Copyright 1993 by the American Psychological Association, Inc.

0022-006X/93/$3.00

Jour nal of Consulting and Clinical Psychology

1993i. Vol. 61. No. 2. 235-247

Cognitive-Behavioral Therapies With Youth: Guiding Theory,

Current Status, and Emerging Developments
Philip C. Kendall
This article begins with a brief description of the guiding theory behind cognitive-behavioral
interventions with youth, such as a therapeutic posture, an important cognitive distinction, and a
specific treatment goal. Next, on the basis of a review of the literature, the nature of cognitive
functioning, the treatments, and the outcome of treatment studies are described and examined for
(a) aggression, (b) anxiety, (c) depression, and (d) attention-deficit hyperactivity. Conclusions and
emerging developments are provided.

sought to have a preventive influence, intervening to reduce

problems in youth at risk for later maladjustment (e.g., Weissberg, Caplan, & Harwood, 1991), whereas others have taken a
therapeutic approach, providing therapy for youth with identified psychopathology (e.g., Kendall, 199la). Some applications
have followed more behavioral guidelines (see Barkley, 1990);
others have been influenced by rational-emotive therapy (Bernard & Joyce, 1984). Some have sought to intervene at the level
of the family (e.g., Robin & Foster, 1989), the school (e.g., Elias,
1989), or the community (e.g., Glenwick & Jason, 1984),
whereas others work directly with youth (e.g., Kendall & Braswell, 1985).
Cognitive-behavioral approaches can be defined as a rational amalgam: a purposeful attempt to preserve the demonstrated positive effects of behavioral therapy within a less doctrinaire context and to incorporate the cognitive activities of the
client into the efforts to produce therapeutic change. Accordingly, cognitive-behavioral strategies with children and adolescents use enactive, performance-based procedures as well as
cognitive interventions to produce changes in thinking, feeling,
and behavior (Kendall, 199 Ib). The cognitive-behavioral analyses of child and adolescent disorders and adjustment problems,
as well as related analyses of treatment-produced gains, include
considerations of the child's internal and external environment,
and represent an integratoonist perspective (Meichenbaum,
1977). The model places the greatest emphasis on the learning
process and the influence of the contingencies and models in
the environment while underscoring the centrality of the individual's mediating-information-processing style in the development and remediation of psychological distress (Kendall,
1985). Cognitive-behavioral therapies do not insult the role of
affect and the social context. Rather, they integrate cognitive,
behavioral, affective, social, and contextual strategies for
change. The cognitive-behavioral model includes the relationships of cognition and behavior to the affective state of the
organism and the functioning of the organism in the larger
social context.

Central to a successful completion of childhood is the child's

development of a confident sense of mastery, of appropriate
social behavior, and of an ability to engage in self-control. As
children enter and pass through school and become more independently involved in social relationships, there is a new emphasis toward carrying through on activities and accomplishing
goals. The child must work to strike a balance between compliance with adult rules and the assertion of independent competence. Industrious work in school and social interactions are the
testing ground for children to compare themselves with others,
to gain a sense of self, and to acquire the skills needed to adjust
to the demands of the environment.
Adjusting and coping with these developmental challenges
can be a struggle for children, and not all manage the task
successfully. Indeed, current estimates of the amount of psychopathology in children in the United States are alarming. Recent
epidemiological data suggest that between 15% and 22% of the
nation's approximately 63 million youth have mental health
problems severe enough to warrant treatment (Costello, 1990;
National Advisory Mental Health Council, 1990). Yet, as Tuma
(1989) noted, of those in need of mental health care, less than
20% received the appropriate services. These data are probably
representative of a concern that is worldwide. Indeed, psychological maladjustment in youth is a major problem confronting
today's society.
All children face developmental challenges, yet not all of
these children are prepared, and not all of the challenges are
met. Thus, the issue facing clinical child psychology is how to
best intervene to reduce or remediate the cognitive, behavioral,
and emotional difficulties in childhood that are associated
with present psychological distress and later psychopathology.

Guiding Theory
Those involved in designing interventions for youth have approached their task from various perspectives. Some have
Preparation of this article was facilitated by National Institute of
Mental Health Grant 44042.
Correspondence concerning this article should be addressed to
Philip C. Kendall, Weiss Hall, Department of Psychology, Temple University, Philadelphia, Pennsylvania 19122.

Therapy With Youth: The Cognitive-Behavioral Posture

The "posture" (used here to refer to one's mental attitude) of
the cognitive-behavioral therapist working with youth can be
235

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PHILIP C. KENDALL

described using the terms consultant, diagnostician, and educator. As a consultant, the therapist is a person who does not have
all the answers but has some ideas worthy of trying out and
some ways to examine whether or not the ideas have value for
the individual youth. The consultant therapist helps create behavioral experiments to test some of the dysfunctional beliefs of
the client. Telling a child or adolescent exactly what to do is not
the idea; rather, the therapist should give the client an opportunity to try something and help him or her to make sense of the
experience. The therapist as consultant-collaborator strives to
develop skills in the client that include thinking on his or her
own and moving toward independent, mature problem solving.
The youngster and therapist interact in a collaborative, problem-solving manner. When the client asks, "Well, what am I
supposed to do?" the therapist might reply, "Let's see, what do
you want to accomplish here?" and then "What are our options?" or "What's another way we could look at this problem?"
The consultative exchange is intended to facilitate the process
of problem solving.
As a diagnostician, the therapist integrates data and, judging
against a background of knowledge of psychopathology, normal development, and psychologically healthy environments,
makes meaningful decisions. Mental health professionals cannot let others tell them what is wrong and what needs to be
fixed (e.g., it is not sufficient that a parent or teacher says that a
child is "hyperactive"). The fact that a parent or teacher suspects hyperactivity is one piece of useful information, but there
are rival hypotheses that must be considered. For example, the
child's behavior may be within normal limits but appear as
troubled when judged against inappropriate parental (or
teacher) expectations. There is also the possibility of alternative
disorders; hyperactivity may be the term used by the referring
adult, but aggressive noncompliance may be a better description
in terms of mental health professionals' communications. A
dysfunctional family interaction pattern may need the greatest
attention, not the child per se. The cognitive-behavioral therapist serves as a diagnostician by taking into account the various
sources of information and, judging against a background of
knowledge, describes the nature of the problem and an optimal
strategy for its intervention.
As an educator, the therapist is involved in interventions for
learning behavior control, cognitive ^kills, and emotional development and in determining optimal ways to communicate to
help young people to learn. A good educator stimulates youth
to think for themselves. A good therapist is an active and involved educator. A good educator observes the student, helps to
maximize strengths and reduce hindrances, and accepts that
individuals can and should do things differently. A good educator pays attention to what the learner is saying to himself or
herself, because this internal dialogue influences performance.
An effective therapist, just as an effective teacher, is involved in
the process. A high-quality intervention is one that alters how
the child makes sense of experiences and the way the child will
behave in the future.
A Treatment Goal: Building a Coping Template
Cognitive-behavioral theorists have promoted the notion
that individuals perceive and make sense of the world through

