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Cognitive Behaviour Therapy

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CBT for Children with Depressive

Symptoms: A Meta-Analysis
a

Alexandra Arnberg & Lars-Gran st

ab

Department of Psychology, Stockholm University, Stockholm,

Sweden
b

Department of Clinical Neuroscience, Karolinska Institutet,

Stockholm, Sweden
Published online: 24 Sep 2014.

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To cite this article: Alexandra Arnberg & Lars-Gran st (2014) CBT for Children with
Depressive Symptoms: A Meta-Analysis, Cognitive Behaviour Therapy, 43:4, 275-288, DOI:
10.1080/16506073.2014.947316
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Cognitive Behaviour Therapy, 2014

Vol. 43, No. 4, 275288, http://dx.doi.org/10.1080/16506073.2014.947316

CBT for Children with Depressive Symptoms:

A Meta-Analysis
Alexandra Arnberg1 and Lars-Goran Ost1,2
Department of Psychology, Stockholm University, Stockholm, Sweden; 2Department of
Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

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Abstract. Pediatric depression entails a higher risk for psychiatric disorders, somatic complaints,
suicide, and functional impairment later in life. Cognitive behavior therapy (CBT) is recommended
for the treatment of depression in children, yet research is based primarily on adolescents. The present
meta-analysis investigated the efficacy of CBT in children aged 812 years with regard to depressive
symptoms. We included randomized controlled trials of CBT with participants who had an average
age of #12 years and were diagnosed with either depression or reported elevated depressive
symptoms. The search resulted in 10 randomized controlled trials with 267 participants in
intervention and 256 in comparison groups. The mean age of participants was 10.5 years. The
weighted between-group effect size for CBT was moderate, Cohens d 0.66. CBT outperformed
both attention placebo and wait-list, although there was a significant heterogeneity among studies
with regard to effect sizes. The weighted within-group effect size for CBT was large, d 1.02. Earlier
publication year, older participants, and more treatment sessions were associated with a larger effect
size. In conclusion, the efficacy of CBT in the treatment of pediatric depression symptoms was
supported. Differences in efficacy, methodological shortcomings, and lack of follow-up data limit the
present study and indicate areas in need of improvement. Key words: youth; depression; cognitive
behavioral therapy; psychotherapy; review.
Received 1 June 2014; Accepted 18 July 2014
Correspondence address: Lars-Goran Ost, Department of Psychology, Stockholm University, S-106 91
Stockholm, Sweden. Tel: 46 737121285. Email: ost@psychology.su.se

Depression in children is a serious condition

that entails an increased risk of psychological
and physiological ill-health in the future,
suicide, and social adjustment problems
(Jonsson et al., 2011; Klein, Lewinsohn, &
Seeley, 1997). Depressive symptoms during
childhood have been shown to be associated
with anxiety symptoms, low self-esteem,
externalizing behavior, alcohol and drug use,
and low school achievements (Harter, 1990;
King, Ollendick, & Gullone, 1991; Rowlison
& Felner, 1988). Without treatment, both
depression and subclinical depressive symptoms may progress into chronic depression or
more severe conditions (DuBois, Felner,
Bartels, & Silverman, 1995; Jonsson et al.,
2011). The risk of developing other affective
disorders is especially high, rather than
psychiatric problems in general (Fonagy,
Target, Cottrell, Phillips, & Kurtz, 2005),
and depression in the adolescence increases
q 2014 Swedish Association for Behaviour Therapy

the risk of new episodes in adulthood

(Costello et al., 2002; Weissman et al., 1999).
Thus, there is a large need of knowledge about
treatment of children already at an early age.
The proportion of children suffering from
depression increases with age. The lifetime
prevalence of depression in preschool children
is about 1%, in school children about 3%, and
in adolescents about 6% (Costello, Erkanli, &
Angold, 2006). Up to puberty, the prevalence
is the same in boys and girls, but thereafter it is
significantly higher in girls (Weissman, Warner, Wickramaratne, Moreau, & Olfson,
1997). Lifetime risk of depression in the
adult population is 5 25% for women and
3 10% for men (Swedish Council on Technology Assessment in Health Care [SBU],
2004).
In contrast to adolescent and adult
depression, depressive disorders during childhood may be expressed in unspecific symptoms

