Child and Adolescent Mental Health Volume 12, No. 4, 2007, pp. 164–172 doi: 10.1111/j.1475-3588.2006.00433.

Cognitive Behavioural Therapy for Anxiety

Disorders in Children and Adolescents:
A Meta-Analysis
Shin-ichi Ishikawa1 , Isa Okajima2 , Hirofumi Matsuoka2 & Yuji Sakano2
1
Faculty of Education and Culture, University of Miyazaki, Japan. E-mail: ishinn@cc.miyazaki-u.ac.jp
2
School of Psychological Science, Health Sciences University of Hokkaido, Japan

We conducted a meta-analysis using 20 randomised controlled studies of cognitive behavioural therapy (CBT) for
anxiety disorders in children and adolescents. The mean pre-post effect size was d ¼ 0.94, which was maintained
at follow-up. The mean effect size when comparing the CBT and control group was d ¼ 0.61. Within the CBT
group, the mean effect size of university clinics (d ¼ 0.77) was larger than that of other clinics (d ¼ 0.37). The
difference in effect sizes was hardly noticeable when comparing CBT with family or parents and CBT with child
only (d ¼ 0.03). Further studies are required to examine the effectiveness of family CBT versus child CBT.

Keywords: Adolescent; anxiety disorders; child; cognitive behavioural therapy; meta-analysis

Introduction
The past decade has seen an increase in research
focusing upon anxiety disorders in children and ado-
lescents (Kendall et al., 2000; Schniering, Hudson, &
Rapee, 2000). Anderson et al. (1987) showed that the
prevalence rate of anxiety disorders in children was
about 10%. In a study of about 800 children, it was
found that 8.9% children who visited general paediatric
departments were diagnosed with anxiety disorders
(Costello, 1989). In addition, Kashani and Orvaschel
(1988) showed that 8.7% adolescents were diagnosed
with one or more anxiety disorders. Anxiety disorders
are therefore one of the most prevalent problems of all
children’s emotional disorders (Albano, Chorpita, &
Barlow, 2003). In addition, Kendall et al. (2000) sug-
gested that anxiety may persist over time, leading to
significant impairment in adulthood if left untreated.
In 1995, the Task Force on Promotion and Dissemin-
ation of Psychological Procedure identified empirically
supported treatments for children (Chambless & Ollen-
dick, 2001). Although Chambless and Ollendick (2001)
concluded that ‘well-established treatments’ did not
exist for anxiety disorders in children and adolescents
(separation anxiety, avoidant disorder, overanxious
disorder), CBT and CBT plus family anxiety manage-
ment training were classified as ‘Probably efficacious
treatments’. Similarly, in the category of phobias, CBT
was classified as ‘Probably efficacious treatments’.
Following the Task Force report, many clinical trials
on CBT for anxious children were conducted. In a review
Compton, Burns and Robertson (2002) noted the
substantial evidence supporting the efficacy of cogni-
tive-behavioural interventions for childhood anxiety
disorders and depressive disorders. Cartwright-Hatton
et al. (2004), in their systematic review on the efficacy of
CBT for anxiety disorders in children and adolescents,
showed that the odds ratio of recovery in a CBT group
Ó 2007 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
was 3.27, and suggested that CBT was an effective
intervention for anxiety disorders in children and ado-
lescents. However, their review used only a number of
diagnosed cases as outcome measures and con-
sequently did not examine any other measure (e. g. self-
report of anxiety or parents’ report). Moreover, there
were no data on the efficacy of CBT at follow-up and CBT
plus family or parents’ intervention.
In this study, we examined through meta-analysis
the therapeutic gain of CBT for children and adoles-
cents with anxiety disorders, including follow-up data.
We were also interested in the difference in therapeutic
gain according to variables such as diagnostic criteria,
treatment settings, treatment formats, and duration of
treatments. We then examined the difference in effect-
iveness between child only CBT and CBT including
family or parents.
Methods
Population and sample
Articles were selected through computer searches of
PsycInfo and Medline (up to November 2004), and
references of Compton et al. (2002). We used three cat-
egories of subject heading referred to in Compton et al.
(2002). First, child, adolescent, and youth were used as
keywords. Second, anxiety disorder, anxiety, separation
anxiety disorder, generalised anxiety disorder, anxiety
neurosis, obsessive compulsive disorder, panic disorder,
phobia, PTSD, social anxiety, social phobia, school refu-
sal, and selective mutism were used as subject headings
representing symptoms of anxiety. Third, efficacy of
treatment, treatment outcome study, clinical trial, and
controlled clinical trial were used. Next, we checked all
extracted studies according to the following five stand-

