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JournalofConsultingandClinical Psychology1997. Vol.65, No.3,366-380 Copyright 1997bytheAi PsychologicalAssociation,Inc.0022-006X/97/S3.00

Therapyfor'fouthsWith Anxiety Disorders:ASecond Randomized ClinicalTrial

PhilipC.Kendall, Ellen Flannery-Schroeder, SusanM.Panichelli-Mindel,Michael Southam-Gerow,AudeHenin,andMelissaWarman

Temple University

Ninety-fourchildren (aged9-13years)with anxietydisorderswere randomly assignedtocognitive-behavioral treatment or waiting-list control. Outcomes were evaluated using diagnostic status, childself-reports, parentandteacher reports, cognitive assessmentandbehavioral observation; maintenancewas examined using 1-year follow-up data. Analyses ofdependent measuresindicated significantimprovements over time, with the majority indicating greater gains for those receiving treatment.Treatment gains returned cases to withinnondeviant limits (i.e., normative comparisons) and weremaintained at 1-year follow-up. Client age andcomorbid status did not moderate outcomes. Apreliminary examination of treatment segments suggested that theenactiveexposure (when it followscognitive-educationaltraining) was an active force in beneficial change. Discussion includes sugges-tions forfuture research.

Children facedevelopmental challenges, yet not all childrenare prepared and not all of the challenges are met. The issuefacing clinical child psychology is how to best intervene toreduceor remediate thecognitive, behavioral, and emotionaldifficulties inchildhood thatare associated with distressandpsychopathology. Strides have been made in researching thetreatmentofchildhood psychopathology,butmuchwork remains(Kazdin, 1993; Kendall&Morris, 1991; Weisz, Weiss, Han,Granger, & Morton,1995).Estimates of the number of childrenwhomay require mental healthservicesis quite high, with recentfigures rangingfrom 12% to 22% in community samples(e.g.,Costello, 1989).Among those children referred for treatment,the acting-out, aggressive child dominates innumberand hasreceivedthelion's shareofresearch.As aresult, childrenwithinternalizing problems may be underserviced and have beenunderresearched.However,the prevalence and course of inter-nalizing disorders, as well as the widespread interference associ-atedwith anxietyin children,necessitatea concurrentfocusonthe treatment of internalizing disorders.

Editor's Note.Thomas Ollendick served as the Action Editor for thisarticlePCK

Philip C. Kendall, Ellen Flannery-Schroeder, Susan M. Panichelli-Mindel, Michael Southam-Gerow,AudeHenin, and Melissa Warman,Department ofPsychology, Temple University.

This research was supported by Grant MH44042fromthe NationalInstituteof Mental Health. Wethankthe following individuals: the partic-ipatingchildren and their families and the referring community agenciesandpracticing clinicians; Tamar Chansky, Bonnie Howard, Martha Kane,Elizabeth Kortlander,LynneSiqueland, and Kim Treadwell; associatesErica Brady, Serena Callahan, Brian dm,Elizabeth Gosch, MargotLevin, AbbeMarrs,JenniferMacDonald,and AmySugarman;andPeterJ. Mikulka for his artistic renderings.

Correspondence concerning this article should be addressed to PhilipC. Kendall, Department of Psychology, Temple University,1701North13th Street, Weiss Hall, Philadelphia,Pennsylvania19122.

Anxiety disorders in childhood have a chronic course and areassociatedwith anxiety problems in adulthood (e.g., Keller etal., 1992; Last,1988).Retrospectivereportssuggestthatadultswithanxiety disorders sufferedfrom anxiety-related symptomsaschildren (Last, Hersen, Kazdin, Francis, & Grubb, 1987;Weissman, Leckrnan,Merikangas,Gammon, &Prusoff, 1984).Anxiety in childhood interferes withadjustment,including so-cial adjustment and academic functioning (e.g., Chansky &Kendall, 1997; Strauss, Frame, & Forehand, 1987; Strauss,Lease,Kazdin, Dulcan, &Last, 1989). Epidemiological datashow anxiousdistress as common in childhood, and anxietydisordersmay be one of the most common psychological ail-ments in childhood and adulthood (Anderson, 1994; Bell-Dolan,Last, & Strauss, 1990).Anxiety disorders are often comorbidwithotherdifficulties (e.g.,depression, attentiondeficithyper-activity disorders [ADHD], conduct problems) and may in-creaserisk forsignificant dysfunction (e.g., Brady&Kendall,1992; Mattison, 1988).Anxiety disorders inchildhoodal-thoughnot as dramatic in presentation as externalizing disor-dersrepresentaserious mental health problemforyouthsandtheir families.

