Group and Individual Cognitive-Behavioral Treatments for Youth with Anxiety Disorders: A Randomized Clinical Trial

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1 Cognitive Therapy and Research, Vol. 24, No. 3, 2000, pp Group and Individual Cognitive-Behavioral Treatments for Youth with Anxiety Disorders: A Randomized Clinical Trial Ellen C. Flannery-Schroeder 1 and Philip C. Kendall 1 Children (aged 8 14 years) with anxiety disorders were randomly assigned to cognitive-behavioral individual treatment, cognitive-behavioral group treatment, or a waitlist control. Treatment outcome was evaluated using diagnostic status, child selfreports, and parent- and teacher-reports. Analyses of diagnostic status revealed that significantly more treated children (73% individual, 50% group) than wait-list children (8%) did not meet diagnostic criteria for their primary anxiety disorder at posttreatment. Other dependent measures demonstrated the superiority of both treatment conditions compared to the wait-list condition. However, a child-report of anxious distress demonstrated only the individual treatment to effect significant improvement. Measures of social functioning failed to discriminate among conditions. Analyses of clinical significance revealed that notable proportions of treated cases were returned to nondeviant limits at posttreatment. Treatment gains were maintained at a 3-month follow-up. KEY WORDS: anxiety disorders; child anxiety; group treatment; cognitive-behavioral therapy. The increasing body of research devoted to childhood anxiety disorders may well reflect the realization of the seriousness and debilitation associated with the disorders. Anxiety disorders have been demonstrated to the one of the most common categories of childhood and adolescent disorders (Bernstein & Borchardt, 1991; Fergusson, Horwood, & Lynsky, 1993; Kashani & Orvaschel, 1990). This parallels the findings that anxiety disorders are the most common psychiatric disorder in adults from the general population (Myers et al., 1984). Estimates of childhood anxiety disorders range from approximately 1% to 21% (e.g., Fergusson et al., 1993; Kashani & Orvaschel, 1990). Aside from the negative emotionality associated with the anxiety itself, childhood anxiety disorders have often been found to be comorbid with depression (Last, Hersen, Kazdin, Fin- 1 Department of Psychology, Temple University, Philadelphia, Pennsylvania. 2 Correspondence should be directed to Ellen C. Flannery-Schroeder, Department of Psychology, Temple University, Weiss Hall, Philadelphia, Pennsylvania /00/ $18.00/ Plenum Publishing Corporation

2 252 Flannery-Schroeder and Kendall kelstein, & Strauss, 1987; Strauss, Lease, Last, & Francis, 1988; see Brady & Kendall, 1992, for a review) and are frequently accompanied by somatic complaints (e.g., Beidel, Christ, & Long, 1991). In addition, research suggests that anxiety disorders do not readily remit in the absence of treatment (Kendall, 1994; Kendall et al., 1997) and are associated with negative long-term complications. Anxiety in youth has been found to impact negatively upon children s social adjustment (e.g., Benjamin, Costello, & Warren, 1990; Klein & Last, 1989; Rubin, 1985), academic achievement (e.g., Benjamin et al., 1990; King & Ollendick, 1989), and later emotional health in adolescence and adulthood (e.g., Achenbach & Edelbrock, 1981; Cantwell & Baker, 1989; Feehan, McGee, & Williams, 1993; Strain & Kerr, 1981). Empirical studies of interventions for childhood anxiety disorders have been increasing over the last decade. Cognitive-behavioral interventions appreciate the complexities of the interactions among behavior, cognition, affect, social factors, and environmental consequences, and these procedures have been used in the treatment of children s fears and phobias, fears in medical and dental settings, fears of evaluation, and anxiety disorders. Research has demonstrated their efficacy in the treatment of anxiety-disordered children (e.g., Eisen & Silverman, 1993; Kane & Kendall, 1989; Kendall, 1994; Kendall et al., 1997; Mansdorf & Lukens, 1987; Ollendick, Hagopian, & Huntzinger, 1991; see also Kazdin & Weisz, 1998). Kendall and colleagues developed and examined the efficacy of a treatment designed to reduce anxious symptomatology in children diagnosed with separation anxiety disorder, overanxious disorder/generalized anxiety disorder, and/or avoidant disorder/social phobia. The manualized treatment (Kendall, Kane, Howard, & Siqueland, 1990) combines both training and exposure components and has demonstrated efficacy in reducing the proportion of children who are diagnosed as anxiety-disordered at posttreatment. Maintenance of treatment gains were maintained across 1 year (Kendall, 1994; Kendall et al., 1997) and longer term (3.35 years) follow-ups (Kendall & Southam-Gerow, 1996). The majority of research on childhood anxiety disorders has utilized cognitivebehavioral procedures in a child-focused individual format, with fewer being conducted with families (Barrett, Dadds, & Rapee, 1996; Howard & Kendall, 1996), and fewer still in groups (Albano, Marten, Holt, Heimberg, & Barlow, 1995). Several cognitive-behavioral group treatments of anxiety in adulthood have been conducted, and all point toward their efficacy in the reduction of anxiety (e.g., Heimberg, Dodge, Hope, Kennedy, Zollo, & Becker, 1990; Renneberg, Goldstein, Phillips, & Chambless, 1990; Shaffer, Shapiro, Sank, & Coghlan, 1981). The majority of these studies with adults are well-controlled treatment outcome investigations, and the results are suggestive of their utility in childhood anxiety disorders. Although group treatments have been conducted with children for over 70 years, a substantial research literature has yet to be established. The use of cognitivebehavioral procedures in a group format appears to have potential advantages over their use in individual formats. Groups provide opportunities for social interactions, peer mediation (e.g., peer modeling, peer and group feedback), leadership, and multiple exposures to feared interpersonal contexts, objects, and/or situations. Also, it is likely that cognitive-behavioral groups therapies will offer some unique advantages (e.g., peer reinforcement, peer modeling, multiple exposures) which are diffi-