ards: (a) treatment elements of CBT were used; (b) sta-
tistical values that could be used in meta-analysis were
included; (c) they were written in English; (d) randomised
controlled design was used; and (e) they were all pub-
lished. We defined CBT as the combination of the six
following treatment elements: relaxation, cognitive
restructuring, exposure, contingency management,
problem solving training, and social skills training.
According to the above criteria, 22 studies were
selected but two studies (Barrett et al., 2001; Deblinger
et al., 1999) were follow-up research studies on the same
samples as the other studies and so 20 studies were
used for the analyses (Table 1).
Design
First, we calculated effect sizes (Cohen’s d value) within-
subjects in the CBT group. We analysed effect size with
regard to diagnostic interview, severity of symptoms,
anxiety by self-report, depression by self-report, parent-
report, and teacher-report. In particular, we classified
informants of effect indices into three categories (anxiety
by self-report, depression by self-report, and parent-
report), and calculated above statistical values for each
informant. In addition, the maintenance of the thera-
peutic gain at follow-up was examined. Many studies
used a wait list control, and so we cannot compare effect
sizes with the no treatment sample at follow-up. Conse-
quently, the maintenance of the therapeutic gain was
examined by comparing the effect size of pretreatment to
different follow-up periods (24 months or more,
12 months, 6 months, and 3 months).
Next, the CBT group and control group were compared.
The group that had not received specific treatment,
including the wait list control, was defined as the no
treatment group, and the group that received any treat-
ment other than CBT was defined as other treatment
group. The control group included both the no treatment
group and other treatment group. We compared the CBT
group to the control group, no treatment group, and other
treatment group. In addition, we examined the difference
of the effect among four informants, including diagnos-
tician data, anxiety by self-report, depression by self-
report, and parent-report.
The research studies were classified according to the
following categories: diagnostic criteria, treatment set-
ting, treatment format, and number of sessions. As for the
diagnostic criteria, DSM-III-R (American Psychiatric
Association, 1987) included overanxious disorder, separ-
ation anxiety disorder, and avoidant disorder in childhood
anxiety disorders. On the other hand, avoidant disorder
was deleted, and overanxious disorder merged with gen-
eralised anxiety disorder in DSM-IV (American Psychi-
atric Association, 1994). Because there were major
differences between DSM-III-R (APA, 1987) and DSM-IV
(APA, 1994), we examined whether the effect sizes were
different depending on which criteria were used. Eleven of
20 studies were conducted in the university clinic or
hospital. It is necessary to compare the treatment effect
with other settings in the point of ‘transportability’ re-
search (Chorpita, 2003). In addition, we compared the
treatment effects between individual CBT and group CBT.
Because one study compared individual CBT to group
CBT directly (Flannery-Schroeder & Kendall, 2000), we
analysed each effect size separately. Finally, we differ-
entiated research studies that used more than 11 sessions
of CBT programs from research studies that used less
Meta-Analysis of CBT for Anxiety Disorders 165
than 10. In eight studies the therapeutic gain of CBT in-
cluding family or parents was compared directly with
child CBT, and so we calculated effect sizes of both treat-
ments in these studies.
Analysis
In the analyses, the effect sizes and fail safe indices were
calculated using the ‘Tougou’ computer software (Ono-
dera, 2000). The number of file drawer studies was cal-
culated by the formula advocated by Rosenthal (1984)
(File drawers studies ¼ 5N + 10; N ¼ number of re-
search studies used for meta-analysis). We calculated
95% confidence interval (95% CI) by using general vari-
ance-base method (Masui, 2003).
Results
Effect sizes of all outcome studies are presented in
Table 2, along with lengths and effect sizes of follow-up
periods. The control group in Table 2 included the wait
list control and the no treatment group.
Therapeutic gain of CBT and long-term treatment
outcome1
Table 3 shows within-subject indices that are d value,
the fail safe index, number of file drawer studies, and
95% CI. The summed pre-post effect size of the 20 out-
come studies was large (d ¼ 0.94; range ¼ 0.24–4.64;
CI ¼ 0.76–0.98). Effect sizes for each informant were
calculated; self-report measures demonstrated medium
effects in anxiety (d ¼ 0.74; range ¼ )0.77–4.83; CI ¼
0.60–0.82), and depression (d ¼ 0.63; range ¼ )0.03–
1.09; CI ¼ 0.48–0.74). Parent-report measures demon-
strated large effects (d ¼ 1.06; range ¼ 0.22–6.40; CI ¼
0.85–1.08).
All effect sizes relating to improvements in anxiety
symptoms at follow-up were significant (p < .001). Five
studies assessed 3-month follow-up periods with the
mean effect size being large (d ¼ 0.99; range ¼ 0.82–
1.39; CI ¼ 0.64–1.17). Effect size at 6-month follow-up
was medium, when seven studies were included (d ¼
0.86; range ¼ 0.45–1.33; CI ¼ 0.62–1.00). Similarly, we
found medium to large effect at 12-month follow-up (d ¼
1.51; range ¼ 0.43–5.94; CI ¼ 1.16–1.40), and 24-
month follow-up (d ¼ 0.84; range ¼ 0.56–1.12; CI ¼
0.50–1.08). Results showed that pre-post effect sizes
were maintained at follow-up.2
1
In this section, if an effect size is larger, it is suggested that
CBT is effective to improve each index from pre to post or from
pre to follow-up.
2
Pre-post d value of Shortt et al. (2001) was much larger than
other studies, and sample size was also large. Thus, when we
calculated all studies in a 12-month follow-up period, we found
that ‘weighted d value’ was not installed between 95% CI. Then,
we calculated statistic values excluded Shortt et al. (2001) in
pre-post effect size, pre-post self-rating of anxiety, pre-post
parent-rating, and 12 month follow-up. Results showed that all
d values were significant (p < .001), and that effect sizes were a
range from medium to large (Table 3). We calculated the pre-
sumption of file drawers and fail safe index, and examined the
possibility of overturning this result by file drawer studies. Be-
cause all fail safe indices exceeded the presumption of file
drawers, the reliability of effect sizes was confirmed.
Table 1. Previous research for effectiveness of CBT for children with anxiety disorders 166

CBT with family/

Number parents vs. CBT
Author Sample & design Age Diagnosis Criteria Manual Setting Format of sessions child-only CBT

Barrett (1998) GCBT ¼ 19 vs. 7–14 OAD DSM-III-R Coping Koala University Group 12 Yes
GCBT + FM ¼ 15 vs. SAD
WLC ¼ 16 SoP
Barrett et al. CBT ¼ 28 vs. 7–14 SAD DSM-III-R Coping Koala University Individual 12 Yes
(1996, 2001) CBT + FM ¼ 25 vs. SoP
WLC ¼ 26
Beidel et al. (2000) SET-C ¼ 30 vs. 8–12 SoP DSM-IV SET-C University Group 24 No
Shin-ichi Ishikawa et al.