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276

Arnberg and Ost

rather than symptoms specific to the prototypical clinical presentation according to the
diagnostic features: young children with
depression complain about somatic symptoms, e.g., stomach pain, chest pain, and
headache. Worry, fear of the dark, irritability,
feelings of discomfort, and separation anxiety
are also common (Birmaher et al., 1996).
Expressions of depression often touch many
other conditions, e.g., anxiety disorders
(Cummings, Caporino, & Kendall, 2014).
That children show signs of low mood through
grief reactions and sadness is a part of normal
development and does not mean that major
depression is at hand.
Comorbidity is common for depressive
disorders in children, and the characteristic
symptoms are found in many child and
adolescent psychiatric diagnoses (Fonagy
et al., 2005). In children with the diagnosis of
major depression, 40 70% fulfill criteria for
another psychiatric disorder and at least 20%
has three or more comorbid disorders (Birmaher et al., 1996). Comorbidity has implications for assessment and treatment. In the
case of anxiety, measures of anxiety and
depression are highly correlated and symptoms of anxiety tend to predate depressive
symptoms (Cummings et al., 2014). Comorbidity with conduct disorder is strongly
associated with problems in all sorts of social
relationships and is linked to an increased risk
of suicide (Angold & Costello, 2001).
Thirty years ago, it was considered improbable that children could suffer from depression
(Fonagy et al., 2005). After the first randomized controlled trial (RCT; Butler, Mietzitis,
Friedman, & Cole, 1980), the second one was
not published until seven years later (Stark,
Reynolds, & Kaslow, 1987). Treatment studies
in children with depression lag far behind
those for adults. Historically, the treatment of
children has applied those methods that have
been shown effective for adults, primarily
medication and cognitive behavior therapy
(CBT; Kaslow & Thompson, 1998). However,
a gradual methodological development has
taken place with focus on a treatment adjusted
to the childs psychological developmental
level. For example, the educative component
about the chain of emotion-thought-action
may use various animal characters and is
shared in a language carefully adapted to the
age of the patient. Furthermore, the social

COGNITIVE BEHAVIOUR THERAPY

context of the child has been shown to be an

important component in order to understand
emergence and maintenance of depression in
children, and the childs parents are often
participating in the treatment to various
degrees (Abela & Hankin, 2008). Current
research focuses on implementing a developmentally sensitive psychotherapy for
depressed children (Kovacs & Lopez-Duran,
2012; Luby, Lenze, & Tillman, 2012). For
example, an ongoing study of Contextual
Emotional Regulation Therapy is based on the
proposition that dysphoric mood is the most
salient feature of clinical depression, which
starts as a response to an initiating stressful
event or process (Kovacs & Lopez-Duran,
2012). Whether or not the dysphoria develops
into a disorder is suggested to depend mainly
on how the affected youngster responds to the
emotion and the kind of support that is
available. Regarding psychological treatment
of children with depressive symptoms, CBT is
the only treatment for which there are several
studies of its efficacy, whereas interpersonal
therapy also may have an effect for adolescents
with depressive symptoms (David-Ferdon &
Kaslow, 2008; SBU, 2004; Watanabe, Hunot,
Omori, Churchill, & Furukawa, 2007),
although the long-term effects have not been
investigated closely enough (SBU, 2004).
Importantly, however, guidelines and recommendations for adolescents and younger
children are based primarily on treatment
results for adolescents (e.g., SBU, 2004)
despite the fact that it is reasonable to believe
that the effect is not equal for younger
children: symptoms, cognitive development,
and the included treatment components differ
between children and adolescents (Compton
et al., 2004; Michael & Crowley, 2002;
Watanabe et al., 2007; Weisz, McCarty, &
Valeri, 2006). A recent meta-analysis concluded that CBT and interpersonal therapy are
probably efficacious when compared to no
treatment, but the authors qualified their
findings by noting that it was likely that the
effect seen in their analysis was restricted to
children 12 18 years of age (Watanabe et al.,
2007). Furthermore, in most published studies
the children have not been diagnosed
(Asarnow, Scott, & Mintz, 2002; Butler et al.,
1980; de Cuyper, Timbremont, Braet, De
Backer, & Wullaert, 2004; Liddle & Spence,
1990; Stark et al., 1987; Weisz, Thurber,

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VOL 43, NO 4, 2014

Sweeney, Proffitt, & LeGagnoux, 1997) and in

a number of studies prevention samples have
been included (e.g., Gillham, Reivich, Jaycox,
& Seligman, 1995; Jaycox, Reivich, Gillham, &
Seligman, 1994). Including prevention
samples, however, may hamper the generalizations to be made, as they seem to have greater
gains from treatment as compared to clinical
samples (Klein, Jacobs, & Reinecke, 2007).
According to a meta-analysis by Durlak,
Weissberg, Dymnicki, Taylor, and Schellinger
(2011), preventive school-based interventions
have a positive impact on youths mental
health. Also, for lasting benefits from preventive programs, interventions for preadolescent children may be more effective than those
for adolescents (i.e., grade 6 vs. grade 9;
Barrett, Farrell, Ollendick, & Dadds, 2006).
The current meta-analysis differs from
previous meta-analyses in that it specifically
concerns the effect of CBT for children. Earlier
meta-analyses have included all types of
psychological treatment (Erford et al., 2011;
Watanabe et al., 2007; Weisz et al., 2006) and
studies of both children and adolescents
(Lewinsohn & Clarke, 1999; Luby et al.,
2012; Watanabe et al., 2007; Weisz et al.,
2006). In the Michael and Crowley (2002)
meta-analysis, a moderate effect size (ES) of
0.65 was found for the controlled studies of
treatments for children with depression. However, of the nine included studies, three
investigated other interventions than CBT.
In Weisz et al. (2006), a small ES of 0.41 was
found for children studies, although the
authors also included prevention samples in
their meta-analysis. The findings from the
Weisz et al. meta-analysis for children and
adolescents were highly similar to those of a
recent meta-analysis of all types of psychological treatments by Erford et al. (2011). Interestingly, a subgroup analysis in the Erford et al.
study suggests that CBT was not significantly
more effective than other treatments. This
finding was also reported by Spielmans, Pasek,
and McFall (2007) who found no difference
between CBT- and non-CBT-based treatments
for youths with depression or anxiety. Unfortunately, none of these two reviews conducted
separate analysis for children. Also in contrast
to the current analysis, Watanabe et al. (2007)
included all psychotherapeutic methods and
used relative risk of response (RR) as the
primary outcome measure. Their separate

