Canadian Psychology / Psychologie canadienne © 2017 Canadian Psychological Association

2017, Vol. 58, No. 2, 105–115 0708-5591/17/$12.00 http://dx.doi.org/10.1037/cap0000101

“Cool” Youth: A Systematic Review and Comprehensive Meta-Analytic

Synthesis of Data From the Cool Kids Family of Intervention Programs
Matthew P. Mychailyszyn
Towson University

To conduct a meta-analysis to synthesize the available research on the family of studies belonging to the
Cool Kids Program, a cognitive– behavioral intervention for anxiety disorders in youth, and evaluate its
overall effectiveness in addressing anxious symptomatology. A search of online databases, combined
with reference list examination and communication with program implementers/developers, led to the
identification of (16) studies that explored the effects of the Cool Kids Program (N ⫽ 1579), or its
forerunners or extensions. Analyses focused on child- and parent-report of anxiety, with effect sizes
aggregated according to a random effects model and calculated as differences between intervention and
control groups at posttreatment (standardized mean difference [SMD]) as well as by considering the
changes in scores between time points (e.g., standardized mean gain [SMG]). Analyses indicate superior
improvement for youth receiving the Cool Kids intervention as compared with controls according to
SMD analyses for both child- and parent-report, as well as for SMG analyses according to parent-report,
though not according to child self-report despite a nearly identical aggregated effect size; the latter was
attributable to greater gains reported by youth in control conditions; secondary analyses also suggest
significantly greater improvements in automatic thoughts for Cool Kids participants. This intervention
has been implemented in different modalities, holds considerable promise, and in the contemporary
context of evidence-based practice, should be considered a program with strong empirical support.

