some were found to be related to long-term positive outcome.

Self-talk in youth with anxiety disorders: states of mind, content specificity, and treatment outcome

This study investigated the relationship between childhood anxiety disorders, the valence and content of self-statements, and the impact of treatment on the internal dialogue. Participants (151 8- to 13-year-olds) included 71 youth with anxiety disorders and 80 control participants. Positive and negative self-statements and a states-of-mind (SOM) ratio were examined. Results indicated that the negative self-statements and SOM ratio (but not positive self-statements) of children with anxiety disorders significantly predicted anxiety. Results also indicated that negative (but not positive cognition) and SOM ratio predicted improvement in anxiety after treatment and mediated treatment gains. Results of analyses to explore the content specificity hypothesis were mixed. The impact of negative self-talk on children's anxious symptomatology and favorable treatment outcome is discussed.

Long-term follow-up of a cognitive-behavioral therapy for anxiety-disordered youth

This study examined the long-term effects of a psychosocial treatment for anxiety-disordered youth. Clients (N = 36) who had completed treatment 3.35 years earlier (on average) were reassessed using self- and parent-report instruments as well as structured diagnostic interviews. Results indicated that previously documented treatment gains were maintained. An examination of participants' recalled events within therapy suggested that the therapeutic relationship, games and activities, and discussion of problems were salient treatment components. Theoretically important components of treatment were also recalled by clients, and some were found to be related to long-term positive outcome.

Psychological effects of weight loss and regain: a prospective evaluation

This study prospectively assessed the psychological effects of weight loss and regain (i.e., weight cycling) in obese women. Measures of mood, binge eating, restraint, disinhibition, and hunger were obtained from 55 participants at baseline, after 6 months of treatment, and 58 months posttreatment. Women lost 21.1 +/- 8.4 kg after 6 months of treatment but were 3.6 +/- 10.9 kg above baseline weight at the time of the follow-up. Contrary to expectations, after this 21-kg cycle of weight loss and regain, women reported significant improvements in mood and binge eating, as well as reductions in hunger and disinhibition. Restraint was unchanged from baseline to follow-up. These data suggest that weight loss and regain are not associated with long-term adverse psychological effects. The findings also confirm earlier reports of significant weight regain after treatment and underscore the need for research to improve the maintenance of weight loss.

Issues in the transportability of treatment: the case of anxiety disorders in youths

This article reviews factors working against or in favor of the transportability of manual-based child treatments from research clinics to service practitioners. The review examines client factors, service-clinic therapist factors, and researcher factors that may contribute to the reported gap between research and practice outcomes. As requested for this special section, this article uses work with anxiety-disordered youths as an example of a potentially transportable manual-based treatment. Issues and future directions are discussed.

Introduction to special section: prediction and prevention of antisocial behavior in children and adolescents

The growing concern about antisocial behavior and violence by children and adolescents has prompted several scientific reviews. Concurrently, 2 major scientific reviews of prevention have published reports. In addition, there has been an increase in the amount, complexity, and coordination of research on prediction and prevention of youth antisocial behavior. This special section is prompted by the co-occurrence of these developments, and it includes studies that focus on longitudinal prediction, testing of methods of risk screening, and evaluating interventions.

Issues in the transportability of treatment: the case of anxiety disorders in youths

This article reviews factors working against or in favor of the transportability of manual-based child treatments from research clinics to service practitioners. The review examines client factors, service-clinic therapist factors, and researcher factors that may contribute to the reported gap between research and practice outcomes. As requested for this special section, this article uses work with anxiety-disordered youths as an example of a potentially transportable manual-based treatment. Issues and future directions are discussed.

A developmental-ecological perspective on antisocial behavior in children and adolescents: toward a unified risk and intervention framework

A developmental-ecological perspective is offered as a framework for prediction and prevention of antisocial behavior in children and adolescents. The primary assumptions of the approach and the advantages of such an approach for relating prediction, prevention, and implementation are high-lighted. It is suggested that such an approach facilitates integration of the recent advances in prevention theory and methods, the accumulating knowledge about the causes and effective interventions for antisocial behavior, and the need for careful consideration of context. Six key advances in the field are listed, and important steps are suggested.

Introduction to special section: prediction and prevention of antisocial behavior in children and adolescents

The growing concern about antisocial behavior and violence by children and adolescents has prompted several scientific reviews. Concurrently, 2 major scientific reviews of prevention have published reports. In addition, there has been an increase in the amount, complexity, and coordination of research on prediction and prevention of youth antisocial behavior. This special section is prompted by the co-occurrence of these developments, and it includes studies that focus on longitudinal prediction, testing of methods of risk screening, and evaluating interventions.

Rigor, but not rigor mortis, in depression research

With reference to the depression research methods review of H. Tennen, J.A. Hall, and G. Affleck (1995) and the earlier recommendations of P. C. Kendall, S. D. Hollon, A. T. Beck, C. L. Hammen, and R. E. Ingram (1987), the present discussion considers and then reaffirms selected methods. Discussion includes issues such as the use of analogue vs. clinical samples, single vs. multiple assessments, self-report vs. structured diagnostic interviews, and the use of multiple gaiting and analyses of symptom clusters.

Rigor, but not rigor mortis, in depression research

With reference to the depression research methods review of H. Tennen, J.A. Hall, and G. Affleck (1995) and the earlier recommendations of P. C. Kendall, S. D. Hollon, A. T. Beck, C. L. Hammen, and R. E. Ingram (1987), the present discussion considers and then reaffirms selected methods. Discussion includes issues such as the use of analogue vs. clinical samples, single vs. multiple assessments, self-report vs. structured diagnostic interviews, and the use of multiple gaiting and analyses of symptom clusters.

Introduction to the special section: the case for training in the provision of psychological therapy

Recent trends, such as the national health care initiative, have brought into focus the importance of identifying the qualifications of those who provide mental health services. This special section explores the research evidence for the value of professional training among those who provide psychological therapy. The set of articles describe what is known about the relationship to therapeutic efficacy of professional training, training in ethnic diversity, and clinical supervision. These articles suggest that professional training enhances clinical efficacy, especially if type of training, setting of practice, and nature of patient problems are considered. They also suggest that supervision and specific training in ethnic diversity enhance knowledge and sensitivity among psychotherapists. It is anticipated that this special section will promote a dialogue about these conclusions.

Introduction to the special section: the case for training in the provision of psychological therapy

Recent trends, such as the national health care initiative, have brought into focus the importance of identifying the qualifications of those who provide mental health services. This special section explores the research evidence for the value of professional training among those who provide psychological therapy. The set of articles describe what is known about the relationship to therapeutic efficacy of professional training, training in ethnic diversity, and clinical supervision. These articles suggest that professional training enhances clinical efficacy, especially if type of training, setting of practice, and nature of patient problems are considered. They also suggest that supervision and specific training in ethnic diversity enhance knowledge and sensitivity among psychotherapists. It is anticipated that this special section will promote a dialogue about these conclusions.

Cognitive-behavioral treatments

The present paper provides an overview of the guiding theory and descriptive features of the cognitive-behavioral approach to psychosocial interventions for youths. Cognitive-behavioral treatment has been applied to various disorders including anxiety, aggression, depression, attention deficit-hyperactivity disorder, pain, and learning disabilities. Research on the nature of these disorders, a description of related treatment strategies, and an illustrative review of treatment outcome data is provided. Discussion focuses on a consideration of familial involvement, developmental factors, and methodological issues (i.e., comorbidity and normative comparisons) that require research attention.