CBT for Children with Depressive Symptoms

277

analysis of the child studies did not find a

significant difference between treatment and
control groups (RR 1.51, p 0.08), which
corresponds approximately to a Cohens d ES
of 0.3 (Chinn, 2000).
It can be concluded that earlier metaanalyses of different forms of psychotherapy
for children and adolescents with depression
or subclinical depressive symptoms have
obtained a large variation in mean ES:
Cohens d between 0.34 (Weisz et al., 2006)
and 1.27 (Lewinsohn & Clarke, 1999). Even if
it is unclear how Lewinsohn and Clarke (1999)
calculated their ES due to insufficient presentation of the method, it is important to better
understand the underlying reasons for this
large variation. Differences in ESs have
previously been shown to covary with the
publication year of the study: in a cumulative
meta-analysis of CBT treatments for adolescents, Klein et al. (2007) reported that the ES
was reduced as years go by. When Klein et al.
(2007) investigated the differences between
studies, these primarily consisted of smaller
ESs being associated with intent-to-treat
analyses, comparison between CBT and
another active treatment, treatment done in
clinical contexts, and application of more
strict methodological procedures.
Weisz et al. (2006) found a relatively large
ES at follow-up two to three months after the
termination of therapy, but essentially no
treatment effect was seen one year posttreatment. A diminishing effect with time was also
found in the Michael and Crowley (2002) and
Watanabe et al. (2007) meta-analyses, where
the latter study found that the effect of
psychotherapy was no longer significant at
follow-up six months or longer. Erford et al.
(2011) stated that depression treatments seem
to have significant effects for perhaps up to
two years, but we have far too few followup studies to ascertain any long-term benefit.
Major depression remits spontaneously within
nine months for the majority of patients,
whereas the relapse risk is as high as 50%
within two years (Fonagy et al., 2005). Hence,
it is important to know much more about the
effects of CBT in relation to spontaneous
remission and if the effect is maintained across
time. There is, as far as we know, no study that
has analyzed the long-term effects of CBT
specifically in the group of patients up to 13
years of age.

278

Arnberg and Ost

The aim of the current meta-analysis was to

investigate the efficacy of CBT for depressive
symptoms in children 8 12 years of age. The
specific research questions were the following:

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1. What is the mean ES of CBT for children

with depressive symptoms?
2. Is the ES associated with the publication
year of the study?
3. Is the ES maintained at follow-up?
In addition to these primary questions,
secondary analyses will be performed on
variables, which, recent meta-analyses in the
area indicate, show a possible relation to the
outcome, such as age, gender, severity of
symptoms, treatment time, number of sessions, quality of the study, attrition, and
therapist experience (Klein et al., 2007;
Michael & Crowley, 2002; Weisz et al., 2006).

Methods
Literature review
Studies published between 1980 and December 2013 were retrieved from major databases
in medicine (PubMed) and psychology (Psy-

COGNITIVE BEHAVIOUR THERAPY

cINFO), and from previous meta-analyses

and relevant review papers (Fonagy et al.,
2005; Ost, 2010; Whittington, Kendall, &
Pilling, 2005). The reference lists of these
publications and of studies with a potential to
be included were manually searched for
further studies (Figure 1).
The search in PsycINFO included the
following search terms: ((treatment or therapy
or intervention*) AND (depression OR
depressive OR mood) AND (children* OR
teen* OR preadolescen* OR adolescen*)).ab.
AND ((randomised OR randomized).ab. OR
(randomised OR randomized).ti.). The
searches were limited to journal articles with
peer-review or unknown peer-review status and
were written in English. The search yielded 561
publications. The search in PubMed included
the following search terms: (treatment[Title/
Abstract] OR therapy[Title/Abstract] OR
intervention*[Title/Abstract]) AND (children
[Title/Abstract] OR teen*[Title/Abstract] OR
youth*[Title/Abstract]) AND (depression
[Title/Abstract] OR depressive[Title/Abstract]
OR mood[Title/Abstract]). The search was
limited to publications indexed as journal
articles of RCTs, and they were written in

Figure 1. Flowchart of inclusion and exclusion of studies in the meta-analysis.