Given the dominantfocusof the literature on aggressive andantisocial children, it is no surprise that the outcome researchwith externalizing children has been far more common thansimilar work with anxious children (e.g., see Borduin et al.,1995; Kazdin,Siegel, & Bass, 1992; see Southam-Gerow &Kendall,inpress). Mostof theearly studiesof anxiety inchild-hood concentratedonnighttimefears,fearofdentalormedicalprocedures, evaluationanxiety,and a fewclinical case studies(forreviews, see Kendall, Kortlander, Chansky, &Brady,1992).More recently,a fewpsychopharmacologicalstudies have beenreported but the results have been disappointing: antidepressantand anxiolytic medications such as clonazepam, imipramine,andbuspironehavenotdemonstratedbenefits forchildren diag-nosed with overanxiousdisorderor social phobia (OAD andSP,respectively; e.g., Ambrosini, Bianchi,Rabinovich,&Elia,

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TREATING YOUTHS WITH ANXIETY DISORDERS 367

1993; Graee,Milner,Rizzotto, &Klein, 1994; Klein,Kople-wicz, &Kanner,1992).Forother anxietydisordersthatoccurinchildhoodpanic disorder and obsessive-compulsive disorder(Apter etal.,1994;Kutcher, Reiter,Gardner, &Klein, 1992)some positive psychopharmacologic results have beenreported.Onerecent study demonstrated the efficacy of fluoxetine forchildrenwithseparation anxiety disorder (SAD),OAD,and SP(Birmaher etal., 1994), but thestudywas not arandomizedclinical trial. Overall,thestatusofpharmacotherapy forchildrenwithanxietydisordersis, atbest, uncertain.

Empiricalstudyofpsychosocial treatmentsforanxietydisor-dersinyouthsisgrowingbut,asyet, incomplete. With obses-sive-compulsiveyouths,some workhasdemonstrated effective-ness(March, Mulle,&Herbel, 1994; Piacentini, Gitow,Jaffer,Graae,&Whitaker,1994).Recently, Kendalland hiscolleaguesdeveloped andtestedatreatmentforchildrenwithOAD, SAD,oravoidantdisorder(AD). The cognitive-behavioral approachisenactive,with performance-basedandcognitive interventionstochange thinking, feeling,andbehaving (Kendall,1993).Thecognitive-behavioral model emphasizes the learning processandthe influence ofcontingenciesandmodels in theenviron-mentwhile underscoringthe centrality of theindividual's man-ner ofprocessing relevant information.Thetreatment strivestoreduce the influence ofdysfunctional processing, to increaseactive problem solving,and tobuildafunctionalcoping outlook.The enactive intervention capitalizes on creating behavioral ex-perienceswithemotional involvement while paying attentiontothecognitive activities of theparticipant.