NSTC ¼ 20
Berliner & Saunders Index ¼ 48 vs. Comparison ¼ 32 4–13 PTSD – Stress inoculation Other Group 10 No
(1999) training + prolonged
exposure
Cobham et al. (1998) Child anxiety only 7–14 SAD DSM-IV Coping Koala University Group 10 Yes
CBT ¼ 17 vs. OAD
CBT + PAM ¼ 15 GAD
Child + parental anxiety SP
CBT ¼ 18 vs. SoP
CBT + PAM ¼ 17 AP
Dadds et al. (1997) CBT ¼ 61 vs. 7–14 GAD DSM-IV Coping Koala Other Group 10 No
NTC ¼ 67 SAD
SP
SoP
Deblinger et al. CBT-C ¼ 24 vs. 7–13 PTSD DSM-III-R Original Other Individual 12 Yes
(1996, 1999) CBT-P ¼ 22 vs.
CBT-CP ¼ 22 vs.
TAU ¼ 22
Flannery-Schroeder ICBT ¼ 13 vs. 8–14 GAD DSM-IV Coping Cat Other Individual 18 No
et al. (2000) GCBT ¼ 12 vs. SAD Group
WLC ¼ 12 SoP
Kendall (1994) CBT ¼ 27 vs. 9–13 OAD DSM-III-R Coping Cat University Individual 17 (a range No
WLC ¼ 20 SAD from 16 to 20)
AvD
Kendall et al. (1997) CBT ¼ 60 vs. 9–13 OAD DSM-III-R Coping Cat University Individual 18 (a range No
WLC ¼ 34 SAD from 16 to 20)
AvD
King et al. (1998) CBT ¼ 17 vs. 5–15 SAD DSM-III-R Original Other Individual 6 No
WLC ¼ 17 AD
OAD
SP
SoP
Dsy
OCD
APD
Table 1. (Continued)

CBT with family/

Number parents vs. CBT
Author Sample & design Age Diagnosis Criteria Manual Setting Format of sessions child-only CBT

King et al. (2000) CBT ¼ 9 vs. 5–15 SAD DSM-III-R Original Other Individual 6 Yes
CBT + FM ¼ 9 vs. AD
WLC ¼ 10 OAD
SP
SoP
Dsy
OCD
APD
Last et al. (1997) CBT ¼ 20 vs. 6–17 SP DSM-III-R Unspecified University Individual 12 No
EST ¼ 21 SAD
OAD
PD
Manassis et al. GCBT ¼ 37 vs. 8–12 GAD DSM-IV Child ¼ Coping Cat Other Individual 12 No
(2002) ICBT ¼ 41 SAD Parents ¼ Keys to Group
SP Parenting Your
SoP Anxious Child
PD
Mendlowitz et al. CBT-CP ¼ 18 vs. 7–12 Anxiety DSM-IV Coping Bear Other Group 12 Yes
(1999) CBT-C ¼ 23 vs. disorder
CBT-P ¼ 21 vs.
WLC ¼ 40
Öst et al. (2001) CBT-C ¼ 21 vs. 7–17 SP DSM-IV Original University Individual 1 Yes
CBT-CP ¼ 20 vs.
WLC ¼ 19
Shortt et al. (2001) CBT + FM ¼ 54 vs. 6–10 GAD DSM-IV FRIENDS University Group 10 No
WLC ¼ 17 SAD
SP
SoP
Silverman, Kurtines, GCBT ¼ 25 vs. 6–16 SoP DSM-III-R Original University Group Unspecified No
Ginsburg, Weems, WLC ¼ 16 OAD
Lumpkin et al. (1999) GAD
Silverman, Kurtines, SC ¼ 41 vs. 6–16 SP DSM-III-R Original University Individual 10 No
Ginsburg, Weems, CM ¼ 40 vs.
Rabian et al. (1999) ES ¼ 23
Spence et al. (2000) CBT-CP ¼ 17 vs. 7–14 SoP DSM-IV Original University Group 12 Yes
CBT ¼ 19 vs.
WLC ¼ 14

Note: AD: Adjustment disorders, AP: Agoraphobia, APD: Avoidant personality disorder, AvD: Avoidant disorder, CBT: Cognitive-behavioural therapy, CBT-C: CBT for children only, CBT-CP: CBT
with children and parents, CBT-P: CBT for parents only, CM: In vivo exposure and contingency management, Comparison: Common treatment for sexual abused children, DSY: Dysthymic disorder,
ES: Non-specific educational support control, EST: Educational support therapy, FM: Family management, GAD: Generalized anxiety disorder, GCBT: Group cognitive behavioural therapy, ICBT:
Individual cognitive behavioural therapy, Index: Stress inoculation training and gradual exposure for sexual abused children, NSTC: Non-specific treatment control, NTC: Non treatment control,
Meta-Analysis of CBT for Anxiety Disorders

OAD: Overanxious disorder, OCD: Obsessive-compulsive disorder, PAM: Parental anxiety management, PD: Panic Disorder, PTSD: Posttraumatic Stress Disorder, SAD: Separation Anxiety Disorder,
SC: In vivo Exposure and self-control procedure, SET-C: Social effectiveness therapy for children, SoP: Social phobia, SP: Specific phobia, TAU: Treatment as usual, WLC: Waiting list control
167
168 Shin-ichi Ishikawa et al.