3 Group and Individual Cognitive-Behavioral Treatments 253 cult to implement in single-child formats. However, research is needed to determine for whom these strategies are the most effective, and additional research is essential in that group therapies may present some distinct disadvantages also worthy of consideration (Satterfield, 1994). The use of a group format in treating children with anxiety disorders appears to have a theortical foundation as well. Numerous research studies find social withdrawal and social reservedness to be correlated with anxiety (e.g., Hartup, 1983; Rubin, 1985; Strauss, Forehand, Smith, & Frame, 1986). Children who did not engage in peer interactions (versus those who did) were found to be more anxious and depressed (Strauss et al., 1986). Although social withdrawal is only a primary criterion in one of the three childhood anxiety disorders (i.e., social phobia), its presence is nonetheless significant in GAD/OAD and SAD. Children with OAD have been characterized as lonely, socially isolated, shy, unpopular, and socially unskilled (Strauss, 1988). SAD has been found to be associated with school refusal (Klein & Last, 1989); school is the location where the vast number of peer interactions occur. Therefore, failure to go to school indirectly results in a reduced number of peer social interactions. Thus, it appears that the implementation of a group format with anxiety-disordered children may result in enhanced treatment efficacy. The purpose of the present research was to evaluate a cognitive-behavioral group treatment for 8- to 14-year-old children diagnosed with a childhood anxiety disorder (i.e., Generalized Anxiety Disorder, Separation Anxious Disorder, Social Phobia). The research compared the efficacy of the cognitive-behavioral group treatment (GCBT) with that of individual cognitive-behavioral treatment (ICBT) and a wait-list control condition (WL). However, due to small sample sizes, the comparison of the group and individual treatments is to be considered preliminary. The cognitive-behavioral therapy protocol that was used for both the GCBT and ICBT conditions consisted of an 18-week manualized intervention. The therapy involved training children to use a variety of coping skills to address the somatic, emotional, cognitive, and behavioral components of anxiety. The first half of treatment consisted in building coping skills and strategies; the second half involved practice using the skills in in vivo exposures to the anxiety-producing situations specific to the child. The treatment also made use of relaxation, problem-solving, role plays, social reward, coping modeling, and homework assignments. The three conditions (GCBT, ICBT, WL) were compared to assess differential outcome. It was expected that the GCBT would lead to equal or greater responsiveness to treatment than the ICBT depending upon type of measure examined. It was hypothesized that the GCBT versus the ICBT would effect significant increases in social competence, friendships, and social activities and significant decreases in social anxiety and loneliness posttreatment. Pre- to posttreatment comparisons of diagnostic status, manifest anxiety, state and trait anxiety, number of excessive fears, internalizing behavior, and perceptions of the therapeutic relationship were expected to yield nonsignificant differences between the GCBT and ICBT. Both treatment conditions were expected to be significantly more efficacious than the WL. Posttreatment gains were expected to be maintained at a 3-month follow-up.

4 254 Flannery-Schroeder and Kendall METHOD Participants Thirty-seven 8- to 14-year-old clinic-referred children, referred from multiple community resources in the tri-state area (PA, NJ, DE), served as participants. The 37 children came from a total sample of 45 participants (8 children failed to complete the treatment protocol). Of the 8 children who failed to complete the protocol, 2 withdrew during the 9-week waiting period, 2 withdrew prior to the first treatment session (1 assigned to the GCBT; 1 assigned to the ICBT), and 4 withdrew during treatment (all 4 from the ICBT). No participants in the GCBT dropped out during treatment. Twenty-five children were treated initially (13 ICBT; 12 GCBT) and the remaining 12 were treated following the 9-week WL period. In the ICBT, 46% were boys and 8% were minorities. Thirty-eight percent were age 8 10 years and 62% were years. In the GCBT, 67% were boys and 17% were minorities. Eightythree percent were age 8 10 years and 17% were age years. In the WL, 42% were boys and 8% were minorities. Fifty percent were age 8 10 years and 50% were years. All children met DSM-IV diagnostic criteria for a childhood anxiety disorder (Generalized Anxiety Disorder, n 21; Separation Anxious Disorder, n 11; Social Phobia, n 5) and completed an 18-week, cognitive-behavioral treatment protocol. In the ICBT, 23% were comorbid with simple phobia, 15% with ADHD, and 8% with dysthymia. None was comorbid with oppositional defiant disorder (ODD), major depression, or conduct disorder. In the GCBT, 50% were comorbid with simple phobia, 33% with ADHD, 8% with dysthymia, 25% with ODD, and 8% with major depression. None was comorbid with conduct disorder. In the WL, 17% were comorbid with simple phobia and 23% with ADHD. None was comorbid with dysthymia, oppositional defiant disorder (ODD), major depression, or conduct disorder. 3 Exclusion criteria for participation included a disabling physical condition, psychotic symptoms, or current use of antianxiety or antidepressant medication. Children whose primary diagnosis was simple phobia were not included; children who had simple phobia as secondary problems were included. Participants in the ICBT and GCBT conditions who missed four or more sessions were not included in the data analyses. Four participants (i.e., noncompleters) met criteria for this exclusion. All noncompleters were from the ICBT condition. Due to the longitudinal nature of the study, children and their families were fully informed of the procedures of the study, which included participating in multiple assessments (e.g., pretreatment, posttreatment, and 3 months following treatment). Setting and Personnel Therapy was provided by eight (six female; two male) doctoral candidates within the Child and Adolescent Anxiety Disorders Clinic (CAADC) of the Clinical 3 Chi-square analyses indicated that with the exception of ODD, 2 (1) 6.80, p.05, none of the rates of comorbidity differed among the three conditions. Further analyses demonstrated that comorbidity with ODD was unrelated to treatment outcome (p.05).