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VOL 43, NO 4, 2014

English, yielding 608 publications. The final

search was conducted on 7 December 2013.
The abstracts were read and full text
versions were retrieved if it was clear or
possible that the publication should be
included. The inclusion criteria were set a
priori and were as follows: the study has to
evaluate CBT, the samples mean age must be
below 13 years, the study has to be published
in a English-language peer-reviewed journal,
the participants should have depressive symptoms above a threshold score on self-rating
scales of depression or fulfill criteria for a
diagnosis of depression, and a RCT design has
to be used.
Evaluating CBT. CBT was defined as psychotherapeutic methods based on empirical
and theoretical research on behavioral, cognitive, or social psychology, and developed to
change emotions and behaviors by teaching
the children to affect their thoughts and overt
behaviors in an active and problem-focused
way. Also, the authors should have specified
the intervention as CBT. We decided to
include all CBT methods because there is no
clear consensus as to whether specific CBT
techniques or methods are more effective than
others in the treatment of children with
depression (Fonagy et al., 2005).
A sample mean age , 13 years. As in previous
meta-analyses, all individuals under 13 years
of age were classified as children (Michael &
Crowley, 2002; Weisz et al., 2006), although
studies that had included adolescents but
where the mean age of the sample was below
13 years were included.
Published in an English-language peer-reviewed
journal. Peer review may be seen as a proxy
measure of methodological rigor in the
included studies (Klein et al., 2007). This
inclusion criterion is further motivated in that
Weisz et al. (2006) in their meta-analysis found
no support for differences in treatment effects
between published and unpublished studies,
which was true also for a study of publication
bias in clinical research (Easterbrook, Berlin,
Gopalan, & Matthews, 1991). Other reviews
of meta-analyses, however, have found that
published studies have 15 33% larger ESs
compared to unpublished studies (McAuley,
Pham, Tugwell, & Moher, 2000).
Participants should have depressive symptoms
above a threshold score in self-rating scales of
depression or fulfill criteria for a diagnosis of

CBT for Children with Depressive Symptoms

279

depression. Because of the few studies of CBT

with children samples, it was deemed impossible to include only samples where a diagnosis
had been established. Potentially, including
both clinical and subclinical samples could
increase the heterogeneity of the present metaanalysis and, thus, negatively affect the
external validity of the findings. However,
previous meta-analyses that have performed
subgroup analyses on studies of children also
included prevention samples. Hence, the
studies included in the present analysis
would be more homogenous than in previous
meta-analyses.
RCT design. Reviews of RCTs across healthcare disciplines suggest that the inclusion of
low-quality RCTs is related to higher pooled
ES (Moher et al., 1998). Thus, the quality of
included studies was assessed and analyzed as
a moderator variable.
We used a number of exclusion criteria.
Pilot studies where the participants were later
included in a full-scale trial were excluded, as
were studies with prevention samples. For the
Childrens Depression Inventory (CDI) to
identify children with depression with acceptable sensitivity, a threshold score of . 13 has
been recommended (Kovacs, 1992). However,
one study that was included herein used a CDI
threshold score . 8 (Asarnow et al., 2002),
which is lower than the recommended cutoff.
The study was included because 48% of the
sample was judged to fulfill tentative criteria
for depression and 39% for depression NOS
(Asarnow et al., 2002).

Study characteristics
Table 1 summarizes descriptive data of the 10
included studies. The studies were published
between 1980 and 2009; six studies were from
the USA and one each from Canada,
Australia, England, and Belgium. Four
studies included samples diagnosed with
depression. All other studies applied CDI as
an outcome measure and used an inclusion
threshold of 8 or 13 points. The majority of the
studies (n 8) recruited participants from
schools and two studies recruited from mental
health clinics. The most common methods
used in the interventions were psycho-education about the association between
thoughts, emotions, and behaviors, problemsolving strategies, and behavioral activation.
Two studies included a component specific to

66.0
67.8
61.8
63.3
56.0
55.9

CDI $ 19

Diagnosis from K-SADS

CDI $ 11d

CDI $ 8

Diagnosis from K-SADS

CDI $ 11d

Diagnosis from ChIPS and

P-ChIPS

School

Clinic

School

School

School

School

Clinic,
adverts

77.7

67.2

WL TAU CDRS-R
(87)

CDI

MF-PEP TAU (78)

Taking action (9)

CDI

CDI

CDI

MFQ

CDI

CDI

CDI

CDI

Face-toface (14)
WL (11)

WL (11)

WL (32)

AP (10)
WL (10)
AP (28)

WL (16)

AP (14)
WL (14)
WL (9)

Control (n) Outcome

Video conference (14)

Primary and secondary control

enhancement training (16)
CBT family education (12)

CBT (29)

Role play (14)

Cognitive restructuring (14)
Self-control (9)
Behavior problem-solving (10)
CBT (17)
Relaxation training (17)
Self-modeling interventions (17)
Social competence training (11)