Table 2. The effect size of CBT for children with anxiety disorders

Effect size

Author Pre vs. post CBT vs. control Follow up

Barrett (1998) d ¼ 2.04 d ¼ 1.61 d ¼ 3.45 12 months

d ¼ 1.33 6 months
Barrett et al. (1996, 2001) d ¼ 0.67 d ¼ 0.69 d ¼ 1.60 12 months
d ¼ 1.12 Long term
Beidel et al. (2000) d ¼ 0.79 d ¼ 0.70 d ¼ 1.26 6 months
Berliner & Saunders (1999) d ¼ 0.24 d ¼ )0.07 d ¼ 0.43 12 months
d ¼ 0.56 24 months
Cobham et al. (1998) d ¼ 0.52 – d ¼ 0.59 6 months
12 months
Dadds et al. (1997) d ¼ 0.40 d ¼ 0.46 d ¼ 0.45 6 months
d ¼ 0.68
Deblinger et al. (1996, 1999) d ¼ 0.77 d ¼ 0.45 d ¼ 0.85 3 months
d ¼ 1.23 6 months
d ¼ 1.00 12 months
d ¼ 1.00 24 months
Flannery-Schroeder et al. (2000) d ¼ 0.93 d ¼ 0.94 d ¼ 0.82 3 months
Kendall (1994) d ¼ 1.12 d ¼ 0.85 d ¼ 1.23 12 months
Kendall et al. (1997) d ¼ 1.21 d ¼ 0.82 d ¼ 1.35 12 months
King et al. (1998) d ¼ 0.45 d ¼ 0.62 d ¼ 1.39 3 months
King et al. (2000) d ¼ 0.96 d ¼ 0.48 d ¼ 0.97 3 months
Last et al. (1997) d ¼ 0.59 d ¼ 0.39 – –
Manassis et al. (2002) d ¼ 0.55 – – –
Mendlowitz et al. (1999) d ¼ 0.35 d ¼ 0.23 – –
Öst et al. (2001) d ¼ 0.50 d ¼ 0.40 d ¼ 0.48 12 months
Shortt et al. (2001) d ¼ 4.64 d ¼ 1.37 d ¼ 5.94 12 months
Silverman, Kurtines, Ginsburg, Weems, Lumpkin et al. (1999) d ¼ 1.02 d ¼ 0.38 – –
Silverman, Kurtines, Ginsburg, Weems, Rabian, et al. (1999) d ¼ 0.80 d ¼ 0.76 d ¼ 0.96 3 months
d ¼ 1.02 6 months
d ¼ 1.28 12 months
Spence et al. (2000) d ¼ 0.78 d ¼ 0.52 d ¼ 0.85 6 months
d ¼ 1.12 12 months

As all effect sizes were significant, we calculated the
presumptive number of file drawer studies and fail safe
index, and examined the possibility of disproving this
result by file drawer studies. As can be seen in Table 3,
all fail safe indices exceeded the number of file drawer
studies. Thus, the reliability of effect sizes was
confirmed.
CBT versus control group3
Next, we compared CBT group with control group,
which included no treatment group and other treat-
ment group. As shown in Table 4, a medium effect size
was obtained d ¼ 0.61(range ¼ )0.07–1.61; CI ¼ 0.46–
0.72; p < .001). Effect size of CBT group versus no
treatment group was medium (d ¼ 0.68; range ¼ 0.23–
1.61; CI ¼ 0.51–0.80; p < .001). Fail safe indices in two
effect sizes values exceeded the presumptive number of
file drawer studies. Although d value of CBT group
versus other treatment group was significant, effect size
value was small (d ¼ 0.27; range ¼ )0.07–0.76; CI ¼
0.00–0.53; p < .001). The fail safe index was below the
number of file drawer studies and as such this finding
needs to be treated with caution.
3
In this section, if an effect size is larger, it is suggested that
CBT is effective as we compared the CBT group with each
group (control group, no treatment group, and other treatment
group).
Next, effect size values by informants were evaluated.
Effect size of diagnostician data was significant and
medium to large (d ¼ 0.87; range = )0.12–1.61; CI ¼
0.63–1.01; p < .001). Results indicated that remaining
three effect sizes were significant and medium (anxiety
by self-report: d ¼ 0.36; range ¼ 0.01–0.78; CI ¼ 0.23–
0.49, depression by self-report: d ¼ 0.43; range ¼
)0.93–0.98; CI ¼ 0.27–0.58, parents: d ¼ 0.63;
range ¼ )0.89–2.70; CI ¼ 0.47–0.75; p < .001). All fail
safe indices exceeded the number of file drawer studies.
We examined whether the therapeutic gain was dif-
ferent depending on each category: diagnostic criteria,
setting, format, and session. All effect sizes were sta-
tistically significant (p < .001). As we calculated effect
sizes per each diagnostic criteria, both effect sizes were
also medium (DSM-III-R: d ¼ 0.70; range ¼ 0.38–1.61;
CI ¼ 0.48–0.87, DSM-IV:d ¼ 0.61; range ¼ 0.23–1.37;
CI ¼ 0.39–0.78). We compared treatment at the uni-
versity clinic with treatment at other settings. Result
showed that both effect sizes were medium, but the ef-
fect size of the university clinic was larger than other
settings (university clinic: d ¼ 0.77; range ¼ 0.38–1.61;
CI ¼ 0.57–0.89, other situations:d ¼ 0.37; range ¼
)0.07–0.94; CI ¼ 0.15–0.58). In the same way, we
compared the treatment effect between group CBT and
individual CBT. Both effect sizes were medium level
(group: d ¼ 0.59; range ¼ )0.07–1.61; CI ¼ 0.39–0.75,
individual:d ¼ 0.66; range ¼ )0.39–1.00; CI ¼ CI ¼
0.46–0.81). Effect sizes of 10 or fewer sessions and 11
or more sessions were also medium (10 or fewer ses-
 Meta-Analysis of CBT for Anxiety Disorders 169