5 Group and Individual Cognitive-Behavioral Treatments 255 Psychology Program at Temple University. The therapists underwent training including didactic presentation, role-plays, videotape observation, and discussion and participated in 2 h of weekly supervision. Therapists did not work with one treatment format (either ICBT or GCBT) exclusively. In other words, several therapists treated both individual cases and group cases. Measures Children, parents, teachers, and diagnosticians completed a variety of instruments to provide a multimethod assessment of child functioning. This study included child self-report measures, parent and teacher ratings, and a structured diagnostic interview. These assessments were completed pretreatment/pre- wait-list, post-waitlist, posttreatment, and 3 months posttreatment. All measures were administered by a diagnostician, not the child s therapist. Child Measures Several self-report measures assessed fears and anxieties in children. A measure of chronic (trait) anxiety was provided by the Revised Children s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978, 1985). The 48-item scale (11 lie items) has internal consistency (Kuder Richardson values from.83 to.85) and adequate retest reliability (r.68 over 9 months). Analyses of convergent validity yield correlations of.85 between the RCMAS and the STAIC A-Trait scale. An index of discriminant validity was provided by the measure s low correlation (r.35) with a state measure of anxiety (STAIC A-State) (Reynolds & Richmond, 1985). The State-Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973) includes two 20-item scales that measure the enduring tendency to experience anxiety (A-Trait) and the situational and temporal variations in the level of perceived anxiety (A-State). Retest reliability over a 6-week interval ranged between.65 and.71 for the A-Trait scale and.31 and.47 for the A-State scale. Concurrent validity was assessed by the STAIC A-Trait s correlations with the Children s Manifest Anxiety Scale (Castaneda, McCandless, & Palermo, 1956), r.75, and the General Anxiety Scale for Children (Sarason, Davidson, Lighthall, Waite, & Ruebush, 1960), r.63. Normative data are available (Spielberger, 1973). The Coping Questionnaire-Child (CQ-C) (Kendall, 1994) is a self-report measure assessing a child s perceived ability to cope with various anxiety-provoking situations. In order for the situations to be relevant, situationally based, and individualized, three situations are chosen from information given during the diagnostic interview. The CQ-C enables the evaluation of improvements in specific target areas. The CQ-C has been found to be internally consistent, sensitive to treatment effects, and to have good retest reliability (Kendall & Marrs-Garcia, n.d.). The Social Anxiety Scale for Children-Revised (SASC-R; La Greca & Stone, 1993) consists of 22 statements which children rate on a 5-point Likert scale. The SASC-R has adequate internal consistencies (.69.86), and social anxiety scores correlate significantly with general anxiety (e.g., RCMAS). In addition, SASC scores have been found to correlate with self-reports of social acceptance (La Greca, Dandes, Wick, Shaw, & Stone, 1988).

6 256 Flannery-Schroeder and Kendall The Children s Depression Inventory (CDI; Kovaks, 1981) assesses the cognitive, affective, and behavioral symptoms of depression. The 27-item scale has high internal consistency, moderate retest reliability, and correlates in expected directions with measures of related constructs such as self-esteem, negative cognitive attributions, and hopelessness (Kazdin, French, Unis, Esveldt-Dawson, & Sherick, 1983; Kovacs, 1981). Normative data are available (Finch, Saylor, & Edwards, 1985; Saylor, Finch, Spirito, & Bennett, 1984). The child s perceived competence in several areas was assessed by Harter s Self Perception Profile for Children (SPPC; Harter, 1985). The SPPC is composed of 36 items in a structured-alternative format which asks the child to first identify which of two statements best describes him/her. The measure yields subscale scores in six domains (scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, and a general self-worth score). Internal consistencies of the subscales have been found to range from.73 to.86, and retest reliabilities for the subscales and general self-worth score range from.70 to.87 (Harter, 1985). A measure of children s perceived loneliness was attained through the use of the Loneliness Scale (LS; Asher, Hymel, & Renshaw, 1984). The LS consists of 24 items that assess children s feelings of loneliness and social dissatisfaction. Children are asked to respond on a 5-point Likert scale with the degree to which they feel the statements are true of themselves. Sixteen of the items comprise the loneliness score. The scale is internally consistent (Cronbach s alpha.90) and internally reliable (split half correlations.91; Spearman Brown reliability coefficient.91) (Asher et al., 1984). Additionally, scores have been found to be significantly negatively correlated with friendship nominations and play ratings received from same-gender peers (Asher et al., 1984). The Friendship Measure-Child (FM-C) is comprised of a subset of items from the Friendship Questionnaire (FQ; Bierman & McCauley, 1987). The items on the FQ fall into three distinct factors (positive interactions, negative interactions, and extensiveness of peer network). The items which comprise the positive interactions factor are those items included in the FM-C. Five additional questions on the FM-C assessed the number of friendships and contacts made with other children participating in the treatment program. Participants endorsed items on the FM-C using a 5-point Likert scale. The FQ (Bierman & McCauley, 1987) discriminates between children with positive versus rejected/neglected social status and correlates significantly with teacher and parent reports of behavior and social competence. The Recall of Content Questionnaire (RCQ) is comprised of five open-ended questions that require the respondent to recall information that was presented during the treatment protocol. The questionnaire was developed to measure the amount of treatment content recall and to examine differences between the GCBT and ICBT conditions. Children in the ICBT and GCBT completed the Child s Perception of Therapeutic Relationship (CPTR; Kendall, 1994) measure at the completion of treatment. This measure is a 10-item, 5-point scale which assesses perceptions of the quality of the therapeutic relationship. Items include rating the therapist in terms of how much the child liked him/her, how close the therapist was to the child, how much