Specifically, treatment addresses (a) problematic thinkingpatterns that contribute toanxious distress (e.g.,Kendall&MacDonald,1993)and (b) behavioral avoidance that maintainsthechild'sdistress. The treatment is manualized (Kendall, Kane,Howard,&Siqueland,1990) and combines skills training andexposurecomponents, bothof whichhave demonstrated effec-tivenessforanxiety-related problemswithadults (e.g., Barlow,Rapee,&Brown, 1992; Heimberg,Salzman,Holt,&Blendell,1993; Ollendick & Francis,1988).Results have been promising,as evidenced by a multiple-baseline evaluationof four cases(Kane& Kendall, 1989) and a randomized clinicaltrialwith1-year (Kendall, 1994) and longer term (3.35 years) follow-ups(Kendall &Southam-Gerow,1996).The first randomizedclinical trial (Kendall, 1994) found that treatment, comparedwithwaiting-list,wasassociatedwithpositive changesinchild-andparent-reportedcoping, child- and parent-reported distress,observationsofchild behavior,anddiagnostic status. Withre-gardto diagnoses, 66% of treated cases at posttreatment did notmeetcriteria fortheir pretreatment primary anxiety diagnosis.Adapting theKendallprogram (Kendall, 1994; Kendalletal.,1990),Dadds, Heard, and Rapee(1992)described success inastudy(Barrett, Dadds,&Rapee, 1996)inwhich nearly70%ofthechildren with anxiety disorderswhocompleted treatmentineitheranindividualor afamilyprogramdid notmeet criteriaforananxietydisorderatposttreatment. Although evidence sug-gests thatthetherapy meetsthecriteriaof theAmerican Psycho-logical Association (APA)Task ForceonPromotion andDis-seminationofPsychological Procedures (1995) for probablyefficacious'' treatment, a replication and extension of the pro-gram isneeded,as is apreliminary considerationofactive treat-mentsegmentsand theinfluenceofcomorbidityonoutcome.

TheDiagnosticandStatisticalManual of Mental Disorders(4th ed.; DSM-IV; AmericanPsychiatricAssociation, 1994)provided achangein theclassificationofchildhood anxiety-related disorders. Twodisorders included in therevised thirdeditionof theDSM(DSM-IH-R; American Psychiatric Associ-ation,1987) have been removedfrom thenosology. OAD hasbeensubsumed under generalized anxiety disorder (GAD),andADhas been subsumedunderSP. Nevertheless, a comparisonofcases diagnosed independentlybyboth systems revealed thatthechangein thenosologyhas notchangedthecharacteristicsofidentifiedcases (Kendall &Warman,1996).Therefore, OAD-GADis characterized by excessive and uncontrollable worryabout avarietyoftopics,including academic, social,andfamil-ialdomains.AD-SPismarkedbyintenseandoften incapacitat-inganxietyin thefaceof specific ormore general social situa-tions. Athird anxiety disorder occurring primarily in child-hoodSADis characterizedby anintenseandchronic fearreactiononseparationfromparentsorcaregivers. Other anxietydisorders (e.g., obsessive-compulsive disorder, panic disorder)alsooccurinchildhood,but thetreatment evaluated hereinad-dresses OAD-GAD, AD-SP,and SAD.

Thepresent investigationis a replication andextensionof theKendall(1994)report, usinganentirelynewsampleofyouthswithanxiety disorders.Theprimaryfocusis ontreatment out-come andmaintenanceeffectsat 1-yearfollow-up. Ancillarytothis arepreliminary analysesof theinfluence ofcomorbidityand theeffectsof thesegmentsoftreatment.It washypothesizedthattreatment wouldbeassociated with beneficial changesex-ceeding thosefoundfor thewaiting-list control condition.It wasalsohypothesized that treatmenteffectswouldbemaintainedat1-year follow-up. Ancillary analyses were undertaken asexploratory.

MethodParticipants

Ninety-four children (aged 9-13 years) diagnosedwithaprimaryanxietydisorder and who hadbeen referred from multiplecommunitysourcesservedasparticipants(60 intreatment condition,34 inwaiting-list control condition). The 94participants camefrom atotalof 118potential participants (attrition included9from treatment,9from wait-ing-list,and 6from treatment after the waiting-list). Of the 60treatedparticipants, 58% were boys; 87% were Caucasian, 7% wereAfricanAmerican, 2%wereHispanic, 2%were Asian, and 3%self-identifiedas other ormixedrace.Forty-seven percent were 9-10 years old;53%were 11-13 years old. Controls (n = 34) were treated afterthewaiting-list period: they were not included in the treatment group foranalyses of outcome but were includedin other analyses thatdid notusethe controlconditioncomparison.Of the 34waiting-list participants,68%were boys;82%were Caucasian,3%were African American,6%were Asian,2%were Hispanic,and 7%were identifiedas other ormixed race. Sixty-two percent were 9-10 years old;38%were 11-13years old.