Table 3. Overall mean effect size on pre-post treatment and pre-follow-up

N Mean ES Min Max Fail Safe Index (p ¼ .01) File drawer studies (N) 95% CI

All treatment
Pre-Post 20 0.94*** 0.24 4.64 7816.59 110 0.76–0.98
Pre-Posta (19) (0.73)*** (0.24) (2.04) (6191.20) (105) (0.59–0.85)
Domain of measurement
Self report of anxiety (Pre-Post) 20 0.74*** )0.77 4.83 1462.61 110 0.60–0.82
Self report of anxiety (Pre-Post)a (19) (0.47)*** ()0.77) (1.95) (1031.70) (105) (0.34–0.58)
Self report of depression (Pre-Post) 16 0.63*** )0.03 1.09 288.15 90 0.48–0.74
Parent report (Pre-Post) 15 1.06*** 0.22 6.40 2497.44 85 0.85–1.08
Parent report (Pre-Post)a (14) (0.75)*** (0.22) (2.06) (1713.00) (80) (0.59–0.85)
Follow-up
3 months 5 0.99*** 0.82 1.39 578.16 35 0.64–1.17
6 months 7 0.86*** 0.45 1.33 1107.14 45 0.62–1.00
12 months 11 1.51*** 0.43 5.94 5226.19 65 1.16–1.40
12 monthsa (10) (1.15)*** (0.43) (3.45) (3926.51) (60) (0.90–1.18)
Over 24 months 3 0.84*** 0.56 1.12 196.96 25 0.50–1.08
a
Statistics values excluding Shortt et al. (2001).
***p < .001

Table 4. Overall mean effect size on CBT-Control

N Mean ES Min Max Fail safe index (p ¼ .01) File drawer studies (N) 95% CI

All treatment
CBT group-Control group 18 0.61*** )0.07 1.61 3504.57 100 0.46–0.72
CBT group-No treatment group 14 0.68*** 0.23 1.61 2801.98 80 0.51–0.80
CBT group-Other treatment group 4 0.27*** )0.07 0.76 24.67 30 0.00–0.53
Domain of measurement
Diagnostician data 7 0.87*** )0.12 1.61 60.51 45 0.63–1.01
Self report of anxiety (CBT-Control) 18 0.36*** 0.01 0.78 260.63 100 0.23–0.49
Self report of depression (CBT-Control) 14 0.43*** )0.93 0.98 84.26 80 0.27–0.58
Parents report (CBT-Control) 14 0.63*** )0.89 2.70 1002.15 80 0.47–0.75
Criteria
DSM-III-R 10 0.70*** 0.38 1.61 1270.11 60 0.48–0.87
DSM-IV 7 0.61*** 0.23 1.37 577.85 45 0.39–0.78
Setting of CBT
University 11 0.77*** 0.38 1.61 1726.06 65 0.57–0.89
Other 7 0.37*** )0.07 0.94 305.34 45 0.15–0.58
Format of CBTa
Group 9 0.59*** )0.07 1.61 798.77 55 0.39–0.75
Individual 10 0.66*** 0.39 1.00 1108.39 60 0.46–0.81
Sessions of CBT
10 or fewer sessions 7 0.54*** )0.07 1.37 271.53 45 0.33–0.72
11 or more sessions 10 0.70*** 0.23 1.61 1579.18 60 0.50–0.84
a
In Flannery-Schroeder and Kendall (2000) group treatment and individual treatment are separately analysed.
***p < .001