7 Group and Individual Cognitive-Behavioral Treatments 257 time the child would like to spend with the therapist, and to what degree the child feels he/she can talk to the therapist. Other items assess the nature and quality of the therapeutic relationship. Several questions are filler items that are not scored. Children in the group condition completed the Child s Perception of the Group Relationship measure (CPGR) at the end of treatment. The CPGR corresponds to the CPTR with each item modified to apply to the group rather than the therapist. A measure of group satisfaction was completed by only those children assigned to the GCBT. The measure was designed for use in the present study and is referred to as the Group Satisfaction Questionnaire (GSQ). The GSQ is comprised of ten 5-point questions assessing the degree to which a child liked other group members, the therapist, the group activities, and the degree to which he/she felt a part of the group. The GSQ was completed at posttreatment and follow-up assessments. Parent Measures Parents (i.e., mothers and fathers) completed six measures concerning child functioning. The Child Behavior Checklist (CBCL; Achenbach, 1991a) is composed of 138 items, 20 of which assess social competencies and 118 of which assess behavioral problems. The behavioral items are rated on a 3-point scale. CBCL Internalizing scores were used to assess change across assessment periods. The CBCL has exhibited good retest reliability (r.87 over 1 week, r.62 over 1 year) and interparent agreement (r.65.76). Content and criterion-related validity have been adequately demonstrated, as nearly all CBCL items as well as scale scores and clinical cutpoints on the scale scores discriminated between referred and nonreferred children. Construct validity has been assessed by the correlations between the CBCL scales and the closest counterpart scales of the Connors (1973) Parent Questionnaire (r.56.86) and the Quay Peterson (1983) Revised Behavior Problem Checklist (r.52.88). Normative data are available for both clinical and nonclinical samples (Achenbach, 1991a). The State-Trait Anxiety Inventory for Children-Parent version (STAIC-P; Strauss, 1987) is a modified version of the Trait scale of the STAIC and was used to assess parents ratings of their children s trait anxiety. Parents endorse the frequency with which several statements apply to their child on a 3-point scale. The Coping Questionnaire Parent (CQ-P) parallels the children s version described previously. The parent rated the child s ability to cope with the three situations which were derived from information given during the diagnostic interview. The measure has been found to have good internal consistency, retest reliability, and sensitivity to treatment effects (Kendall & Marrs-Garcia, 1997). The Parent s Rating Scale of Child s Competence (PRSC; Harter, 1982) corresponds to the children s version. It is composed of 28 items which assess the child s specific competencies and three items which require the parent to provide a global rating for intellectual competence, social competence, and physical competence. The Social Activities Scale-Parent (SAS-P) measures children s participation in social activities and was designed to enable the measurement of potential changes in the type or amount of social activities over time. The SAS-P consists of two questions that ask the parents to list those group social activities in which their children participate currently or participated in the past. Parents also indicate the

8 258 Flannery-Schroeder and Kendall length of time the child participated in the listed activities and the age of the child when he/she participated. The Friendship Measure-Parent (FM-P) corresponds to the children s version. The parent is asked to respond on a 5-point Likert scale to 10 questions assessing their perceptions of their children s peer relationships. Teacher Measures Teachers completed the Teacher Report Form (TRF; Achenbach, 1991b). The TRF is similar in format to the CBCL. This measure is particularly useful in the measurement of change in social and evaluative contexts (e.g., school). The TRF has demonstrated high retest reliability (r.90.92) over an interval of 15 days. Interteacher agreements range from.54 (problem scores) to.55 (academic and adaptive scores) under different conditions and teacher teacher s aide agreements range from.55 (problem scores) to.60 (academic and adaptive scores) under similar conditions. The validity of the TRF has been supported by the ability of most items to discriminate successfully between referred and nonreferred children. Normative data have been reported (Achenbach, 1991b). Structured Diagnostic Interview Clinical diagnosticians used the Anxiety Disorder Interview Schedule (ADIS- IV-C and ADIS-IV-P; Silverman & Albano, 1996), a structured diagnostic interview schedule consistent with the DSM-IV criteria, to assess child functioning in separate interviews with the child and with the parents. The ADIS-IV is geared toward the diagnosis of childhood anxiety disorders, but the inclusion of other disorders (e.g., dysthymia, attention deficit hyperactivity disorder, panic disorder) allowed the diagnostician to assess alternative conditions. Procedure Cases came from the children who were routinely referred to the CAADC by multiple community agencies and schools. Within a week of referral, clinic staff arranged an intake evaluation (Pre 1) with the parents. Parents and the child signed informed consent and completed the measures on site; the teacher forms were sent home with the parents to be given to the teacher within the week. Teachers were provided with stamped envelopes to mail forms. Children receiving a childhood anxiety disorder diagnosis were randomly assigned to either the WL control (9- week) condition, ICBT, or GCBT (one of four single-gender groups). Those participants assigned to the WL completed another assessment evaluation (Pre 2) at the end of the waiting period and prior to entering their treatment. These participants were then randomly assigned to either group or individual treatment. A restricted randomization procedure was used in which participants assigned to the GCBT (either immediately or following wait-list) were assigned in blocks of four. Children and parents who were assigned to the GCBT signed an agreement of confidentiality within the group. All participants were assessed again after treatment (Post) and 3 months following treatment (Follow-up). All assessments followed the same procedures as in the initial evaluation.