For thefullsample,38%weregirls.Eighty-fivepercent were Cauca-sian, 5%wereAfricanAmerican, 2%were Hispanic, 2%were Asian,and5%werefromother minorities. Fifty-two percent were9-10yearsold,and 48%were11-13years old.Familyincomewasbelow$20,000for6.4%,$40,000for27.7%,$60,000for33%,$80,000for23.5%,andabove$80,000for 6.4%. Withregard toeducational attainment, 1.1%offathersand7.4%ofmothershad notcompleted high school, whereas

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368 KENDALL ET AL.38.3% of fathers and4.28% of mothers were high school graduateswithoutcollege;26.6% of fathers and 17% of mothers had somecollegeeducation, and30.9% offathersand 51% ofmothershadcompleteda4-yearcollege education.Treatmentand waiting-list participants did notdiffersignificantlyonthese variables.

Participants receivedprimaryanxietydisorder diagnoses (OAD,n =55;SAD,n= 22; AD,n= 17) on thebasisof structured interviewsconducted separately withboth the parents and the participant. Whenparentand child differed, diagnoses were basedon parental reports.1Children whose primarydiagnosiswassimple phobia(or phobias)werenot included;childrenwithdiagnosablespecific phobias as secondaryproblems were included. Forty-eight percentof the participants werecomorbidwith simple phobia; 14%,withADHD;8%,withoppositionaldefiant disorder; 6%, with major depression; and 1%,with conductdisorder. Children were excluded if they displayed psychotic symptomsor were currently using antianxiety medications.

Setting andPersonnelTherapy wasprovided by 11doctoral candidates(9 women) within

theChildandAdolescent Anxiety Disorders Clinic (CAADC), DivisionofClinicalPsychology, Temple University.

MeasuresMultimethodassessment,asrecommendedin thechild therapylitera-

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

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

theADISforparents(ADIS-P)were developedfordiagnosis ofchild-hoodanxiety disorders(Silverman,1987). Theseconsist of independentparent andchild interviewsforDSM-I11-R categories thatenablethediagnostician toobtain information about symptomatology, course, etiol-ogy, and severityof problem behaviors,and toscreen out additionaldisorders. The interview has interrater reliability(e.g.,r =.98 for parentinterview and r .93 forchild interview; Silverman&Nelles, 1988)and retestreliability(e.g.,k =.76 for parent interview; Silverman &Eisen, 1992),and it hasshown sensitivitytotreatmenteffectsinstudiesofyouths with anxietydisorders(e.g.,Albano,Knox,&Barlow, 1995;Kendall, 1994).

Children's Self-Report MeasuresRevised Children's Manifest Anxiety Scales (RCMAS). These 37

items, 9 of whichcomposea Liescale,measure achild's chronicortrait anxiety (Reynolds & Richmond, 1978).The scale reveals threeanxiety factors (Physiological Symptoms, Worry andOversensitivity,andSocialConcern-Concentration),and factor-analytic studies supportthepresenceof anoverall traitaswellas thedistinction between factors.The RCMAS has high internal consistency, moderateretestreliability(r= .68; Reynolds & Richmond, 1985), and reasonable construct validity(RCMAS correlated .85with the State-TraitAnxiety Inventory forChildren, Trait Anxietysubscale(STAIC, A-Trait)but had littlecorrela-tion with theState Anxiety subscale (A-State;Spielberger, 1973).Na-tional reliability andnormative dataareavailable (Reynolds &Paget,1982).

The STAIC. TheSTAIC (Spielberger, 1973) has two20-item self-report scales assessing both enduring tendencies to experience anxiety(A-Trait) andtemporalandsituationalvariationsinanxiety (A-State).Normative andreliability dataareavailable. Evidencefor theSTAIC'sdiscriminantand convergent validity has been reported (Hodges,1990),and theTrait versionof the STAIC correlates with other measuresof

anxiety in children (e.g., RCMAS; Carey, Faulstich, & Carey, 1994;Reynolds & Paget,1982).Factor-analyticstudiessupport thestate-traitdistinction (Finch, Kendall, & Montgomery, 1974).