sions: d ¼ 0.54; range ¼ )0.07–1.37; CI ¼ 0.33–0.72, 11
or more sessions:d ¼ 0.70; range ¼ 0.23–1.61; CI ¼
0.50–0.84). All fail safe indices exceeded the number of
file drawer studies.
4
CBT including family or parents versus child CBT
The effect size of CBT including family or parents with
child CBT for eight research studies was calculated
(Table 5). Effect size was significant but very small (d ¼
0.03, p < .05). Fail safe index was greatly below the
number of file drawer studies (fail safe index ¼ )6.242,
4
In this section, if an effect size is larger, it is suggested that
CBT including family or parents is effective as compared with
child CBT.
number of file drawer studies ¼ 50) suggesting that
further research is required.
Discussion
Compared to a no treatment group the effect size of CBT
for children and adolescents with anxiety disorders was
0.68. Lambert and Bergin (1994) indicated that the
average placebo effect size was 0.42. Weisz et al. (1995)
indicated that an effect size that exceeded 0.50 was
beneficial. The effect size in this meta-analysis exceeded
these standards and is consistent with the suggestion by
Cartwright-Hatton et al (2004) that CBT is an effective
treatment for anxiety disorders with children and ado-
lescents. Moreover, the effect size of diagnostician data
was large (d ¼ 0.87) suggesting that many anxious
children could be below the clinical range of significance
170 Shin-ichi Ishikawa et al.
Table 5. Effect size on CBT with children and family/parents
Author Sample and design Effect size
Barrett (1998) GCBT ¼ 19 vs. GCBT + FM ¼ 15 d ¼ )0.77
Barrett et al. CBT ¼ 28 vs. CBT + FM ¼ 25 d ¼ 0.56
(1996, 2001)
Cobham et al. Child anxiety only d ¼ )0.22
(1998) CBT ¼ 17 vs. CBT + PAM ¼ 15
Child + parental anxiety
CBT ¼ 18 vs. CBT + PAM ¼ 17
Deblinger et al. CBT-CP ¼ 22 vs. CBT-C ¼ 24 d ¼ 0.07
(1996, 1999)
King et al. (2000) CBT ¼ 19 vs. CBT + FAM ¼ 9 d ¼ 0.17
Mendlowitz et al. CBT-CP ¼ 18 vs. CBT-C ¼ 23 d ¼ 0.23
(1999)
Öst et al. (2001) CBT-C ¼ 21 vs. CBT-CP ¼ 20 d ¼ )0.03
Spence et al. (2000) CBT ¼ 19 vs. CBT-CP ¼ 17 d ¼ 0.01
Note: CBT: Cognitive-behavioural therapy, CBT-C: CBT for children
only, CBT-CP: CBT with children and parents, CBT-P: CBT for
parents only, FAM: Family anxiety management, FM: Family
management, GCBT: Group cognitive behavioural therapy, PAM:
Parental anxiety management
after they participated in CBT. Results of the meta-
analysis therefore strongly support the effectiveness of
CBT for anxious children.
Follow-up ranged from 3 months to 24 months and
yet there were no differences among d values across
these follow-up periods. In the meta-analysis of CBT for
adults with anxiety disorders, it was shown that the
effects of CBT were maintained at follow-up (e.g. Gould
et al., 1997). Likewise, the present study proved that
the effects of the CBT remained for up to two years. The
goal of CBT for children and adolescents with anxiety
symptoms is to improve anxiety symptoms not only for
the present but also in the future (Kendall, 2000).
Therefore, meta-analysis in this study suggested that
CBT achieved that therapeutic purpose. However, be-
cause many outcome studies adopted waiting list con-
trol design, we could not examine the therapeutic
effects of CBT compared to a no treatment group over
time. In future, more studies designed to compare CBT
group with the control sample at follow-up will be
needed.
Results indicated that effect size in parent-rating was
the largest of the three effect indices excepting diag-
nostician data. Most children do not refer themselves
for treatment and often attend specialised agencies
because of concerns by adults, usually parents.
Therefore, parents may be very aware of their child’s
difficulties and could notice greater changes in anxiety
symptoms.
Research studies have highlighted the comorbidity
and overlap of anxiety and depression in children
(Kendall et al., 1992). As results of this study, CBT for
anxious children appears to be effective for depressive
symptoms. However, due to the small number of stud-
ies included in this review further studies are required
to examine the influence of CBT for anxiety disorders on
depression symptoms.
There was comparatively little difference in the effect
sizes of short (10 or less sessions) v long CBT and be-
tween group v individual CBT. Thus, group CBT or
short-term CBT can be a useful treatment from the
viewpoint of cost effectiveness. The most important re-
sult is that the effectiveness of CBT is proved regardless
of its length or mode of delivery. However, in terms of
delivery settings the results suggest that CBT provided
at university clinics was more effective. This may be due
to researchers at universities being better able to en-
sure treatment and protocol fidelity. These ‘transport-
ability’ problems (Chorpita, 2003) apply not only to CBT
for anxious children but to all CBT.
Finally, in this meta-analysis, effects of CBT inclu-
ding parents or family were unclear and as such it is
difficult to conclude whether parents should be inclu-
ded in CBT. In the manuals of child CBT, procedures for
the intervention for parents or family were not clear. In
addition, research studies in this meta-analysis were
not consistent as regards psychopathological condi-
tions of parents and, some studies showed efficacy of
family CBT when parents had their own psychopatho-
logy. To examine the difference of treatment outcomes
in family CBT versus child CBT, it is necessary to
accumulate studies that take into consideration poss-
ibly important factors.
References
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003).
Childhood anxiety disorders. In E. J. Mash & R. A. Barkley
(Eds.), Childhood psychopathology (2nd ed.) (pp. 279–329).
New York: Guilford Press.
American Psychiatric Association (1987). Diagnostic and sta-
tistical manual of mental disorders (3rd ed., revised). Wash-
ington DC: Author.
American Psychiatric Association (1994). Diagnostic and sta-
tistical manual of mental disorders. (4th ed.) Washington DC:
Author.
Anderson, J. C., Williams, S., McGee, R., & Silva, R. (1987).
DSM-III disorders in preadolescent children: Prevalence in a
large sample from the general population. Archives of
General Psychiatry, 44, 69–76.
*Barrett, P. M. (1998). Evaluation of cognitive-behavioral group
treatments for childhood anxiety disorders. Journal of Clin-
ical Child Psychology, 27, 459–468.
*Barrett, P. M., Dadds, M. R., & Rapee R. M. (1996). Family
treatment of childhood anxiety: A controlled trial. Journal of
Consulting and Clinical Psychology, 64, 333–342.
*Barrett, P. M., Duffy, A. L., Dadds, M. R., & Rapee, R. M.
(2001). Cognitive-behavioral treatment of anxiety disorders
in children: Long-term (6-year) follow-up. Journal of Con-
sulting and Clinical Psychology, 69, 135–141.
*Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral
treatment of childhood social phobia. Journal of Consulting
and Clinical Psychology, 68, 1072–1080.
*Berliner, L., & Saunders, B. E. (1996). Treating fear and
anxiety in sexually abused children: Results of a controlled
2-year follow-up study. Child Maltreatment, 1, 294–309.
Cartwright-Hatton, S., Roberts, C., Chitsabesan, P., Fothergill,
C., & Harrington, R. (2004). Systematic review of the efficacy
of cognitive behaviour therapies for childhood and adoles-
cent anxiety disorders. British Journal of Clinical Psychology,
43, 421–436.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically
supported psychological interventions: Controversies and
evidence. Annual Review of Psychology, 52, 685–716.
Chorpita, B. F. (2003). The frontier of evidence-based practice.
In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based
psychotherapies for children and adolescents (pp. 42–59).
New York: Guilford Press.
*Cobham, V. E., Dadds, M. R., & Spence S. H. (1998). The role
of parental anxiety in the treatment of childhood anxiety.
Journal of Consulting and Clinical Psychology, 66, 893–905.