9 Group and Individual Cognitive-Behavioral Treatments 259 Intervention The treatment protocol adapted the manual by Kendall et al. (1990) for use in the group condition (Flannery-Schroeder & Kendall, 1996). Treatment methods included education including learning to recognize anxious feelings, physiological reactions to anxiety, and negative thoughts. Behavioral strategies included coping modeling, role playing, relaxation training, contingent reinforcement, and in vivo exposures. The therapist provided each child with the Coping cat workbook (Kendall, 1990) as an aid in learning the coping skills presented during treatment. Children recorded their homework assignments ( Show That I Can or STIC tasks) in the Coping cat notebook and brought this notebook along with them to each session. The therapist reviewed the STIC tasks with the children at the start of each session. Treated participants received the cognitive-behavioral treatment protocol in either an individual or group format. The treatment consisted of 18 weeks of 50- to 60-min sessions for the individual treatment, 18 weeks of 90-min sessions for the group treatment, both typically meeting once a week. The treatment was largely child-centered; however, several parent sessions were included in both treatment formats. The first half of the treatment protocol involved the teaching of coping skills; the second half involved exposure to anxiety-eliciting situations and the practice of the skills acquired in the first half of treatment. Both treatments consisted of four main components: (1) the recognition and labeling of somatic reactions and anxious feelings; (2) the recognition and modification of anxious self-talk; (3) the development of a plan to cope with the anxious situation; and (4) the evaluation of performance and provision of reward. The treatment outline for the individual treatment was as follows: The first session included rapport-building, the identification of specific situations that the child found frightening, and the normalization of anxiety and anxious reactions. The second session involved affective education and the identification of various emotions. Session 3 included construction of a hierarchy of anxiety-provoking situations and identification of individual responses to anxiety. After session 3, a parent meeting was held to elicit more information concerning the child s anxious behavior and to provide additional information to the parents. Session 4 was devoted to relaxation training, and children received a personalized relaxation training audiotape for their use at home. Session 5 focused on introducing the concept of selftalk and identifying self-talk in anxiety-provoking situations. Session 6 emphasized the modification of noncoping self-talk and the development of problem-solving strategies for anxiety management. Session 7 introduced self-evaluation and selfreward following attempts at managing anxiety. Session 8 involved a review of the skills and their use in a four-step plan for coping with anxiety. Session 9 involved a review of the material covered during the first half of the treatment. Sessions involved practicing the skills learned in the first half of the treatment. Skills were first applied to imaginal situations with low levels of anxiety and then gradually progressed to in vivo exposures with increasing levels of anxiety. At the close of the therapy, the child was asked to make a commercial that summed up what he/ she learned during the program. This provided an opportunity for consolidation of

10 260 Flannery-Schroeder and Kendall skills learned during therapy, and the child was given a videotaped copy to take home. Following the last session, a posttreatment assessment was conducted. The treatment outline for the group treatment was as follows: The first session included rapport-building and the outlining of basic information about the program. The second session involved affective education and the identification of various emotions. Session 3 included the identification of individual responses to anxiety. Session 4 involved the normalization of the experience of anxiety and the construction of a hierarchy of anxiety-eliciting situations for both the group as a whole and for individual members. After session 4, parent meetings were held individually with each group member s parents to elicit more information concerning the child s anxious behavior and to provide additional information to the parents. Session 5 was devoted to relaxation training, and each group member received a personalized relaxation training audiotape for their use at home. Session 6 focused on introducing the concept of self-talk and identifying self-talk in anxiety-provoking situations. Session 7 emphasized the modification of noncoping self-talk and the development of problem-solving strategies for anxiety management. Session 8 introduced selfevaluation and self-reward following attempts at managing anxiety. Session 9 involved a review of the skills and their use in a four-step plan for coping with anxiety. Session 10 was a group social event designed to continue to heighten group cohesion and affiliation. Sessions involved practicing the skills learned in the first half of the treatment. Skills were first applied to imaginal situations with low levels of anxiety and then gradually progressed to in vivo exposures with increasing levels of anxiety. In vivo exposures began with group participation and progressed to individually conducted exposures. At the close of the therapy, the group made a commercial that summed up what they learned during the program. This was intended to serve as an opportunity for consolidation of skills learned during therapy, and each group member was given a videotaped copy to take home. Following the last session, the posttreatment assessments were conducted. RESULTS Power Analyses Effect sizes found by Kendall (1994) in a similar randomized clinical trial of anxiety disorders in children were found to average greater than one standard deviation for the treatment condition and less than 1/10 of one standard deviation for the wait-list condition. Using Cohen s (1977) f, estimates of effect size for significant interactions (condition by assessment period) averaged.47. Power estimates as determined from Kendall (1994) demonstrate that the power actually obtained averaged.83 on measures which assessed anxiety (e.g., RCMAS, STAIC- A-State, and A-Trait) and internalized distress (Internalizing score on the CBCL and TRF). Using Cohen s (1977) guidelines, with 12 ICBT, 12 GCBT, and 12 control participants, the power to detect a strong within-participants (assessment period) main effect is.91. Power to detect medium and small within-participant main effects