Treatment (n)

4 (37) 18 ( )

4 (18)

9 ( )

24 (5)

2 ( )
2 ( )
1 (0)
1 (0)
1 (0)
2 (36)

Follow-up months
(% attrition)b

Arnberg and Ost

Note. AP attention placebo; CDI Childrens Depression Inventory; CDRS-R Childrens Depression Rating Scale-Revised; ChIPS childrens interview
for psychiatric syndromes; P-ChIPS parent version of ChIPS; K-SADS schedule of affective disorders and schizophrenia for school-age children;
MF-PEP Multifamily Psychoeducational Psychotherapy; NTC no treatment control; TAU treatment as usual; WL wait-list.
a
The group mean scores were transformed to T-scores according to normative population samples.
b
Follow-up interval with respect to the treatment group.
c
Self-esteem scale, CDI, Moyal-Miezitis Stimulus Appraisal Questionnaire and Nowicki-Strickland Locus of Control Scale for Children.
d
CDI without the suicide item.

Liddle and
Spence (1990)
Vostanis et al.
(1996)
Weisz et al.
(1997)
Asarnow et al.
(2002)
Nelson et al.
(2003)
de Cuyper
et al. (2004)
Fristad et al.
(2009)

74.5

CDI $ 15 diagnosis
from clinical interview

School

School

69.9

Score . 1.5 SD for $2 of 4

measuresc
CDI $ 13

School

Butler et al.
(1980)
Stark et al.
(1987)
Kahn and
Kehle (1990)

Inclusion criteria

Recruitment

Symptom
severity
T-scorea

Study

Table 1. Study characteristics

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280
COGNITIVE BEHAVIOUR THERAPY

VOL 43, NO 4, 2014

parents. Of seven studies with a followup assessment, only four reported data on
the number of treatment group participants
who completed the assessment and the time to
follow-up varied from one to nine months.

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Study quality assessment

To assess the potential effect of an intervention, the studies that evaluate this method
should be well designed and of high methodological quality (Chambless & Ollendick, 2001).
The quality of the included studies was
therefore assessed using the psychotherapy
outcome study methodology rating form by
Ost (2008). The rating form has previously
been used in a meta-analysis by Ost (2008) to
assess the study quality and was used as a
moderator variable. The rating form includes
22 items: (1) clarity of description of participants, (2) severity/chronicity of the disorder,
(3) representativeness of participants, (4)
reliability of diagnosis, (5) specificity of outcome measures, (6) validity and reliability of
outcome measures, (7) use of assessors blind to
assignment, (8) method-specific training of
assessors, (9) group allocation sequence, (10)
study design, (11) power analysis, (12) timing
of assessments, (13) manualized, replicable,
specific intervention programs, (14) number of
therapists, (15) therapist method-specific
training and experience, (16) assessment of
adherence, (17) therapist competence assessment, (18) assessment of concurrent treatments, (19) methods to adjust for attrition,
(20) statistical analysis and presentation of
results, (21) clinical significance, and (22)
equality of therapy duration (only for designs
with treatment arms $ 2). The sum score was
used to assess study quality.
The quality of all the included studies was
assessed by the first author who is qualified to
use the rating form after receiving training
from the author of the rating form. The form
has good inter-rater reliability for both the
total rating (ICC 0.92) and for each item
(kappa mean 0.75, range 0.50 1.00) and
good internal consistency (Cronbachs
a 0.86) (Ost, 2008).

Coding procedure
The following variables were selected a priori
to be retrieved in order to be used in
moderator analyses: age, sex, symptom severity at baseline, attrition from baseline to post,

CBT for Children with Depressive Symptoms

281

attrition from post to follow-up, treatment

format (individual, group), treatment duration, treatment context, study quality, and
therapist experience. Age was coded as mean
and range; if the mean age was not reported, it
was assumed to be the midpoint of the range.
To assess symptom severity, all scores were
transformed to a T-distribution because two
studies did not report CDI ratings. First, the
study by Vostanis, Feehan, Grattan, and
Bickerton (1996) reported only the Mood
and Feelings Questionnaire (MFQ), for which
norms were not reported in the original
publication (Angold, Costello, Messer, &
Pickles, 1995), and so a T-score was arrived
at by computing the mean value of all studies
that included the CDI. Second, the study by
Fristad, Verducci, Walters, and Young (2009)
included the Childrens Depression Rating
Scale-Revised (CDRS-R), and a T-score was
calculated from a normative sample (Poznanski et al., 1984). Treatment duration was
coded as the number of planned sessions times
the session duration in minutes. One study did
not report the session duration (Vostanis
et al., 1996), which then was assumed to be
50 minutes. The number of actual sessions that
were delivered was not coded because of a lack
of reported data in the included studies.
Therapist experience was assessed by item
15 in the quality rating form (Ost, 2008).
To achieve the highest rating (2), the therapists
needed to have extensive clinical experience
with both depression and the relevant treatment method. The coded data were assessed
and reassessed twice by both authors to
increase reliability and arrive at consensus.