their cognitive structures, also referred to as schemata (Beck,

1976). Such a template has an influence on what is perceived
and how it is processed and understood. Children and adolescents are in the process of developing ways to view their world,
and cognitive-behavioral treatments provide educational experiences and therapist-coached reconceptualizations of problems to build a new "coping" template. That is, the treatment
goal is for the child to develop a new cognitive structure, or a
modified existing structure, through which he or she can look
at formerly distressing situations. Therapy helps in reducing the
support for dysfunctional schemata and in constructing a new
schema through which the child can identify and solve problems. An effective intervention capitalizes on creating behavioral experiences with emotional involvement while paying attention to the cognitive activities of the participant. The therapist guides both the youngster's attributions about prior
behavior and his or her expectations for future behavior. Thus,
the youngster can acquire a cognitive structure for future events
that includes the adaptive skills and appropriate cognition associated with adaptive functioning. The child's acquisition and
use of a coping template is a major goal of the treatment, a goal
that requires the therapist's use of several treatment strategies.
A Cognitive Differentiation: Distortion Versus Deficiency
With cognitive dysfunction emerging as a target for therapy, it
is important to recognize that all cognitive dysfunction is not
the same and that an understanding of the nature of the cognitive dysfunction associated with specific psychological disorders has important implications for treatment. With reference to children and adolescents, I have made the distinction
between cognitive distortions and cognitive deficiencies (Kendall, 1985,1991b). Deficiencies in cognitive functioning refer to
an absence of thinking. Youth with cognitive deficiencies lack
careful information processing in situations in which thinking
would be beneficial. In contrast, cognitive distortions are evident in youth who engage in information processing but do so
in a dysfunctional or biased fashion. Acting without thinking is
in marked contrast to action that follows misguided thinking,
and treatment strategies must be modified accordingly. Targeting cognitive deficiencies requires stopping nonthoughtful activity and developing and deploying skills in thoughtful problem solving. Cognitive distortions require that the faulty thinking first be identified and that the distorted processing then be
corrected.
Anxiety and depression in youth have been linked to distorted thinking, such as misconstruals and misperceptions of
the social situation and the demands in the environment, as
well as harsh and critical views of the self. For example, a recent
study showed that depressed youngsters viewed themselves as
less capable than nondepressed youth, even though teachers
perceived the groups as indistinct (Kendall, Stark, & Adam,
1990). Impulsive children are often found to act without thinking and to perform poorly because of a lack of forethought and
planning (deficiencies in information processing; e.g., Douglas,
1972). In aggression, there is evidence of both cognitive deficiency and cognitive distortion (e.g., Lochman, White, & Wayland, 1991). As will become evident as cognitive-behavioral
interventions are reviewed, interventions often consider and

SPECIAL SECTION: THERAPIES WITH YOUTH

target the nature of the cognitive dysfunction in the specific

HicnrHpr
disorder.
Areas of Application: Current Status
Cognitive-behavioral approaches to interventions for children and adolescents have been applied to a wide variety of
topics (see Kendall, 199 la; Meyers & Craighead, 1984), including anger (e.g., Lochman et al., 1991), attention-deficit hyperactivity disorder (ADHD; e.g., Braswell & Bloomquist, 1991; Hinshaw & Erhardt, 1991), anxiety disorders (Kendall et al., 1992),
medical and dental stress (Melamed, Klingman, & Siegel,
1984), depression (Stark, Rouse, & Livingston, 1991), and impulsivity (Kendall & Braswell, 1985). Cognitive-behavioral approaches have also been used with children with chronic illness
(e.g., Walco & Varni, 1991) and with learning disabilities (e.g.,
Keogh & Hall, 1984; Wong, Harris, & Graham, 1991). Inclusion
of the parents (e.g., Braswell, 1991; Braswell & Bloomquist,
1991; Kendall et al., 1992) and the families (e.g., Turkewitz,
1984) of youth has also been undertaken from the cognitive-behavioral perspective. In the present discussion,11 provide a selective review of applications and their outcomes across several
areas: (a) aggression, (b) anxiety, (c) depression, and (d) ADHD.
In each, I describe the nature of the disorder, the components of
the intervention, and illustrative outcomes.
Aggression in Youth
Although common in mild forms during early childhood,
aggression becomes clinically significant when it occurs with
high frequency or intensity or across multiple settings (e.g.,
home and school; e.g., Loeber & Dishion, 1983). Five percent to
10% of children display clinically significant aggressive behavior, with boys outnumbering girls by about three to one (Kazdin, 1987; Quay, 1986). Clinical concern has been focused on
aggressive children because of the substantial stability of aggressive behavior over time (Huesmann, Eron, Lefkowitz, &
Walker, 1984; Olweus, 1979) and because childhood aggressive
behavior has emerged as a significant risk marker for subsequent substance abuse, delinquency, and school failure (Coie,
Lochman, Terry, & Hyman, 1991; see also Pepler & Rubin,
1991).
What is the nature of cognitive functioning in aggressive
youth? Aggressive children can be said to surfer from both
distortions and deficiencies in their cognitive processing (Kendall, Ronan, & Epps, 1991). Cognitive distortions involve dysfunctional thinking processes, whereas cognitive deficiencies
involve an insufficient amount of cognitive activity in situations
in which greater forethought prior to action is needed.
Several factors have been identified in the cognitive distortions of aggressive children. Aggressive children have been
found to use fewer environmental cues to mediate their behavior. Dodge and Newman (1981) found that in a "detective" game
in which children were to determine whether a fictitious peer
had committed a hostile act, aggressive kindergarten children
(identified by teacher ratings) used 30% fewer bits of information than did nonaggressive children. Likewise, when allowed
to listen to an audiotape about another child's intentions, nonaggressive boys listened to 40% more statements than did ag-