FearSurvey Schedulefar ChildrenRevised (FSSC-R). Ollendick(1983) revisedthe80-item,5-pointscale (Scherer &Nakamura,1968)tocreate a 3-point scale assessing specificfearsinchildren,witheightfearcategories including school, social,and physical fears. The scalehassolid internal consistency (alpha coefficients in therangeof .92),adequate retestreliability (Ollendick, 1983), and has been shown tocorrelate with trait anxiety(asmeasuredby theSTAIC A-Trait; range,.46-.51).Normative data are available (Ollendick, King, &Frary, 1989;Ollendick,Matson, &Helsel, 1985).

Children's Depression Inventory (CDI). The CDI (Kovacs, 1981)has 27 items related to the cognitive, affective,and behavioral signs ofdepression. Each item containsthreestatements, andchildren selecttheonethat best characterizes them during the past 2weeks.The scale hashigh internal consistency, moderate retest reliability,andcorrelates inexpected directions with measures ofrelated constructs (self-esteem,negativeattributions, andhopelessness;Kazdin, French, Unis, Esveldt-Dawson,&Sherick,1983; Saylor, Finch, Spirito, &Bennett,1984; seereview by Kendall, Cantwell, & Kazdin, 1989). Normative data areavailable (Finch,Saylor,&Edwards, 1985).

CopingQuestionnaire-child version (CQ-C). TheCQ-C(Kendall,1994) assesseschildren's perceivedability to manage highly anxiety-provoking situations. The assessment issituationallybased and individu-alized:Three areasofdifficulty specifictoeach childarechosenbasedoninformation obtainedin theinterviews,andchildren rate their abilitytocopewitheach situationon a7-pointscaleranging from not at allable tohelp myself (1)incompletelyabletohelpmyselffeel comfortable(7).Acceptable retest reliability was obtained for theCQ-C, and themeasure issensitive totreatment.

Children's NegativeAffectivity Self-Statement Questionnaire (NASSQ).TheNASSQ includes self-statements that children endorse on ascalerangingfromnot at all(1)toall thetime(5), representingthefrequencywithwhich each thought occurred during thepastweek (Ronan, Ken-dall, &Rowe,1994).Within the NASSQ areseparatescales of anxiousself-talk for 7- to 10-year-olds (11 items) and 11- to 15-year-olds (31items). Scores for the two agegroups were converted to a uniformmetricandcombined.TheNASSQwasfoundto beinternally reliable,andretest reliability over a 2-month interval was .73. Analyses supporttheconcurrentandconstructvalidityof themeasure.

Parent MeasuresChildBehavior Checklist(CBCL). TheCBCLis a 118-itemscale

assessing behavioral problems andsocial competencies (Achenbach,199la).Items arerated from nottrue(0) to very trueor often true(2). The CBCL has broadband internalizing and externalizing factorsandeight specificscales (e;g.,anxiety-depression).Normative data areavailable.TheCBCLhashigh retestreliability,interparent agreement,andvalidity.It washighly correlated withsimilar parent measures ofchild behavior, and scaled scores andclinicalcutpoints discriminatedbetweenreferred and nonreferred children. Inaddition, theCBCL in-cludes items that can form a separate anxiety score (CBCL AnxietyScale;CBCL-A;Kendall,MacDonald,Benin, & Treadwell, 1997).

STAICModification oftrait versionforparents(STAIC-A-Trait-P).Strauss(1987)modified thetrait versionof theSTAICto beusedas acomplementary parent ratingof thechild's trait anxiety.

CopingQuestionnaire-parent version (CQ-P), TheCQ-P parallels

1In onecase, adiagnosiswasbased on aparticipant's report. Theparents' report approached but did not yield adiagnosis;becausetheparticipantwas anadolescent,his or herreportwasdeemedreliableandused.

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TREATING YOUTHS WITH ANXIETY DISORDERS 369the CQ-Cdescribedearlier. Parents ratethechild'sabilityto copewiththree anxiety-provoking situations identified from the interview. Out-come data (Kendall, 1994) support thesensitivity of this measure totreatment.