Primary outcome
The primary outcome measure was self-report
of depressive symptoms since this was used in
all studies. The CDI (Kovacs, 1992) was used
in eight of the included studies. It is a selfrating scale for depression in the 7 17 year age
range and includes 27 items. The CDI has
satisfactory psychometric properties in the
case of internal consistency and excellent
validity generalization (Dougherty, Klein,
Olino, & Laptook, 2008). And many studies
have reported good short-term test retest
reliability (Brooks & Kutcher, 2001; Kovacs,
1992). CDI has been widely used both in
clinical practice and in research, and shows
high sensitiveness to change. One study

282

Arnberg and Ost

included the MFQ (Vostanis et al., 1996) and

one study used the CDRS-R (Fristad et al.,
2009): both measures have provided psychometric properties that are similar to those of
the CDI.

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Statistical analyses
The computer software Comprehensive MetaAnalysis, version 2.2 (Biosoft, 2006), was used
to calculate ESs and heterogeneity and to
perform meta-regression analyses for the
moderator variables. Corrections were made
for small samples by calculating Hedges g as
the ES. To evaluate the homogeneity of ESs,
we used the Q-statistic; if statistically significant heterogeneity was found, this was
examined by moderator analyses. A randomeffects model was used if the Q-statistic was
significant. Comparison of the ESs at posttreatment and follow-up was done by a
dependent t-test performed in SPSS v. 19 for
Windows (IBM, Chicago, IL).

Results
In total, the 10 included studies included 267
participants in active treatment groups and
256 participants in control groups. The mean
age of the participants was 10.5 years (range
9.2 12.7 years). In six studies, all participants
were , 13 years of age (Asarnow et al., 2002;
Butler et al., 1980; de Cuyper et al., 2004;
Liddle & Spence, 1990; Stark et al., 1987;
Weisz et al., 1997). In two studies, there were
participants who were up to 14 years of age
(Kahn & Kehle, 1990; Nelson, Barnard, &
Cain, 2003). In one study, the participants
were up to 17 years old (Vostanis et al., 1996).
One study did not report the age range
(Fristad et al., 2009). The proportion of boys
was on average 54.2% (range 25 76%). There
was no difference in symptom severity
( p 0.46) between studies with diagnosed
samples (n 4; T-score M 69) and not
diagnosed samples (n 6; T-score M 64)
(see Table 1). The attrition ranged from 0% to
37%. Eight studies provided treatment in
group format. The number of sessions ranged
from 8 to 18 and the length of the sessions
from 50 to 90 minutes. The total treatment
duration was on average 656 minutes (range
450 1080 minutes). The treatment context
was predominantly in a school environment
(n 7). The study quality was on average

COGNITIVE BEHAVIOUR THERAPY

50% of the maximum score on the quality

rating form (range 18 69%) and only two
studies were judged to be of good quality.
There was a uniform distribution of studies
with experienced therapists, somewhat experienced therapists, and not experienced therapists. For seven studies, a CDI score was
reported at follow-up assessment with an
average time to follow-up of 17.7 weeks after
the treatment ended (range 4 36 weeks).

Controlled effect sizes

Based on 16 comparisons, CBT had a
moderate ES (g 0.66) at postassessment
and was associated with a better outcome than
both attention placebo (AP) and wait-list
(WL); however, there were substantial differences in ES among the studies (Figure 2). For
CBT versus AP (n 5), there was a moderate
ES (g 0.54) favoring CBT. For CBT versus
WL (n 11), there was also a moderate ES
(g 0.70) in favor of CBT (Table 2).
Sensitivity analysis. Two of the included
studies differed from the others in specific
ways. Vostanis et al. (1996) included youth
up to 17 years of age, and Asarnow et al.
(2002) used a CDI score of 8 as inclusion
criterion. When these two studies were
excluded, the overall ES increased somewhat
to g 0.72 [0.41; 1.02], z 4.62, p , 0.0001.
The CBT versus AP ES also increased to some
extent, g 0.71 [0.01; 1.41], z 1.99,
p 0.046, and the CBT versus WL ES to
g 0.73 [0.41; 1.05], z 4.49, p , 0.0001.
The removal of the Vostanis et al. and
Asarnow et al. studies yielded nonsignificantly
higher ESs than when they were included, and
thus we decided to keep them in the metaanalysis.

Publication bias
Publication bias might pose a potential threat
to the validity of the findings. Therefore, we
estimated the number of unpublished studies
with null results needed to render the observed
ES nonsignificant, by using the methods
proposed by Rosenthal (1991) and Orwin
(1983). The number of unpublished studies
with null findings needed is 173, whereas
24 studies with a g-value of 0.00 are needed to
reduce the ES to a clinically insignificant level
(g 0.20).
However, the trim-and-fill method by
Duval and Tweedie (2000) indicated that in

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VOL 43, NO 4, 2014

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283

Figure 2. Forest plot for comparisons of CBT versus attention placebo (AP) and wait-list (WL). Note.
CI confidence interval; CDI Childrens Depression Inventory; CDRS-R Childrens Depression
Rating Scale-Revised; MF-PEP Multifamily Psychoeducational Psychotherapy; MFQ Mood and
Feelings Questionnaire; TAU treatment as usual.