237

gressive boys (Dodge & Newman, 1981). In addition, aggressive

children have been found to pay greater attention to aggressive
environmental cues than do nonaggressive children and have
been found to recall high rates of hostile cues present in social
stimuli (Dodge, 1985; Dodge, Pettit, McClaskey, & Brown,
1986; Milich & Dodge, 1984), to attribute others' behavior in
ambiguous situations to their hostile intentions (Dodge et al.,
1986), to underperceive their own level of aggressiveness and
their responsibility for early stages of dyadic conflict, and to
generate fewer verbal assertion solutions and more action-oriented and aggressive solutions to social problems (Asarnow &
Callan, 1985; Lochman & Lampron, 1986; Richard & Dodge,
1982). It appears, then, that aggressive children are hypervigilant in scanning their social environment for hostile cues, and
that their tendencies to perceive hostile intentions in others'
behavior lead them to respond in a nonverbal, action-oriented
manner (Kendall & Lochman, in press).
Other cognitive processes have been investigated. Aggressive
children have shown an unusual pattern of affect labeling
(Garrison & Stolberg, 1983) in that they anticipate that they will
have fewer feelings of fear or sadness in difficult social situations. When they suddenly experience these states, aggressive
children are likely to be ill prepared to cope, and they are apt to
label the generalized arousal as anger. Aggressive children's
problem solving has been found to be limited; however, when
aggressive children respond to social conflicts in a more deliberate (rather than automatic) manner, they generate higher rates
of competent, assertive solutions (Lochman, Lampron, & Rabiner, 1990; Rabiner, Lenhart, & Lochman, 1990). Aggressive
children think of nonverbal, action-oriented solutions when
they use quick, automatic processing of social events rather
than using deliberate, memory-retrieval strategies. Aggressive
children expect that an aggressive solution will reduce aversive
reactions from others and allow them to acquire tangible positive outcomes (Perry, Perry, & Rasmussen, 1986), and aggressive adolescents believe that aggressive behavior will enhance
self-esteem, will avoid a negative image, and will not cause
victims to suffer (Slaby & Guerra, 1988). Boldizar, Perry, and
Perry (1989) found that aggressive children placed more value
on controlling the victim and less value on victim suffering,
victim retaliation, peer rejection, and negative self-evaluation.
Similarly, Lochman et al. (1991) have found that aggressive boys
value social goals of dominance and revenge more, and a social
goal of affiliation less, than do nonaggressive boys.
Aggressive children also demonstrate deficiencies in the
final stages of Dodge's (1985, 1986) information-processing
model: (a) generation of alternative solutions, (b) a decision concerning which solution is most appropriate, and (c) behavioral
implementation of the solution (Kendall et al., 1991; Lochman
et al., 1991). In generating alternative solutions, aggressive children have been shown to demonstrate both quantitative and
qualitative deficiencies (Lochman et al., 1991). For instance,
Richard and Dodge (1982) found that in response to a conflict

' Some portions of this section appear in an expanded form in Kendall and Lochman (in press), Kendall and Braswell (1993), and Ken-

dall, Chansky, and Kortlander (in press). I wish to acknowledge and

thank my coauthors for their valuable input.

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PHILIP C. KENDALL

situation, poorly adjusted children (including aggressive children) produced fewer solutions and a proportionally higher
number of hostile, ineffective responses than did cooperative
children. Deluty (1981) found that in comparison with assertive
and submissive children, aggressive children generated more
aggressive solutions to interpersonal conflict situations.
Cognitive-behavioral treatment addresses the various distortions and deficiencies that characterize aggressive children's
thinking. To address distortions in the appraisal of situations as
well as deficiencies in the generation, selection, and implementation of effective solutions, the treatment relies on the active
involvement of the therapist. For instance, through modeling,
the therapist overtly verbalizes his or her appraisal of the situation, various solutions to the situation, and possible consequences of the different solutions. Role plays provide the aggressive child not only with a chance to practice interpersonal
social-cognitive skills, but also with the opportunity to increase
skills in perspective taking. In role plays, which may involve the
therapist or a group of other children, aggressive children are
given the opportunity to hear the other person's perspective on
the situation and thereby increase their abilities to make more
accurate attributions about the intent of others as well as to
develop greater empathy for the feelings of others.
Self-monitoring and self-instruction components assist children in accurately monitoring their arousal state, labeling the
arousal as coexisting with an appropriate emotional state, recognizing situations that typically provide intense feelings of anger
and frustration, and using inhibitory self-directives (e.g., "Stop!
Think! What can I do?") to slow down the automaticity of their
response. Social perspective-taking components focus on helping children to be more aware of nonhostile cues in social situations and to become aware of the variety of intentions that
peers and adults might have in ambiguous social situations.
Social problem-solving training is a core element in most cognitive-behavioral interventions and involves assisting children to
think of a wider array of possible solutions to perceived social
provocations, with particular emphasis on verbal assertion,
bargaining and compromise solutions, and competent enactment of selected solutions.
What are the effects of cognitive-behavioral therapy for aggressive youth? Research has indicated that cognitive-behavioral
therapy is a promising form of treatment and secondary prevention of conduct and oppositional disorders (Kazdin, 1987).
Using a 20-session problem-solving skills training program
(combining the Kendall & Braswell [1985] and Spivack & Shure
[1974] programs) with aggressive psychiatric inpatient children, Kazdin, Esveldt-Dawson, French, and Unis (1987) reported that problem-solving skills training produced significant reductions in parents' and teachers' ratings of aggressive
behavior at posttest and at a 1 -year follow-up. These results have
been replicated in a study combining problem-solving skills
training with parent behavioral management training with inpatient children (Kazdin et al., 1987) and in a study with antisocial children treated in outpatient and inpatient settings (Kazdin, Bass, Siegel, & Thomas, 1989). Some treatment effects for
cognitive-behavioral therapy have also been found with
day-hospital conduct-disordered children (Kendall, Reber,
McLeer, Epps, & Ronan, 1990) and with hospitalized aggressive adolescents (Feindler, Ecton, Kingsley, & Dubey, 1986).