ParentSelf-Report MeasuresTheState-TraitAnxietyInventory. Twentyitemsassesshow respon-

dents generally feel (A-Trait)and 20itemsassessrespondents' feelingsat that moment(A-State; Spielberger,Gorsuch,&Lushene,1970).Nor-mative, reliability, and validity data are available (Spielberger, 1973);factor analyses supportthestate-traitdistinction.

Beck Depression Inventory (BDI). This21-iteminventory measuresdepressive symptoms (Beck, Rush, Shaw,&Emery, 1979).Reliability,validity,andnormativedata areavailableand thescalehas widespreadapplication(Kendall, Hollon, Beck,Hammen,&Ingram,1987).

Teacher ReportTheCBCLTeacher Report Form(TRF)mirrorstheparent version

ofthe CBCL andprovidesapictureof thechild'sclassroom functioning(Achenbach, 1991b).This measurewascompletedby thechild'spri-mary teacher; however, children often changed grades over thecourseoftheprogramsothatdieprimary classroom teacher couldvaryacrossassessments.The TRFpossesseshigh retest reliability(2-weekinterval),moderate interteacheragreement,and theabilitytodiscriminate betweenreferred andnonreferred children.

BehavioralObservationsThe coding systemwasappliedtoobservations during performance

of a videotaped task. Six observational codes were used during taskperformance: gratuitous verbalizations (e.g., stating a physical com-plaint, negative performance evaluation,dislikefor thetask); gratuitousbody movements(e.g.,kicking or shaking leg; rockingbody);avoidingtask (e.g., leavingtheroom,nottalking);absenceof eyecontact (e.g.,not looking at camera for the observational interval); fingers in mouth(e.g.,bitingfingernails, touching hand to lips); and trembling voice(gigglingwithinobservationalinterval; inaudiblespeech).Theoccur-renceofeach codeduring ten 30-s intervals was scored and reportedasa percentage of the observed units.

Therapy MeasuresChild's Perceptionof Therapeutic Relationship (CPTR). This 10-

item,5-pointscale assessesthechild's perception of thequalityof thechild-therapist relationship. Five items tap the child's liking, feelingclose to, feeling comfortable with, talking to, and wanting to spend timewiththe therapist. Other items refer to the quality andclosenessof therelationship.TheCPTRwasincludedtoexaminethecorrelation betweenthe therapist-childrelationship andoutcome (Kendall .Morris, 1991;Strupp & Hadley, 1979) and was givenby a diagnostician (not thetherapist)at posttreatment.

Parental Involvement Ratings(PIRs). At completion of treatment,thetherapistratedparental involvementon7-pointscales.ThePIRtapsthree aspects of involvement: (a) amountofcontact with parent (orparents),(b)degreeofbeneficial parental involvement,and (c)degreeof parental interference.

ProcedureCaseswere referredtoCAADC through multiplesourcesin thecom-

munityincluding clinics andpractitioners,public and nonpublic counsel-ors, and media descriptions. Within a week, staff contacted parents and

arrangedanintake evaluation. Parent(orparents)and thechild signedinformedconsents, participatedin theinterviews,andcompleted ques-tionnaires.The TRF wascompletedby thechild's primary teacherandreturned directlyto theclinic.Forbehavioral observations,thechildwasprompted, Tellus aboutyourself for 5 min while being videotaped.Sample topics (e.g., friends; favorite TV shows) were provided, andthediagnosticianleft theroom.

After intake, participants who met criteria were randomly assignedto either the 16-week cognitive-behavioral treatment or the 8-weekwaiting-listcontrol condition.2Participants who did not meet diagnosticcriteriawere provided with referrals. Waiting-list children completedanadditionalassessment at the end of the 8-week period. All control-groupchildrenand their parents were asked if they sought alternate treatmentduring the waiting-listperiod, and participants who did not maintainintegrity werenotincludedin thestudy. Followingthewaiting-list,chil-dren were provided with therapy. Randomization was used in all in-stances ofclientsbeing assignedtotherapists.