Table 2. Between-subjects effect sizes posttreatment

Comparison

95% CI

Total
CBT vs AP
CBT vs WL

16
5
11

0.655
0.536
0.695

0.40 0.91
0.02 1.05
0.40 1.00

4.96
2.05
4.54

, 0.001
0.04
, 0.001

35.5
13.8
16.2

0.002
0.008
0.09

Note. AP attention placebo; CI confidence interval; g Hedges g effect size; k number of comparisons;
Q measure of heterogeneity; WL wait-list.

order to obtain a symmetric funnel plot, four

studies should be imputed to the left of the
mean, which would reduce the Hedges g to
0.44 (95% CI [0.15 0.73]), which is still
significantly different from zero. The rank
correlation test of publication bias using
Kendalls tau (Begg & Mazumdar, 1994) was
not significant (0.21, z 1.13, p 0.26).
Thus, it can be concluded that publication
bias is probably not a significant problem for
the current meta-analysis.

0.78]. There was a large uncontrolled ES from

pretreatment to follow-up for the 10 treatment
groups, g 1.34, 95% CI [0.97; 1.71]. From
posttreatment to follow-up, there was a
subsequent improvement in six treatment
conditions. However, the increase in uncontrolled ES for those studies having follow-up,
from 1.20 at post to 1.44 at follow-up, was not
significant [t(9) 1.73, p 0.12]. There was
heterogeneity in ESs among studies at followup, Q 22.0, p 0.009.

Uncontrolled effect sizes

Moderator analyses

The estimation of within-group (uncontrolled)

ES was based on 15 treatment groups, 4 AP
groups, and 7 WL groups. The ES was large
for CBT, g 1.07, 95% CI [0.70; 1.43], small
for AP, g 0.38, 95% CI [0.13; 0.62], and
moderate for WL, g 0.54, 95% CI [0.31;

Meta-regression analyses were carried out

using a fixed effect model (Borenstein, 2009).
Five of the moderator variables were significantly associated with the ES (Table 3).
Publication year was a negative predictor in
that later year (newer studies) was associated

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Arnberg and Ost

COGNITIVE BEHAVIOUR THERAPY

Table 3. Meta-regression analyses of moderator variables

Moderator

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Publication year
Mean age
Sex, % girls
Symptom severity
Number of sessions
Study quality
Attrition pre post
Therapist experience

2 0.0284
0.1571
0.0102
2 0.0065
0.2751
2 0.0101
2 0.0230
2 0.3126

with a lower ES. Age was a positive predictor,

indicating that the higher the mean age of the
sample, the higher was the ES. The removal of
the Vostanis et al. (1996) study led to an even
higher B-coefficient (0.38) than when it was
included (0.16), so we kept the study in the
analysis. Another positive predictor was the
number of therapy sessions; a higher number
of sessions were associated with a larger ES.
Attrition and therapist experience were negatively associated with ES; higher dropout rate
and higher therapist experience were both
associated with lower ES. Finally, proportion
of girls and mean symptom severity of the
sample, as well as methodological quality of
the study, did not emerge as significant
moderators of ES.

Discussion
The present meta-analysis investigated the
effect of CBT on depressive symptoms in
young children, the long-term effects of the
treatment, and potential moderators of the
ES. The controlled ES was moderate (0.66)
when CBT was compared to a control
condition; CBT was significantly better than
AP (0.54) and WL control (0.70). Regarding
pre- to postassessment, CBT had a large
within-group ES (1.07). The effect was large
(1.44) also at follow-up, although the scarcity
of follow-up data limits the reliability of the
finding. Older studies, older age of the
participants, and more treatment sessions
were associated with a larger effect. Nonetheless, differences in efficacy and methodological shortcomings in the studies indicate
areas in need of improvement.
The controlled ES is in agreement with that
found in the meta-analysis by Michael and
Crowley (2002) that analyzed studies with

SE
0.0081
0.0798
0.0061
0.0144
0.0577
0.0099
0.0071
0.1084

z
2 3.506
1.967
1.667
2 0.453
4.766
2 1.018
2 3.251
2 2.884

p
0.0005
0.0492
0.0955
0.6509
0.0000
0.3089
0.0012
0.0039

younger children separately (d 0.65).