Treatment and client characteristics predictive of outcome

have been examined by Lochman and his colleagues in a series
of studies using a 12- to 18-session school-based anger coping
program. Reductions were found in independently observed
disruptive classroom behavior and in parents' ratings of aggressive behavior, and improvements in self-esteem were enhanced,
when the cognitive-behavioral anger coping program was augmented with a behavioral goal-setting component (Lochman,
Burch, Curry, & Lampron, 1984) and when the program was
lengthened to include 18 weekly group sessions (Lochman,
1985). Aggressive boys who initially had the poorest problemsolving skills were found to have the greatest behavioral improvement after the anger coping program (Lochman, Lampron, Burch, & Curry, 1985). In a 3-year follow-up study, aggressive boys treated in the anger coping program maintained
significant improvements in self-esteem and social problemsolving skills and had a markedly lower substance use rate
(Lochman, 1991) than did untreated aggressive boys.
Anxiety Disorder in Youth
Anxiety can be a normal and adaptive response to a variety
of situations. The ability to recognize and avoid harm and
threat is a necessary component of a child's repertoire. Most
childhood fears are transitory, emerge in the course of encounters with new challenges, and are resolved by facing these
demands. In contrast to normal anxious reactions, fears or anxieties that are excessive, occur beyond the developmental timetable, or disrupt the child's life are considered maladaptive.
Whereas fear is a discrete response to a circumscribed threat
and phobias are severe fears involving persistent behavioral
avoidance (Barrios & Hartmann, 1988; Miller, Barrett, &
Hampe, 1974; Morris & Kratochwill, 1983), anxiety is more
diffuse both in stimulus and response and is more long-standing and disruptive than an isolated fear or phobia (Kendall et
al., 1992; Morris & Kratochwill, 1991).
Separation anxiety provides a clear illustration of the contrast between normal and pathological forms of anxiety. Anxiety about separation involves a child's being distressed when
apart from caregivers: School and social activities are often
avoided to maintain contact with caregivers (see also Campbell,
1986). Separation anxiety appears naturally and recedes in early
childhood, and it is characterized by the child's protests at
times of separation or in anticipation of separation. In contrast,
when separation anxiety disorder occurs in a 9- or 10-year-old,
this signals a maladaptive anxiety past the developmental timetable and, although it may spring from achild'ssomewhat realistic concerns about a parent (e.g., in cases of parent conflict),
signals the need for intervention in the child's world to rectify
the anxiety provocation.
Clinicians and researchers view childhood anxiety as a multidimensional construct manifested at physiological, behavioral, and cognitive levels. Common beliefs hold that the motoric components of anxiety responses include, most prominently, avoidance, as well as shaky voice, rigid posture, crying,
nail biting, and thumb sucking (Barrios & Hartmann, 1988).
Physiological reactions are said to include an increase in automatic nervous activity, perspiration, diffuse abdominal pain
("butterflies in the stomach"), flushed face, urgent need to uri-

SPECIAL SECTION: THERAPIES WITH YOUTH

nate, trembling, and gastrointestinal distress (see also Barrios &

Hartmann, 1988). The physiological assessment of anxiety in
adults has received wide attention (see Himadi, Boice, & Barlow, 1985), yet little empirical data on these indicators in children exist (Barrios & Hartmann, 1988; Beidel, 1988), even
though such indicators may be a promising area of research. An
exception is a recent study by Beidel (1988) in which significant
differences in autonomic activity were found in anxious children, compared with nonanxious controls, during a test-taking
task. Overall, test-anxious children had significantly higher
heart rates than did nonanxious controls; however, no differences were found in systolic or diastolic blood pressure. Such
results confirm cautions by some (e.g., Haynes, 1978) who advocate monitoring more than one physiological indicator because
concurrent indicators may not correlate.
What is the nature of cognitive functioning in anxious youth?
A variety of anxious children's thoughts have been described,
including thoughts of being scared or hurt, self-critical
thoughts, and thoughts of danger (see Barrios & Hartmann,
1988). However, until recently, little empirical work has examined cognitions in clinically anxious children. Francis (1988), in
her recent review of cognitions of anxious children, concluded
that "no definitive statements about the cognitions of anxious
children can be made" (p. 276). Studies on circumscribed fears,
such as test anxiety (Prins, 1985), in nonclinical samples have
found that high anxiety is associated with negative self-referent
cognitions (e.g., "I'm going to mess up" or "I'm going to get hurt
again").
In terms of information processing, anxious children do not
appear to show deficiencies but do evidence a distortion or
bias: The individual attends to social or environmental cues but
does so in a distorted and dysfunctional manner. Anxious children, for example, seem preoccupied with concerns about evaluations by self and others and the likelihood of severe negative
consequences. They seem to misperceive characteristically the
demands of the environment and routinely add stress to a variety of situations.
Anxious children endorsed more threat-related self-statements than did nonanxious youth (Ronan, Kendall, & Rowe,
1993) when responding to a self-statement questionnaire and
provided more coping self-talk when responding to a thoughtlisting task (Kendall & Chansky, 1991). Although they reported
a higher frequency of coping self-talk at pretreatment, it was
also noted that the coping self-talk was excessive and nonfunctional.
What treatments are best for anxiety-disordered youth?
Although the treatment of adult anxiety disorders has received
much research attention (see Barlow, 1988; Beck & Emery, 1985;
Kendall & Watson, 1989; Maser & Cloninger, 1990; Meichenbaum, 1986; Michelson & Ascher, 1987), the outcome literature
on treating child anxiety disorders is negligible. Strategies that
have proven useful for adults can serve as building blocks in
child interventions, with the addition of age-specific intervention materials (e.g., Coping Cat Workbook, Kendall, 1990). A
brief description of the components used in the treatment of
anxiety disorders in children is presented; however, there is
increasing recognition that a combination of strategies is most
efficacious (Kendall et al., 1992; King & Ollendick, 1989).
Combining strategies is consistent with the multicomponent

239

conceptualization of anxiety: cognitive, behavioral, and physiological response pathways.