Cohen, J. (1977). Statistical power analysis for the behavioral
sciences. New York: Academic Press.
Compton, S. N., Burns, B. J., & Robertson, E. (2002). Review of
evidence base for treatment of childhood psychopathology:
Internalizing disorders. Journal of Consulting and Clinical
Psychology, 70, 1240–1266.
Cooper, H. M. (1979). Statistically combining independent
studies: A meta-analysis of sex differences in conformity
research. Journal of Personality and Social Psychology, 37,
131–146.
Costello, R. J. (1989). Child psychiatric disorders and their
correlates: A primary care pediatric sample. Journal of the
American Academy of Child and Adolescent Psychiatry, 28,
851–855.
*Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M., &
Laurens, K. R. (1997). Prevention and early intervention for
anxiety disorders: A controlled trial. Journal of Consulting
and Clinical Psychology, 65, 627–635.
*Deblinger, E., Lippmann, J., & Steer, R. (1996). Sexually
abused children suffering posttraumatic stress symptoms:
Initial treatment outcome findings. Child Maltreatment, 1,
310–321.
*Deblinger, E., Steer, R. A., & Lippmann, J. (1999). Two-year
follow-up study of cognitive behavioral therapy for sexually
abused children suffering post-traumatic stress symptoms.
Child Abuse & Neglect, 23, 1371–1378.
*Flannery-Schroeder, E. C., & Kendall, P. C. (2000). Group and
individual cognitive-behavioral treatments for youth with
anxiety disorders: A randomized clinical trial. Cognitive
Therapy and Research, 24, 251–278.
Gould, R. A., Otto, M. W., Pollack, M. H., & Yap, L. (1997).
Cognitive behavioral and pharmacological treatment of gen-
eralized anxiety disorder: A preliminary meta-analysis. Be-
havior Therapy, 28, 285–305.
Kashani, J. H., & Orvaschel, H. (1988). Anxiety disorders in
mid-adolescence: A community sample. American Journal of
Psychiatry, 145, 960–964.
*Kendall, P. C. (1994). Treating anxiety disorders in children:
Results of a randomized clinical trial. Journal of Consulting
and Clinical Psychology, 62, 100–110.
Kendall, P. C. (2000). Guiding theory for therapy with children
and adolescents. In P. C. Kendall (Ed.), Child and adolescent
therapy: Cognitive-behavioral procedures (2nd ed., pp. 3–27).
New York: Guilford Press.
Kendall, P. C., Chu, B., Pimentel, S. S., & Choudhury, M. (2000).
Treating anxiety disorders in youth. In P. C. Kendall (Ed.), Child
and adolescent therapy: Cognitive-behavioral procedures (2nd
ed., pp. 235–287). New York: Guilford Press.
*Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S.
M., Southam-Gerow, M., Henin, A., & Warman, M. (1997).
Therapy for youths with anxiety disorders: A second rando-
mized clinical trial. Journal of Consulting and Clinical
Psychology, 65, 366–380.
Kendall, P. C., Kortlander, E., Chansky, T. E., & Brady, E. U.
(1992). Comorbidity of anxiety and depression in youth:
Treatment implications. Journal of Consulting and Clinical
Psychology, 60, 869–880.
*King, N. J., Tonge, B. J., Heyne, D., Pritchard, M., Rollings, S.,
Young, D, Myerson, N., & Ollendick, T. H. (1998). Cognitive-
behavioral treatment of school-refusing children: A controlled
evaluation. Journal of the American Academy of Child and
Adolescent Psychiatry, 37, 395–403.
*King, N. J., Tonge, B. J., Mullen, P., Myerson, N., Heyne, D.,
Rollings, S., Martin, R., & Ollendick, T. H. (2000). Treating
sexually abused children with posttraumatic stress symptoms:
Meta-Analysis of CBT for Anxiety Disorders 171
A randomized clinical trial. Journal of the American Academy of
Child and Adolescent Psychiatry, 39, 1347–1355.
Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of
psychotherapy. In A. E. Bergin & L. Garfield (Eds.), Handbook
of psychotherapy and behavioral change (pp. 143–189). New
York: Wiley.
*Last, C. G., Hansen, C., & Franco, N. (1998). Cognitive-
behavioral treatment of school phobia. Journal of the Amer-
ican Academy of Child and Adolescent Psychiatry, 37, 404–
411.
*Manassis, K., Mendlowitz, S. L., Schapillato, D., Avery, D.,
Fiksenbaum, L., Freire, M., Monga, S., & Owens, M. (2002).
Group and individual cognitive-behavioral therapy for child-
hood anxiety disorders: A randomized trial. Journal of the
American Academy of Child and Adolescent Psychiatry, 41,
1423–1430.
Masui, K. (2003). Kokokara hajimeru Meta-analysis: Excel wo
tsukatte kanntan ni [Introduction to Meta-analysis: Easily by
using Excel]. Tokyo, Japan: Shinko Trading.
*Mendrowitz, S. L., Manassis, K., Bradley, S., Scapillato, D.,
Miezitis, S., & Shaw, B. F. (1999). Cognitive-behavioral group
treatments in childhood anxiety disorders: The role of
parental involvement. Journal of the American Academy of
Child and Adolescent Psychiatry, 38, 1223–1229.
Mullen, B. (1989). Advanced basic meta-analysis. New Jersey:
Lawrence Erlbaum Associates.
Onodera, T. (2000). Tougou (version 1.0) [Computer software]
Kyoto, Japan: Nakanishiya Shuppan.
*Öst, L. G., Svensson, L., Hellström, K., & Lindwall, R. (2001).
One-session treatment of specific phobias in youths: A
randomized clinical trial. Journal of Consulting and Clinical
Psychology, 69, 814–824.
Rosenthal, R. (1984). Meta-analytic procedures for social
research. Beverly Hills, CA: Sage Publications.
Schniering, C. A., Hudson, J. L., & Rapee, R. M. (2000). Issues
in the diagnosis and assessment of anxiety disorders in
children and adolescents. Clinical Psychology Review, 20,
453–478.
Schroeder, H. E., & Dush, D. M. (1987). Relinquishing the
placebo: Alternatives for psychotherapy outcome research.
American Psychologist, 42, 1129–1130.
*Shortt, A., L., Barrett, P. M., & Fox, T. L. (2001). Evaluating the
FRIENDS program: A cognitive-behavioral group treatment
for anxious children and their parents. Journal of Clinical
Child Psychology, 30, 525–535.
*Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C.
F., Lumpkin, P. W., & Carmichael, D. H. (1999). Treating
anxiety disorders in children with group cognitive-behavioral
therapy: A randomized clinical trial. Journal of Consulting
and Clinical Psychology, 67, 995–1003.
*Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C.
F., Rabian, B., & Serafini, L. T. (1999). Contingency manage-
ment, self-control, and education support in the treatment of
childhood phobic disorders: A randomized clinical trial.
Journal of Consulting and Clinical Psychology, 67, 675–687.
*Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (2000).
The treatment of childhood social phobia: The effectiveness of
a social skills training-based, cognitive-behavioural interven-
tion, with and without parental involvement. Journal of Child
Psychology and Psychiatry, 41, 713–726.
Weisz, J. R., Donenberg, G. R., Weiss, B., & Han, S. S. (1995).
Bridging the gap between laboratory and clinical in child and
adolescent psychotherapy. Journal of Consulting and Clinical
Psychology, 63, 688–701.
172 Shin-ichi Ishikawa et al.