Participants receivedanaverageof 18sessions (range,16-20),last-ing 60 min once a week, except for illness or vacations. The self-,parent-, andteacher-report questionnaires were administeredatmidtreat-ment,and afullbattery assessment including structured diagnostic inter-views, questionnaires, and behavioral observations was conducted atposttreatment and at 1-year follow-up. Tohelpensure contact with thechildrenafter treatment, a parent (or parents) provided the names andphone numbers of twopeopleclosestto thefamily.

Treatment Manual and MaterialsThe treatmentmanual(Kendall etah,1990) describes the goals and

strategies to be implemented for each treatment session; however,aflexible andclinically sensitive applicationof theprocedureswasapplied(Dobson&Shaw, 1988; Kendall, Kortlander, Chansky,&Brady, 1992)with consideration of the client's age, intellectual ability, and familyfactors. Also,anaddendum,Workingwith PotentialDifficulties, detailedthemodest shifts intreatment emphasis used incases of comorbidityandwithdifficulties in compliance or denial. A workbook for use bychildren,TheCoping Cat(Kendall,1990),and stimulus materials (i.e.,age-appropriatesketches) were usedtopresent goalsandpromote inter-estandinvolvementintreatment.Toreinforceandgeneralizetheskills,we assigned homework tasks for the children to complete using theCoping CatNotebook.

TreatmentMethod:Cognitive-Behavioral TherapyChildren received individual cognitive-behavioral therapy aimed at

the recognition and analysis of anxious cognition and the developmentof management strategies to cope with anxiety-provoking situations(Kendall, Chansky, etal.,1992).The focus was onfour related compo-nents:(a)recognitionofanxious feelingsandsomatic reactionstoanxi-ety; (b) clarification ofanxious cognitioninanxiety-provoking situa-tions(i.e. unrealisticornegative expectations); (c) developmentof acopingplan(i.e.,modifying anxious self-talk into coping self-talk, aswellas determining what coping actions might be effective); and (d)evaluationof performance and administration of self-reinforcement asappropriate. The therapist guides both theyoungster'sattributions aboutprior behavior and his or herexpectationsforfuturebehavior. Thus, theyoungster can acquire a cognitive structure forfutureevents that includes

2A16-week (4-month) waiting-listwasdeemedtoolongforclinicallyreferred cases. Such a long wait period may increase attrition (anddifferentialattrition),withmany parents seeking alternate treatment fortheirchildren during the wait period and, thereby, reducing the represen-tativeness of theresulting sample.

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37 KENDALL ET AL.

the adaptive skills and appropriate thinkingassociatedwith adaptivefunctioning (Kendall,1993).

Behavioral training strategies with demonstrated efficacy such asmodeling,invivoexposure,roleplay,relaxationtraining,andcontingentreinforcementwere used. Throughout, therapists used social reinforce-mentto encourage and reward thechildren,and children were promptedtoreinforce theirownsuccessful coping. Children were encouraged topractice theskillsin anxiety-provoking situations at home andschooland were rewarded for successfully completing weekly assignments.The firsthalfand thesecondhalf of thetreatment addressed differentcomponentsof theprogram.

Ineach of the first eightsessions,the basicconceptswere introduced,followedbypracticeand reinforcement of theskill.Session 1 was de-votedtobuilding rapportwiththechildandcollectingspecificinforma-tionaboutthesituationsandexperiencesinwhichthechildfeltanxiousandhis or herreactions tothat anxiety. Session 2introduced affectiveeducation through the identification of various kinds of feelings. InSession 3, ahierarchyofanxiety-producing situationswasdeveloped tohelpdistinguish anxious reactions fromothersand toidentifyhis or herownsomaticreactionstoanxiety.AfterSession3, aparent meeting tookplace toelicitmore information concerning the child's anxiety,discussparentalconcerns,andreviewthetreatment goals. Session4introducedrelaxation training (both progressive muscle relaxation and visualiza-tion) and its use incontrollinganxiety-relatedmuscle tension. Childrenwereprovided witha personalized relaxation cassettefor use outsideof the session. Session 5consistedof teaching the child to recognizeand assess anxious self-talk during anxiety-provoking situations and topractice alternate coping self-talk. Session 6 introduced the conceptof coping strategies and verbal self-direction, as well as developingappropriate actions to aid in coping with anxious situations. Session 7introduced theconcepts ofself-evaluation andself-reward. Session 8,thefinaltraining session,comprisedareviewof allconceptsandskillspresented during the previoussessions.