Physiological arousal accompanies anxious cognition; thus,
methods that help identify children's physiological symptoms
and teach them methods to reduce the arousal are often used.
Relaxation training is useful in this regard, with scripts available at the child's developmental level (see Koeppen, 1974; Ollendick & Cerny, 1981). Often, the combination of progressive
muscle relaxation, deep breathing, and cognitive imagery is
used. There are several examples of use of relaxation training
with circumscribed anxiety, such as test anxiety (Richter, 1984).
It remains unclear whether relaxation alone is helpful for anxiety-disordered children.
Relaxation training, along with the establishment of a fear
hierarchy and the pairing of relaxation and fearful situations,
composes systematic desensitization (Wolpe, 1973). The underlying principle in systematic desensitization is the pairing of
two incompatible emotional states: fear and relaxation. A critical element of desensitization is the hierarchical presentation of
feared situations. Beginning with the least threatening situation
and building on success experiences allows the child to progress to more frightening situations. Although there is a substantial literature supporting the efficacy of systematic desensitization with children, most studies have used nonclinical subjects with circumscribed fears such as speech anxiety, test
anxiety, or dog phobia (e.g., see Deffenbacher & Kemper, 1974);
the efficacy of the treatment with more generalized, pervasive
fears is not known.
Modeling involves the demonstration of the desired coping
behaviors in a feared or stressful situation such that they can be
subsequently imitated by the child. Feedback and reinforcement can be used to maintain the desired behaviors (Ollendick
& Francis, 1988). Modeling can be accomplished by having a
child observe live or symbolic (videotaped) models or participate with a live model. Ollendick (1979) suggested that not all
modeling experiences are equally powerful; he noted that the
more involved the modeling, the more effective the outcome.
Using opportunities for the therapist to serve as a coping model
for the child has been found to be an effective and powerful
therapeutic tool when working with anxiety-disordered children (Kendall et al., 1992). As a coping model, the therapist
self-discloses feared situations that are pertinent to the child's
difficulties, describes his or her feelings about these situations,
shares whether he or she would feel the same or different in
similar situations, and models a strategy for coping with unwanted arousal.
Because practice is essential, role plays and in vivo experiences provide excellent opportunities to try out a variety of
coping strategies. The therapist can be active in setting up the
behavioral experiments, providing the appropriate amount of
concrete detail to engage the child and assist in creating the
scene as authentically as possible. Particularly with younger
children who may be less able to identify the precipitating
events in their anxious reactions, role plays can be used to help
the therapist to notice when the child begins to become distressed. In vivo exposure is essential, because it is in these real
situations that the newly developed coping skills can be best
practiced.
Cognitive models of psychopathology highlight the impact of

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PHILIP C. KENDALL

maladaptive thinking (e.g., distortions) on maladaptive behavior and stress interventions that modify self-talk and address
faulty cognitive processing. In an example of a controlled comparative study, Kanfer, Karoly, and Newman (1975) taught children with nighttime fears positive self-talk (e.g., "I am a brave
boy (girl); I can take care of myself in the dark") or encouraged
them to use stimulus-oriented self-talk (e.g., "There are many
good things in the dark; the dark is a fun place to be"). A third
group repeated nursery rhymes as a control. In terms of the
amount of time a child could stay in a dark room, the results
suggested that both active treatments significantly increased
the duration of staying alone as compared wiih the control
group children. Altering self-talk had a positive impact on
anxiety.
The goal of cognitive interventions is to build a new (or elaborate on an existing) coping template. Building a coping template involves disputing or correcting the characteristic misinterpretation and looking at the events through the alternative
template (based on coping). Problem-solving (e.g., D'Zurilla,
1986; Kendall & Siqueland, 1989; Spivack & Shure, 1974) interventions include problem identification and successive stages
of problem definition and formulation, generation of alternative solutions, choice of desired strategy, and implementation
and evaluation. Problem-solving skills provide the underlying
model for using available coping actions.
Cognitive-behavioral interventions have been applied to
children facing stressful medical or dental procedures. Although a child facing a bone marrow transplant, chemotherapy,
or painful dental procedures has a reality-based distress, efforts
to increase the coping armamentarium of these children have
been successful. Also, they provide guidelines as to what interventions are most helpful to children in other stressful situations. Peterson and her colleagues (Peterson &Shigetomi, 1981;
Siegel & Peterson, 1980, 1981) demonstrated that children
equipped with coping strategies, as compared with either educational information or no preparation, were less anxious and
more cooperative and had lower pulse rates (Siegel & Peterson,
1980). Children who received a combination of coping and
modeling were even better able to cope with their medical procedure (tonsillectomy; Peterson & Shigetomi, 1981).
In one of the few investigations of an integrated cognitive-behavioral treatment for children with diagnosed anxiety disorders, Kane and Kendall (1989) reported meaningful improvements. Specifically, using a multiple baseline design with 4 subjects diagnosed with overanxious disorder, they found
reductions in anxiety as reported by child, parents, and an independent diagnostician. These changes showed significant improvements from pretreatment assessment and returned the
child to scores within the normal range, as expected from normative data (see Kendall & Grove, 1988, for discussion of the
method of normative comparisons).
In a randomized clinical trial (Kendall, 1993), anxiety-disordered youth were assigned to either a treatment or a wait-list
condition. Children receiving therapy were taught a variety of
strategies, including relaxation, imagery, problem solving, and
modification of self-talk. These strategies enabled the child to
change the fearful, threat template into one that views anxietyprovoking situations as situations that can be managed. The
active treatment integrates cognitive strategies, such as modifi-