11 Group and Individual Cognitive-Behavioral Treatments 261 is.54 and.12, respectively. The power to detect a strong between-participants (condition) main effect is.84. Power to detect medium and small between-participant main effects is.43 and.10, respectively. The power to detect a strong interaction (condition by assessment period) effect is.84. Power to detect small and medium interaction effects is.43 and.10, respectively. Reliabilities Diagnosticians were trained to use the structured interview (ADIS) via written and videotaped samples. A reliability criterion of 85% agreement (kappa) was set and obtained by all diagnosticians prior to the study. Group Comparability One-way analyses of variance (ANOVAs) and chi-square analyses were used to assess for pretreatment differences in age, gender, race, family income, mother s level of education, and father s level of education; no significant differences were found among conditions (WL, ICBT, GCBT). In a comparison of pretreatment dependent variable scores across conditions, some means on child-reported measures were found to differ significantly. Scores on the STAIC-A-State, F(2, 34) 13.53, p.001, and the STAIC-A-Trait, F(2, 34) 6.81, p.01, were significantly lower in the GCBT compared to the ICBT and WL conditions. The mean scores on these measures did not differ significantly between ICBT and WL conditions. Additionally, mean scores in the GCBT were significantly lower than scores in the WL condition on the LS, F(2, 34) 3.39, p.05, and the SASC-R, F(2, 34) 5.39, p.01. Mean scores on these two measures did not differ significantly between GCBT and ICBT or between ICBT and WL. 4 In analyses comparing treatment completers and noncompleters, the groups did not differ in age, gender, race, or family income. However, the groups did differ on primary diagnoses and some dependent measures. A greater percentage of children who dropped out had social phobia as their primary diagnosis, 2 (2) 9.13, p.01. Additionally, noncompleters reported significantly less depressive symptoms (CDI) at the pretreatment assessment, t(26) 2.85, p.01. Mothers of noncompleters reported significantly less child anxiety on the STAIC-P, t(42) 2.25, p.05; fathers of noncompleters reported significantly higher coping scores on the CQ-C, t(43) 2.13, p.05. The remaining dependent measures yielded nonsignificant differences between completers and noncompleters. Therapist Comparability An examination of therapist effects revealed nonsignificant relationships with treatment gains or maintenance of treatment gains. In other words, individual therapists (therapist a, b, c,..., k) and therapist s experience (number of times 4 Analyses of covariance were considered, but deemed inappropriate in this instance due to the lack of independence between the covariates (e.g., pretreatment scores) and the independent variable (condition).

12 262 Flannery-Schroeder and Kendall Table I. Means and Standard Deviations for Dependent Measures in Tests of Differential Treatment Gains Individual Group Wait-list control Measure Pretest Posttest Pretest Posttest Pretest Posttest Child self-report STAIC A-State M SD A-Trait M SD RCMAS M SD SPPC-Social M SD LS M SD FM-C M SD SASC-R-Total M SD CQ-C M SD CDI M SD a therapist completed the treatment protocol) were unrelated to treatment outcome or maintenance of gains. Treatment Integrity An independent experienced cognitive-behavioral therapist reviewed 10% of randomly selected audiotapes and videotapes of treatment sessions. The rater completed treatment integrity checklists (used in Kendall, 1994; Kendall et al., 1997) to assess adherence to the treatment manual. All sessions and therapists were represented in the rated sample. Adherence to treatment content and session goals was rated 100%, and no other forms of intervention (i.e., alternative treatment strategies) were used. Treatment Outcome Treatment outcome was assessed via two methods: (a) analyses of diagnostic status and (b) analyses of the child-, parent-, and teacher-reports. The latter were analyzed using 3 (Condition: WL, ICBT, GCBT) 2 (Assessment Period: pre, post)

13 Group and Individual Cognitive-Behavioral Treatments 263 Table I. (Continued) Individual Group Wait-list control Measure Pretest Posttest Pretest Posttest Pretest Posttest Parent- and teacher-report STAIC-P Mother-report M SD Father-report M SD CQ-P Mother-report M SD Father-report M SD PRSC-Social a M SD FM-P a M SD SAS-P-Current a M SD CBCL-internalizing T Mother-report M SD Father-report M SD TRF Internalizing T M SD Note: STAIC, State-Trait Anxiety Inventory for Children; RCMAS, Revised Children s Manifest Anxiety Scale; SPPC-Social, Self-Perception Profile for Children-Social Acceptance subscale; LS, Loneliness Scale; FM-C, Friendship Measure-Child; SASCR-Total, Social Anxiety Scale for Children-Revised- Total of subscales; CQ-C, Coping Questionnaire-Child; CDI, Children s Depression Inventory; STAIC- P, State-Trait Anxiety Inventory for Children-Parent version; CQ-P, Coping Questionnaire; PRSC- Social, Parent s Rating Scale of Child s Competence; FM-P, Friendship Measure-Parent, SAS-P, Social Activities Scale-Current Number of Social Activities; CBCl, Child-Behavior Checklist; TRF, Teacher Report Form. a Mother- and father-reports were averaged on these measures. mixed factorial analyses of variance. Multivariate analyses of variance (MANOVAs) and Wilks criterion were used on highly interrelated, same-method, same-constructdependent measures. Univariate analyses of variance (ANOVAs) were used on dependent measures which singularly assessed a particular construct (e. g., CDI for depressive symptomatology). Means and standard deviations are presented in Table I, and changes across treatment and follow-up are presented in Fig. 1 and 2. When significant interactions were found, only the interactions were interpreted. Due to