The second eightsessionsinvolved practicing theskillslearned, usingboth imaginaland invivo exposure, beginning with low-anxiety situa-tions and progressing to high stress and anxiety situations. Situationswere individualized foreach child to specifically address his or heranxieties. The child was encouraged to apply the newly learned skillsto these anxiety-provoking situations, and therapist modelingandroleplayswere used.The final session wasdevotedtopreparinga ' testimo-nial or commercial in which the child is the expert and the goal isteaching other children how to copewithdistressing anxiety. The childwas given a copy of the videotaped commercial to take home.

Treatment IntegrityAllsessions were audiotaped. Randomly, 15% of tapes wereselected

for each of thechild-therapist combinations andwere independentlyrated usingatreatment integritychecklist(usedinKendall, 1994) as-sessingconformity to theprocedures in themanual.

ResultsReliabilities

Diagnosticiansandobserversorraters were trained withwrit-tenandvideotape samples. Initial discrepancies were discussedto reach agreement. Diagnosticians met an initial reliability cri-teria of 85% agreement. Reliability (kappa,85%agreement)waschecked periodically,witheach diagnostician rating fourchild and four parent interviews. Interobserver reliability forcodingbehavioral observations(sixseparatecodes)andmakingglobal behavioral ratings (three ratings)also met thekappacriterionof 85%agreement.

Group ComparabilityOne-wayanalysesofvariance (ANOY\s)or chi-squareval-

ues(fornoncontinuousdata) were examinedforpretreatmentdifferences in age, gender, race and alldependent variables:Waiting-list andtreated participants were found not to differsignificantly. Similar analyses indicated nonsignificant differ-encesforparents' marital status,family income, mothers'andfathers'levelsofeducation,andmothers' andfathers' levelsofdepression (BDI)andanxiety(STAI).

Regardingsample representativeness, there werenonsignifi-cantdifferences(ANOVAsandchi-squarevalues)between com-pleters (n =94)anddropouts(n =24) inage, gender, race,primarydiagnosis (OAD, SAD,andAD), pretreatment scoresondependent measures, andparents'andteachers'ratings (oneexception: Mothers'ofdropouts reported less CBCLinternaliz-ingdistress thanmothersofcompleters,f(1, 115)=2.65,p 1 SDbelow themean (i.e.,

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376 KENDALL ETAL.

cant. When changesdue towaiting-listand due to the firsthalfof treatment were compared, the results were nonsignificant,indicating that the first half of the treatment, byitself,was notresponsiblefor the beneficial gains that were produced by theentire treatment.

Toprovide apreliminary evaluationof theeffects of thesec-ondsegment, the midpoint assessments were again used. How-ever,theseMANCAAswere2(treatmentvs.waiting-list)X 3(assessments; seeTable2 for themidpoint means).Fortheseanalyses,thethree assessmentsfor thetreatment condition wereat pre-, mid-and posttreatment whereas the assessments forthewaitlist condition wereprewaiting-list, postwaiting-list, andmidtreatment.Thus, across comparable durations(8weeksbe-tweenassessments),this analysis permitsapreliminary consid-eration of thesecondsegment of treatment: Changes over the 8weeksfrommidtreatmenttoposttreatment(treatment condition)were compared with changes overthe 8weeksfrom midtreat-

mentto posttreatment (treatment condition). Itmustbe noted,however, that this comparison addresses the relative effects ofthe first half of treatment versus thecombined effects of thefirst and second half of treatment. Thus, it is not a test of thesecond half of treatment alone.

UsingMANO\A,wefoundasignificantinteraction forchildself-report measures,F(}4,63) =2.81,p

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TREATING YOUTHS WITH ANXIETY DISORDERS 377

CBCLreports ofinternalized distress, F(2, 172)=47.04,p