cation of anxious self-talk and problem solving, with behavioral

strategies of relaxation, exposure, evaluation, and reward.
These strategies were put into practice in graduated imaginal
and in vivo exposure opportunities. At posttreatment assessment, treated subjects evidenced significant reductions in selfreported distress and pathological responses, and were often
within normative ranges. Children's self-rated coping ability
was also found to be significantly higher. Parents' reports also
evidenced significant reductions in reports of anxiety in their
children. Diagnoses based on a structured interview were compared from pretreatment to posttreatment: Using the parents'
diagnostic interview data, 64% of the treated cases had no diagnosis at posttreatment. whereas only one subject in the wait-list
condition showed such change. These findings provide support
for the use of cognitive-behavioral treatment for anxiety disorders in youth.
Depression in Children and Adolescents
Depression is a relatively common mood state, with 40% of
14- and 15-year-olds in the Isle of Wight study reporting feelings
of misery and depression (Rutter, Tizard, & Whitmore, 1970).
As with many areas of developmental psychopathology, some
controversy exists about when the classification of disorders
such as dysthymia and major depressive disorder begins on this
continuously distributed set of symptoms. Consistent age and
gender effects have been noted on depressive symptomatology
(Kazdin. 1989) with no sex differences evident in childhood,
but with female adolescents having a higher rate of depression
than male adolescents.
The nature of depressive symptoms shifts with age, with adolescents displaying more anhedonia, hopelessness, hypersomnia. weight change, and lethality of suicide attempts and children having primarily depressive appearance, somatic complaints, and agitation (Ryan et al., 1987). Depressive disorders
may be combined with anxiety (Brady & Kendall, 1992) and
conduct disorders (Kazdin. 1989). Major depressive disorder
(MDD) includes a more severe set of symptoms than dysthymia, but MDD is not as stable over time as is dysthymic disorder. The mean duration of MDD has been found to be only 32
weeks, with 92% recovery rate for children 1.5 years later (Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein,
1984). Children who had an earlier onset of their depressive
symptoms had a more stable, chronic course for their depressive disorder.
What is the nature of cognitive functioning in depressed
youth? Research on the cognitive characteristics of depressed
children and adolescents has found distortions in attributions,
self-evaluation, and perceptions of past and present events.
Kaslow, Rehm, Pollack, and Siegel (1988) found that depressed
clinic children had more depressogenic attributions than did
nondepressed clinic children or nonclinic children. Depressed
children have a more external locus of control (Mullins, Siegel,
& Hodges, 1985), indicating that they feel less capable of obtaining valued consequences through their own behavior. Separating attributions for positive and negative events, Curry and
Craighead (1990) found that adolescents with greater depression attributed the cause of positive events to external, unstable,
and specific causes, consistent with prior findings that adoles-

SPECIAL SECTION: THERAPIES WITH YOUTH

cents experience more anhedonia. Attributions for positive

events were more closely associated with depression than were
attributions for negative events. The relationship between attributions and depression has been found only for currently depressed inpatient children, and not for children with resolved
depression (McCauley, Burke, Mitchell, & Moss, 1986).
Depressed children have low levels of self-esteem and low
perceived academic and social competence (Asarnow, Carlson,
& Guthrie, 1987; Kaslow, Rehm, & Siegel, 1984). Kaslow et al.
(1984) examined the nature of these self-evaluation difficulties
on a design-copying task and found that depressed children
experienced more self-punishment and set more stringent standards for poor scores. These depressed children were particularly concerned about not doing well on the task. The low selfevaluations of depressed children also seem to produce distorted perceptions of past and present (Haley, Fine, Marriage,
Moretti, & Freeman, 1985; Rehm & Carter, 1990). Depressed
children in the fifth to eighth grades display a variety of cognitive errors, including overgeneralizing their predictions of negative outcomes, catastrophizing the consequences of negative
events, incorrectly taking personal responsibility for negative
outcomes, and selectively attending to negative features of an
event (Kendall, Stark, & Adam, 1990; Leitenberg, Yost, &
Carroll-Wilson, 1986). In addition to these biased appraisal
processes, depressed children also have displayed problemsolving deficits in some studies, with low rates of impersonal
(but not interpersonal) problem solving (Mullins et al., 1985)
and a high rate of depressogenic strategies (Asarnow et al.,
1987).
What are the outcomes of cognitive-behavioral treatments of
depression in youth? Cognitive-behavioral treatment programs have been developed to address the cognitive distortions
seen in depressed children. The treatment components contained in these interventions include (a) self-control skills involving self-consequation (reinforcing themselves more and
punishing themselves less), self-monitoring (paying attention to
positive things they do), self-evaluation (setting less perfectionistic standards for their performance), and assertiveness training; (b) social skills, including methods of initiating interactions, maintaining interactions, handling conflict, and using
relaxation and imagery; and (c) cognitive restructuring, involving confronting children about the lack of evidence for their
distorted perceptions (e.g., Stark et al, 1991).
Only a few studies have been reported on the posttreatment
effects of the full cognitive-behavioral therapy with depressed
children (Kazdin, 1989; Stark et al, 1991). For example, Reynolds and Coats (1986) compared a cognitive-behavioral intervention and a relaxation intervention with a wait-list control
condition. Thirty moderately depressed adolescents were randomly assigned to the three conditions. The two interventions
met twice weekly for 5 weeks. Both the cognitive-behavioral
and the relaxation training interventions, compared with the
wait-list control condition, produced significant reductions in
depression symptoms according to self-reports and clinical ratings. These treatment effects were maintained at a 5-week follow-up, along with reductions in anxiety and improvements in
academic self-concept.
Stark, Reynolds, and Kaslow (1987) assigned 29 moderately
to severely depressed children (aged 9-12 years) to self-control,