14 264 Flannery-Schroeder and Kendall Fig. 1. Changes on child self-reports for treated and wait-list participants as a function of condition and assessment period. Note that follow-up includes all treated participants. the significant number of dependent measures examined, Bonferroni adjustments were used to make hypothesis-wise corrections. Diagnostic Status Using parent-reports of child s diagnostic status, analyses were performed to assess the percentage of children who did/did not meet criteria for their primary anxiety disorder at posttreatment. Only 8% of the WL condition did not meet criteria for their primary anxiety disorder at posttreatment, whereas 73% of the ICBT and 50% of the GCBT did not meet criteria at posttreatment. The differences among the three conditions were significant, 2 (2) 10.09, p.01. A comparison of ICBT and GCBT conditions yielded a nonsignificant difference (p.05). In an evaluation of the percentage of children in each condition who no longer met criteria for any anxiety disorder (i.e., GAD, SAD, or SP) at posttreatment, significant differences were found among conditions, 2 (2) 11.25, p.01. No one in the WL did not meet criteria for at least one of these disorders, yet 64% of children in the ICBT and 50% of children in the GCBT failed to meet criteria for GAD, SAD, or SP.

15 Group and Individual Cognitive-Behavioral Treatments 265 Fig. 2. Changes on parent- and teacher-reports for treated and wait-list participants as a function of condition and assessment period. Note that follow-up includes all treated participants.

16 266 Flannery-Schroeder and Kendall Although several children retained a diagnosis at posttreatment (GCBT, n 8; ICBT, n 5), analyses conducted on ADIS-IV severity scores of the persisting diagnosis revealed that severity was significantly reduced from pre- to posttreatment for children in the GCBT, t(7) 3.42, p.05. Severity of the persisting diagnosis was not significantly reduced for children in the ICBT. Child-, Parent-, and Teacher-Reports Using MANOVA, the combination of dependent measures assessing anxiety (STAIC-A-State, STAIC-A-Trait, RCMAS) demonstrated a significant interaction between condition and assessment period, F(6, 54) 2.71, p.03. Univariate analyses revealed that both the A-Trait and A-State measures yielded significant Condition by Assessment Period interactions, F(2, 29) 4.67, p.02, and F(2, 29) 4.66, p.02, respectively. Using the A-Trait, simple main effects (Assessment Period within Condition) demonstrated that both the ICBT, F(1, 29) 31.62, p.001, and the GCBT, F(1, 29) 6.18, p.02, demonstrated a significant reduction from pre- to posttreatment. Using Cohen s (1977) formula for simple main effect sizes, the effect size for the ICBT was f 1.75; the effect size for the GCBT was f.72. The WL condition failed to demonstrate significant change. Using the A- State, only the ICBT evidenced improvement across treatment, F(1, 29) 14.24, p.001. The effect size for the ICBT was f Neither the GCBT nor WL condition revealed a significant reduction in anxiety across assessments (see Fig. 1). A MANOVA conducted on combined child-reports of social functioning (SPPC Social Acceptance subscale, LS, FM-C, SASC-R) yielded a main effect for Condition, F(8, 56) 2.46, p.03, and Assessment Period, F(4, 28) 5.64, p.01, and a nonsignificant interaction (p.03). Separate ANOVAs were conducted on CQ-C and CDI as these were considered to be separate constructs each measured by a singular dependent measure. Using the CQ-C, a significant Condition by Assessment Period interaction was found, F(2, 32) 7.88, p.01. Simple main effects (Assessment Period within Condition) demonstrated that both treated groups improved their self-reported coping from pre- to posttreatment ICBT, F(1, 32) 10.40, p.01; GCBT, F(1, 32) 42.82, p.001. The WL condition failed to demonstrate change. Effect sizes for the ICBT and GCBT were f.92 and f 1.87, respectively (see Fig. 1). A significant main effect for Assessment Period was found for child-reported depression, F(1, 32) 5.50, p.03. The interaction was nonsignificant. A one-way ANOVA was conducted to compare scores on the RCQ. Posttreatment means differed significantly between the ICBT (M 13.27) and GCBT (M 8.64), F(1, 23) 5.87, p.03. GCBT participants recalled significantly less information relating to the treatment protocol (e.g., What are the FEAR steps? What is a thought bubble?). Additionally, posttreatment means were compared on the CPTR using ANOVA. There was no significant difference between the ICBT (M 23.53) and GCBT (M 23.43). A MANOVA conducted on the combination of mother s and father s reports of child s anxiety (STAIC-P) demonstrated a significant interaction between Condition and Assessment Period, F(4, 62) 7.02, p.001. Univariate F-tests demonstrated interactions for father-report, F(2, 32) 12.58, p.001. Simple effects showed