A number of the studies in the present metaanalysis were also included in that metaanalysis. Michael and Crowley had nine
studies, six of which are included in the
present meta-analysis (the remaining three
studies did not use CBT). Weisz et al. (2006)
found a lower ES (d 0.41), which may be
due to the fact that they had a somewhat
younger sample or that they used a procedure
for calculating ES that has been criticized
(Klein et al., 2007).
The present meta-analysis did not find a
significant correlation between pretreatment
symptom severity and ES. However, there
were indications that recruitment from and
treatments in a clinical context were associated
with a lower ES, which has been reported
earlier (Klein et al., 2007). A possible explanation may be that comorbidity is higher in a
clinical population, which can contribute to
maintenance of symptoms. It can be concluded that we so far know little about the
effect of CBT for clinical samples with a
diagnosed depressive disorder.
For children and adolescents, Weisz et al.
(2006) did not find a difference in ES between
CBT and other psychosocial treatment
methods. However, the database for calculation of ES almost exclusively contained CBT
studies, which makes the conclusion of no
differences tentative at best.
The analysis of moderators showed that the
ES was lower in later compared to earlier
published studies. This finding corroborates
that of Klein et al. (2007) in their cumulative
meta-analysis of CBT for adolescents. There
are a number of methodological differences
between the studies in the present metaanalysis, which may be a possible reason for
the lowering of the ES for CBT. In contrast to

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VOL 43, NO 4, 2014

what Klein et al. (2007) reported, the present

meta-analysis did not find a relation between
study quality and ES. It should be mentioned
that the validity of the research quality rating
scale used in the present study has not
formally been evaluated. One difference
compared to other quality scales is that the
one used here does not weigh different quality
variables when the total score is calculated.
Thus, the result concerning quality of the
studies should be interpreted cautiously.
The within-group ES increased from postassessment (g 1.20) to follow-up assessment
(g 1.44), but the variations were large
concerning both ES and time to followup. Furthermore, the description of attrition
left a lot to be desired. Only three studies had a
follow-up period of nine months or longer.
Taking these factors into account, the results
are promising but equivocal concerning longterm effects. The findings regarding followup in the present study partly concur with
previous meta-analyses of depression that
have aggregated children and adolescent
samples, which show a relatively large ES at
follow-up two to three months after the
termination of therapy. However, these
meta-analyses reported that no effect could
be seen after one to two years posttreatment
(Erford et al., 2011; Weisz et al., 2006),
something the present meta-analysis could not
evaluate since only two follow-ups were longer
than one year. The relative lack of long-term
follow-up assessment highlights an important
area for improvement since we know that
childhood depression entails an increased risk
of psychological and physical problems later
on. It is particularly important, therefore, to
develop and evaluate treatments for children
that can prevent depressive symptoms to
progress into chronic depression or more
severe conditions.
The present meta-analysis has its limitations. In order not to risk excluding studies
that could contribute to increased knowledge
in the area, few exclusion and generous
inclusion criteria were used. This contributed
to the fact that the studies varied concerning
treatment format and treatment components,
which complicate the interpretation of the
results. There were large differences in degree
of symptoms between studies, and we included
studies of both diagnosed and undiagnosed
children. However, the variation was lower

CBT for Children with Depressive Symptoms

285

than in earlier meta-analyses due to exclusion

of prevention studies and the use of a cutoff
score on a depression rating scale or clinical
diagnosis as inclusion criteria. It should be
noted that there was not a significant
difference in degree of depressive symptoms
between diagnosed and undiagnosed samples.
The decision to include children without a
depression diagnosis was motivated by the few
studies in the area. In order to increase
homogeneity among studies, it was decided to
use CDI as the primary outcome measure.
In the analysis, the size of the study was also
taken into consideration and a correction for
small sample size was done by transforming
Cohens d to Hedges g. Despite taking these
measures, the ESs of the included studies were
heterogeneous.
The calculation of fail-safe N, the trim-andfill method by Duval and Tweedie (2000), and
the rank correlation test of publication bias
using Kendalls tau indicated that publication
bias was improbable but it cannot be ruled out
completely. However, it is worth noticing that
Weisz et al. (2006) did not find a difference in
ES between published and unpublished studies
in their meta-analysis.
In conclusion, CBT for children with
depressive symptoms is a neglected research
area with a few RCTs. There is a great need for
more studies of high quality. Large variations
in ES between studies point to the importance
of more methodologically stringent studies
with properly diagnosed children, which
would strengthen the translation of research
into clinical practice. So far, the findings are
based on group treatments, almost exclusively
carried out in school settings in the USA,
which hampers the generalizability to clinical
practice and other countries. In addition,
more data are needed to understand the effect
of individual treatment and parental involvement. Future research should adjust the
treatments to the developmental level of the
patients to an even larger extent than has been
the case hitherto and should include long-term
follow-ups. The research area would be
developed through the reporting of followup data to enable reliable assessments of how
the treatment effects are maintained in the
long run. Despite current limitations in our
knowledge of CBT for children with depressive symptoms, CBT is a well-documented
treatment, compared to other forms of

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Arnberg and Ost

therapy, with a moderate ES for children with

depressive symptoms.

Acknowledgements

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We thank Filip Arnberg for generously

sharing his statistical and language
knowledge.
Disclosure statement: The authors have
declared that no conflict of interest exists.

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