Appendix 1: Statistical terms

Meta-analysis. The purpose of meta-analysis is to integrate results of multiple studies and to summarise trends (e.g.
Mullen, 1989). Therefore, meta-analysis means that one magnitude of the effect is derived from multiple magnitude of
the effect (Masui, 2003).

Effect size. When a meta-analysis is conducted, effect sizes, which show magnitude of effectiveness, are calculated.
According to effect sizes, effectiveness of each treatment can be compared absolutely and relatively. Statistical
indices of effect size can use various standards of measurements, including Fisher’s z, product-moment correlations,
or Cohen’s d. We calculated Cohen’s d in this study.
Cohen (1977) indicated that d ¼ 0.2 is small, d ¼ 0.5 is medium, and d ¼ 0.8 is large. Schroeder and Dush (1987)
indicated that 0.33–0.93 is medium level, 0.93–1.53 is large, and 1.53 or more is very large. Effect sizes in this study
were based on the two standards. We used either of chi-square value, F value, mean value, or standard deviation as
input values. We calculated ‘weighted d value’, in which the influence on the result of integration was strengthened
when the studies had used a large sample.

File drawer problem and fail safe index. In general, research studies that fail to show a significant difference are not
published, resulting in some biases in meta-analysis at the document collection stage (Rosenthal, 1984). Put
simply, published studies were sometimes part of larger trials, and so many studies that did not support the
hypothesis could be hidden. This problem we called ‘file drawer problem’. To examine this, we calculated the
number of file drawer studies and fail safe indices (Cooper, 1979). Fail safe index shows the necessary number of
negative results to deny a conclusion of meta-analysis. Negative results mean studies that had non-significance
results or the rejection of the experiment’s hypothesis. The result of the meta-analysis can not be disproved by file
drawer studies when the presumption of file drawers does not come up to the fail safe index (Mullen, 1989). Thus,
we defined that the validation of the meta-analysis was confirmed if the fail safe index was more than the number
of file drawers.

Confidence interval. If we want to a get the true value of effect size, all outcome studies should be included in the
meta-analysis. Therefore, published outcome studies are extracted randomly from all populations and the effect size
is estimated from extracted studies. A confidence interval means an interval of including true effect size. If a prob-
ability of including true effect size is 95%, that estimated interval is called 95% confidence interval.