17 Group and Individual Cognitive-Behavioral Treatments 267 significant reductions in anxiety for both the ICBT,F(1, 32) 30.76, p.001, and GCBT, F(1, 32) 49.22, p.001, but not for the WL condition. Effect sizes for the ICBT and GCBT were f 1.64 and f 2.00, respectively (see Fig. 2). Mother-report failed to demonstrate a significant interaction (p.025); however, main effects for both Condition, F(2, 32) 4.60, p.025, and Assessment Period, F(1, 32) 29.05, p.025, were found. A MANOVA was conducted on mother s and father s report of child s ability to cope with specific anxiety-provoking situations (MCQ, FCQ). A significant interaction was found, F(4, 62) 10.21, p.001. Univariate ANOVAs revealed significant interactions on both mother-report, F(2, 32) 18.53, p.001, and fatherreport, F(2, 32) 17.45, p.001. Simple main effects (Assessment Period with Condition) on mother-reported coping demonstrated that both the ICBT, F(1, 32) 51.80, p.001, and the GCBT, F(1, 32) 44.52, p.001, evidenced increases in coping from pre- to posttreatment. Nonsignificant change was noted in the WL condition. Effect sizes for the ICBT and GCBT conditions were f 2.15 and f 1.90, respectively. Simple main effects on father-reported coping revealed similar results. Both the ICBT and GCBT showed an increase in coping across treatment, F(1, 32) 43.16, p.001, and F(1, 32) 63.24, p.001, respectively. Pre to post change was not found in the WL condition. Effect size for the ICBT was f 2.58; the GCBT was f 3.21 (see Fig. 2). Using MANOVA on the combination of dependent measures assessing social functioning (mother- and father-reports on the PRSC-Social Acceptance subscale, FM-P, SAS-P), neither significant main effects nor interaction were found (p.03). Using MANOVA on the combination of mother-, father-, and teacher-reports on CBCL/TRF-Internalizing T scores, the Condition by Assessment Period Interaction was significant, F(6, 54) 3.12, p.02. Univariate tests indicated an interaction on father-reports of internalized distress, F(2, 29) 8.30, p.01. Simple main effects on father-reports demonstrated that both the ICBT and GCBT showed a decrease in internalized distress across treatment, F(1, 29) 25.76, p.001, and F(1, 29) 21.46, p.001, respectively. The WL condition failed to effect significant change. Effect size for the ICBT was f 2.25; the GCBT was f 1.43 (see Fig. 2). Mother- and teacher-reports yielded a nonsignificant interaction (p.02). Intent-to-Treat Analyses Treatment effects were also assessed using the intent-to-treat sample (i.e., treatment and treatment noncompleters). Noncompleters (n 6) included were those participants who were involved at the point of randomization to condition. Diagnostic Status Using parent-reports of child s diagnostic status, analyses were performed to assess the percentage of children who did/did not meet criteria for their primary anxiety disorder at the postassessment. Pretreatment diagnoses were substituted for posttreatment diagnoses for participants who did not complete the treatment protocol. Only 8% of the WL condition did not meet criteria for their primary anxiety disorder at posttreatment, whereas 50% of the ICBT and 46% of the GCBT

18 268 Flannery-Schroeder and Kendall did not meet criteria at posttreatment. These differences among conditions were significant, 2 (2) 5.82, p.05. In an evaluation of the percentage of children in each condition who no longer met criteria for any anxiety disorder (i.e., GAD, SAD, or SP), significant differences were found among conditions, 2 (2) 7.90, p.01. Although no one in the WL did not meet criteria for at least one of these disorders, 44% of children in the ICBT and 46% of children in the GCBT failed to meet criteria for GAD, SAD, or SP. Child-, Parent-, and Teacher-Reports Analyses of the intent-to-treat sample paralleled those used in analyses involving treatment completers (i.e., 3 2 Condition by Assessment Period mixed factorial analyses of variance). Pretreatment scores were substituted for posttreatment scores for participants who did not complete the treatment. Using MANOVA on the combination of child self-report measures assessing anxiety (STAIC-A-State, STAIC-A-Trait, RCMAS), main effects for Condition, F(6, 66) 3.99, p.01, and Assessment Period, F(3, 33) 7.53, p.001, were found. The interaction was nonsignificant (p.03). Similarly, only main effects for Condition, F(8, 66) 2.74, p.02, and Assessment Period, F(4, 33) 4.40, p.01, were found on the combination of dependent measures of child-reported social functioning (SPPC Social Acceptance subscale, LS, FM-C, SASC-R). Using ANOVA on the CQ-C, a Condition by Assessment Period interaction was noted, F(2, 36) 5.69, p.01. Simple main effects tests (Assessment Period within Condition) revealed that both the ICBT, F(1, 36) 14.20, p.001, Cohen s f.91, and GCBT, F(1, 36) 35.14, p.001, Cohen s f 1.62, showed significant improvement in child coping. The WL failed to demonstrate pre- to posttreatment gains. An ANOVA on the CDI indicated main effects for Condition, F(2, 38) 4.30, p.05, and Assessment Period, F(1, 38) 4.93, p.05. The interaction was nonsignificant. An interaction between Condition and Assessment Period was found on a MANOVA using parents reports of child anxiety (STAIC-P), F(4, 72) 5.33, p.01. Univariate analyses revealed only the fathers reports to be significant, F(2, 37) 8.45, p.01. Simple main effects (Assessment Period within Condition) demonstrate, according to father-reports, that both the ICBT, F(1, 37) 18.84, p.001, Cohen s f 1.09, and GCBT, F(1, 37) 38.26, p.001, Cohen s f 1.69, effected significant pre- to posttreatment improvements. The WL did not elicit significant change across assessments. A significant Condition by Assessment Period interaction was found for mother- and father-reports on the CQ-P, F(4, 72) 5.57, p.001. Univariate tests indicated improvements on both mother-reports, F(2, 37) 10.29, p.001, and father-reports, F(2, 37) 9.00, p.001. Using mother-reports, simple main effects (Assessment Period within Condition) demonstrated significant improvements across assessments for only the treated groups, ICBT: F(1, 37) 28.43, p.001, Cohen s f 1.35; GCBT: F(1, 37) 29.89, p.001, Cohen s f Fatherreports revealed similar findings, ICBT: F(1, 37) 25.09, p.001, Cohen s f 1.27; GCBT: F(1, 37) 34.84, p.001, Cohen s f A MANOVA on the combination of parent-report measures assessing child