241

behavioral problem-solving, or wait-list conditions. At posttreatment and at an 8-week follow-up, the self-control and behavioral problem-solving conditions produced significant reductions in depression using self-report and clinical interviews
in comparison with the wait-list subjects. However, betweengroup treatment effects were not evident on mothers' behavioral checklist ratings. This study provided some evidence for
the generalization of the treatment effects to home setting
(Stark etal, 1991).
The clearest evidence for the specific effects of cognitive-behavioral treatment emerged in the study reported by Stark et al.
(1991) with 24 depressed children (Grades 4 to 7) assigned to
cognitive-behavioral therapy or to traditional counseling. Both
interventions lasted 24 to 26 sessions over 3.5 months and were
conducted in small groups. The cognitive-behavioral treatment
was a more broad-band intervention than in previous studies
and included self-control, social skills, and cognitive restructuring components (see Stark, 1990; Stark et al, 1991). At posttreatment, cognitive-behavioral therapy produced greater improvements in depression and reductions in depressive cognition than did traditional counseling. However, because these
treatment gains were not maintained at the 7-month follow-up,
the long-term effects of cognitive-behavioral therapy with depressed children have yet to be documented.
Attention-Deficit Hyperactivity Disorder (ADHD)
Currently, the diagnostic category of ADHD reflects a conceptualization in which motor and cognitive components coexist. ADHD involves heightened motor activity, impulsivity, deficits in attention, and deficits in rule-governed behavior (Barkley, 1990). In addition to the cognitive and behavioral
components, ADHDoften involves a relatively high association
with conduct problems and aggression (Hinshaw, 1987).
What is the nature of the cognitive dysfunction in ADHD?
That impulsive children often act without thinking is generally
accepted and has been widely researched for decades. Although
various labels have been used, these children nevertheless have
many essential features in common. Douglas and Peters (1979)
traced the difficulties of hyperactive children to deficiencies in
the "mechanisms that govern (a) sustained attention and effort,
(b) inhibitory controls, and (c) the modulation of arousal levels
to meet task or situational demands" (p. 67). Barkley (1990) has
discussed the "holy trinity" of ADHD symptoms, two of which
(inattention and impulsivity) are cognitively related. Recently,
the current conception of ADHD has been summarized as a
style that shows deficiencies in higher order problem solving, in
modulation of behavior to match environmental demands, and
in overall self-regulation (Hinshaw & Erhardt, 1991; Whalen,
1989; Douglas, Barr, Amin, O'Neill, & Britton, 1988).
Numerous studies document the various cognitive deficiencies that are found in hyperactive and impulsive children (see
Barkley, 1990). For example, research demonstrates that hyperactive children are deficient in their ability to sustain and
maintain attention to tasks (e.g., Barkley & Ullman, 1975;
Douglas, 1983; Routh & Schroder, 1976; Zentall, 1985), with
the attentional deficiency being most dramatic in situations
involving dull, repetitive tasks (Luk, 1985; Milich, Loney, &
Landau, 1982; Ullman, Barkley, & Brown, 1978; Zentall, 1985).

242

PHILIP C. KENDALL

Research focusing on distractors has shown that hyperactive

children encounter the most difficulty in focusing attention
when distractors are integrated into the particular task (Ceci &
Tishman, 1984; Mclntyre, Blackwell, & Denton, 1978) or when
distractors are especially appealing (Radosh & Gittleman,
1981; Rosenthal & Allen, 1990). Pearson, Lane, and Swanson
(1990) reported that impulsive hyperactive children were unable to allocate attention during complex tasks, whereas their
nonhyperactive peers were able to do so.
Other research has suggested that the cognitive functioning
of hyperactive children is characterized by an inability to cognitively mediate their behavior. Douglas (1980) summarized the
cognitive difficulties of ADHD youngsters as an inability to
"stop, look, and listen" and considered this inability to be the
most important symptom of the disorder. Cognitive impulsivity
has been assessed, with the data suggesting that hyperactive
and impulsive children have considerably more difficulty using
problem-solving strategies and inhibiting responses on this task
than do nonhyperactive children and that they possess inefficient search strategies (Douglas & Peters, 1979) and problemsolving skills (Tant & Douglas, 1982). Measures of cognitive
problem solving have been shown to be strong discriminators
of hyperactive and nonhyperactive children (Homatidis &
Konstantareas, 1981).
What treatments are best for ADHD? The multifaceted nature of ADHD has implications for determining the type of
treatment to follow. For instance, treatment that produces positive effects in one symptom area may not affect functioning in
another area. The most widely used treatment approach, stimulant medication, effectively addresses attention but may not
always improve symptoms in complex cognitive skills. The appeal of stimulant medication lies in the relatively rapid behavior improvements that medication produces. However, Whalen, Henker, and Hinshaw (1985) warned that improvement in
the most salient areas of the ADHD child's disruptive behavior
(e.g., excessive motor activity in young children) may lead to a
failure to address deficits in other areas of functioning such as
academic performance. Medication has also been shown to reduce motor activity, aggression, and noncompliance and to produce improvements in relationships with mothers, peers, and
teachers (Barkley & Cunningham, 1979, 1980; Barkley, Karlson, Strzelecki, & Murphy, 1984; Whalen, Henker, & Dotemmoto, 1980,1981). Despite the apparent effectiveness of medication in addressing facets of ADHD, this treatment approach
remains controversial.
Reacting to the negative factors associated with medication,
researchers and clinicians have sought alternative treatments
(e.g., behavior modification, cognitive-behavioral treatment,
and parent training). Broadly speaking, research on alternative
treatments has involved examining their efficacy both independent of medication and in combination with medication. For
present purposes, I focus on cognitive-behavioral therapy.
With its attention to cognitive processes (e.g., problem solving
and anticipation of the consequences of actions), as well as observable behavior, cognitive-behavioral therapy appears particularly well suited to the problems of the ADHD child, many of
which have been linked to deficits in cognitive processing. However, the data suggest that although cognitive-behavioral training can reduce one feature of ADHDimpulsivity (Kendall &

Braswell, 1982,1985)it has not been uniformly found to rectify other features of ADHD. Despite the promising results with
impulsive children and the apparent theoretical match of cognitive-behavioral therapy with symptoms of ADHD, the effectiveness of cognitive-behavioral therapy as a treatment of
ADHD has remained relatively inconsistent. Although some
studies have shown promising preliminary results (e.g., Cameron & Robinson, 1980; Douglas, Parry, Marton, & Garson,
1976), others have failed to show a positive impact (e.g., Brown,
Wynne, & Medenis, 1985: see Abikoff, 1987, for a review; Hinshaw & Erhardt, 1991; Whalen et al., 1985).
Research has considered the effectiveness of certain versions
of cognitive-behavioral treatment in combination with medication. Results of several studies, however (Abikoff, Ganeles,
Reiter, Blum, Foley, & Klein, 1988; Abikoff& Gittelman, 1985;
Brown et al., 1985), did not show a cognitive-behavioral treatment to be as effective as medication or as providing an enhancing effect over medication when the two treatments were combined. However, it is worth noting that the form of cognitivebehavioral treatment used varies substantially across studies.
For instance, Kendall and Reber (1987) noted that the treatment used by Abikoffand Gittelman (1985) did not include the
full behavioral component of contingent reinforcement and response costs for learning the problem-solving skills. In light of
this situation, suggestions for refinement both in the assessment of children's functioning and in treatment approaches
have emerged. More specifically, Abikoff (1987) argued that
effective cognitive-behavioral treatment will require understanding the specific nature of the child's problems accompanied by a more tailored application of the various components
of the treatment to the particular child's needs. In a similar
vein, Whalen et al. (1985) noted that different situations (e.g.,
academic vs. social) may require different cognitive strategies,
with the former creating a situation in which the task demands
are much more clear-cut than the latter, which may involve such
variables as inconsistent or ambiguous feedback about the
child's behavior. It should also be noted that contemporary applications of cognitive-behavioral therapy for ADHD place a
greater emphasis on the role of the parents and family in program implementation (Braswell & Bloomquist, 1991).
Summary. Although the outcomes of reports provide evidence to support the continued development and evaluation of
psychosocial treatments (e.g., cognitive-behavioral interventions) for disorders in youth, there is reason to draw different
conclusions depending on the specific disorder. When treating
aggression, for example, the data are supportive and the encouragement of continued research is appropriate, although therapies of longer duration are recommended. Portions of the problems seen in ADHD can be addressed, but the comparisons
with medications suggest limited optimism until greater specificity is achieved. Applications with internalizing disorders,
such as anxiety and depression, are much fewer, although the
results are very encouraging and continued work should be
supported.
Emerging Developments
To assume that there is a single monolithic "right" way to
think, behave, and feel is to make a fatal error. Indeed, quite the

SPECIAL SECTION: THERAPIES WITH YOUTH

contrary is true (Kendall, 1992). The human experience, including childhood and adolescence, is replete with opportunities for a diversity of thoughts, feelings, and actions. The definition of what is "normal" is broad and inclusive; thoughts, feelings, and actions are abnormal only when they are maladaptive
for the individual or interfering or destructive for others. Coverage of interventions for children does not suggest that all children should conform to a single-minded definition of appropriate childhood behavior. Rather, interventions are designed
to remove detrimental cognitive, affective, or behavioral styles
that children may be developing and to offerat an early point
in lifevaluable educational experience that can modify unwanted features of their developmental trajectory.
Consistent Treatment Strategies
Interventions with youth are perhaps best when they mesh
effectively with the normal developmental trajectory. In the target years of development, the move toward autonomy and independence is a central developmental challenge. A decided
strength of the cognitive-behavioral strategy is that it works in a
collaborative fashion with the youth and, correspondingly, fosters independent development and prosocial behavior change.
The cognitive-behavioral therapies are neither monolithic
nor narrow minded (Mahoney, 1977). Quite the opposite is
true: Although there are treatment strategies that appear in
therapies for the various disorders (see Table 1), there are no
rules carved in stone, and the emphasis on cognitive information processing within a context that uses social reward and
behavioral procedures to modify maladaptive methods of adjusting is intentionally flexible. Therapy workbooks are often
used with youthful clients, thus providing concrete content and
enjoyable activities as well as a guide for the implementation of
the treatment (e.g., Kendall, 1990).
Table 1
General Treatment Strategies, With Specific Instances, Used in
the Cognitive-Behavioral Therapies With Youth
General strategy
Modeling
Building a coping
template
Rewards

Enactive procedures

Affective education

Training tasks

Specific instances
Use of coping modeling, with therapist
self-talk
Changing client self-talk, reframing of
problems
Use of different contingencies, given
the nature of the disorder being
treated
Modifying the frequency and standards
of self-evaluation, depending on the
disorder
Role-play exercises
Opportunities for practice
In vivo exposure
Behavioral experiments
Learning about feelings, in self and
others
Learning to use coping skills when
emotionally aroused
In-session tasks (i.e., workbooks)
Homework (out-of-session)
assignments

243

Broader Treatment Applications

Contemporary cognitive-behavioral therapy has moved
beyond the sole focus on the child client and has incorporated
strategies that involve parents, peers, and school personnel. The
literature clearly suggests the movement to include interpersonal and social contexts and parents as collaborators or coclients, but treatment evaluation studies have not kept pace
with these expanded clinical applications.
When significant others (peers, teachers, and parents) provide positive feedback for a child's efforts and change their perceptions and attributions about the child, the child's behavioral
change is likely to be maintained. However, if these interpersonal systems are not accepting of the child's recent behavior
changes, then the child's behavior and cognitions can easily
revert to earlier maladaptive levels. Thus, cognitive-behavioral
therapy should actively intervene with key individuals in the
child's social environment (parents, teacher, and, possibly,
peers) to maintain therapeutic change (see Braswell, 1991; Kendall & Morris, 1991). The direction and movement are
strengths; the emerging need is for additional evaluation of the
broader interventions.
Comparative Treatment Outcomes
The basic applications of cognitive-behavioral therapy need
added research in terms of the relative efficacy of the treatment
as compared with alternative forms of psychological and pharmacological intervention. For example, there are needed comparisons with parent training, parent therapy, family therapy,
and behavior modification. As additional alternative therapies
(e.g., psychodynamic) begin to be examined empirically, further
comparative studies will be needed. Multimethod assessments
are needed for all such studies, along with tests of clinical significance (e.g., normative comparisons; Kendall & Grove, 1988)
and statistical significance and consideration of cost-effectiveness (e.g., professional cost and child and family time commitment). Comparative studies of medications and cognitive-behavioral therapy for anxiety and depression are much needed.
These outcome comparisons need to include and examine the
comorbid status of the clients. For instance, there may be differential outcomes for ADHD with or without comorbid conduct problems or anxiety disorders with or without comorbid
depression.
Nonspecific factors that affect treatment outcome have
rarely been examined (e.g., Reynolds & Coats, 1986). Nonspecific factors concern, for example, the relationship between the
therapist and the child (Kendall & Morris, 1991) and the child's
involvement in treatment (Braswell et al., 1985). The social reinforcement provided by the therapist can be a major source of
motivation for children. The therapeutic relationship assumes
particular importance because many behaviorally and emotionally disordered children have weak relationships with parents and teachers, and thus have been minimally motivated by
adults' reinforcement. When a positive therapeutic relationship
develops, children are more accepting of therapists' perceptions of events and more open to reframing their own perceptions of events.
Cognitive-behavioral therapies with youth are intentionally

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PHILIP C. KENDALL

integrative. Nevertheless, studies of the active and nonactive

(less active) components of the treatment modality are needed.
Identification of active components will not only benefit future
applications of cognitive-behavioral therapy, but also enhance
other models of psychotherapy with youth.

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Received December 20,1991

Revision received June 19,1992
Accepted July 2,1992