Keywords: anxiety, youth, Cool Kids, meta-analysis, systematic review

Anxiety disorders represent a significant concern across the
developmental course of youth. Epidemiological studies consis-
tently report that anxiety disorders are among the most prevalent
forms of psychopathology during early to late childhood
(Cartwright-Hatton, McNicol, & Doubleday, 2006). In one of the
most recent and largest epidemiological efforts, the National Co-
morbidity Survey Replication–Adolescent Supplement (NCS-A),
anxiety disorders were found to be the most prevalent mental
health difficulty among a nationally representative sample of ad-
olescents in the United States (Merikangas et al., 2010), with
nearly one in every three adolescents (31.9%) meeting criteria for
a diagnosis. Moreover, such contemporary prevalence data are
consistent with epidemiological studies over the last 30 years (e.g.,
Costello, Egger, & Angold, 2005; Vikan, 1985), reflecting the
persistent threat of internalizing psychopathology to the mental
health well-being of youth.
Anxiety disorders in youth are associated with a number of
negative outcomes and sequelae. Anxiety disorders increase
vulnerability to development of comorbid conditions, and, if
left untreated, may persist into adulthood and lead to the de-
velopment of substance abuse problems (Albano, Chorpita, &
Barlow, 2003; Kendall, Safford, Flannery-Schroeder, & Webb,
2004; Woodward & Fergusson, 2001). “Research has supported
a temporal relationship, with anxiety disorders typically pre-
This article was published Online First March 16, 2017.
Correspondence concerning this article should be addressed to Matthew
P. Mychailyszyn, Department of Psychology, Towson University, 8000
York Road, Baltimore, MD 21252. E-mail: mmychailyszyn@towson.edu
105
ceding the onset of substance use disorders” (Kendall et al.,
2004, p. 276). One hypothesized mechanism by which this
might occur is that youth struggling with anxiety may seek to
self-medicate (Manassis & Monga, 2001) using substances that
provide an escape from such negative emotion. This reflects the
powerful influence of negative reinforcement paradigms, and
correspondingly how self-destructive behaviors can become
easily ingrained according to behavioral models. Indeed, the
World Health Organization (WHO) has predicted that by 2030,
internalizing problems such as anxiety disorders will be second
only to HIV/AIDS in international burden of disease (Mathers
& Loncar, 2006).
Of major concern, however, is that the majority of youth strug-
gling with anxiety disorders have never received treatment (Cha-
vira, Stein, Bailey, & Stein, 2004). Perhaps most disturbing of all
is that relatively little ground has been gained, as the estimated
percentage of those with unmet needs has remained virtually
unchanged over the past two decades (United States Congress,
Office of Technology Assessment, 1986).
This predicament has inspired a number of researchers to de-
velop programs to meet the needs of such youth with anxiety
disorders. One such intervention package, known as the Cool Kids
Program, is an approach based upon cognitive– behavioral therapy
principles, and was developed as a 10-session treatment for anx-
ious youth between 7 and 17 years of age, as well as their parents
(Rapee, Wignall, Hudson, & Schniering, 2000). This intervention
is acknowledged by its creators to be founded on the Coping Koala
program (Barrett, Dadds, & Rapee, 1996), the authors of which
acknowledge their program to be an Australian adaptation of
Kendall’s (1994) Coping Cat program.
106 MYCHAILYSZYN
Barrett, Dadds, and Rapee (1996) conducted what is cited by the
program developers in subsequent Cool Kids articles as the first
trial of the Cool Kids program. The study therefore sought to
explore the role of parental involvement this aspect by implement-
ing a randomized controlled trial comparing individual CBT to a
condition wherein the child and caregivers would have a Family
Anxiety Management therapy sessions following the child’s indi-
vidual CBT session; both of these conditions were also compared
with a waiting-list control group. A total of 79 children between
the ages of 7 and 14 (⬃57% male) participated in the study.
Results were mixed across child-, parent-, and clinician-report,
though mostly demonstrating superiority of active treatments, with
gains maintained through follow-up.
Rapee (2000) followed up on the prior study by investigating
whether the efficiency of treatment delivery could be enhanced if
offered in group-based format and in shorter duration. As such,
90-min sessions to small groups of approximately 5 families, were
administered in by graduate clinical psychology students who
received supervision from the article author. By posttreatment,
youth receiving the Cool Kids intervention demonstrated signifi-
cant improvement that was on par with results yielded from
evaluations of longer treatment protocols (e.g., Barrett et al., 1996;
Kendall, 1994). Rapee concluded that treatment for anxious youth
can indeed be made more cost-effective without sacrificing clinical
effectiveness.
Rapee (2003) sought to extend the knowledge base by compar-
ing treatment outcomes of anxious youth with only one anxiety
disorder to those with additional disorders. As findings were
largely consistent with results obtained by Kendall and colleagues
(2001), Rapee concluded “there appears to be little influence of
overall comorbidity on treatment outcome for children whose
principal diagnosis is an anxiety disorder” (p. 110).
In 2005, Mifsud and Rapee investigated the effectiveness of a
school-based trial of the Cool Kids program, noting that, at the
time of their research, “no study has looked at early intervention
for anxiety in socioeconomically disadvantaged areas, despite
these areas being at greatest need for identification and interven-
tion for mental health disorders” (p. 997). Youth were recruited
from across 9 schools where, according to government school
funding program, the community has the highest concentration of
families disadvantaged by socioeconomic factors. Of note, unlike
the studies described thus far which would be deemed “treatment”
studies (as participants were diagnosed with anxiety disorders
based on clinical interview), the present investigation would be
classified as an “indicated prevention” study because the criterion
for selection was elevated anxious symptomatology as evidenced
by a score above the 75th percentile on the RCMAS. Results
revealed that youth receiving the intervention demonstrated sig-
nificant improvement from baseline to postintervention as well as
from baseline to follow-up on self-report of anxiety and teacher-
report of internalizing symptoms, but that those in the waitlist
condition did not experience such improvement.
McLoone and Rapee (2012) sought to extend research in the
school area by comparing directly the outcomes achieved when the
intervention is implemented at school versus at home, as well as to
a waitlist control group. This study also took an indicated preven-
tion approach as youth were selected via elevated scores (e.g., top
10%) on the SCAS combined with school counselor nomination of
highly anxious students. The home-based intervention involved
caregivers being provided with program leader materials for the
Cool Kids program along with a commercially available book that
guides parents helping their anxious child, and independently
delivering the program’s 10 modules over 10 weekly sessions
conducted in the family’s home. Parent-report of anxiety for chil-
dren receiving either of the active treatments showed significant
decreases compared with waitlist, though no such significant dif-
ferences were obtained for child- or teacher-report. As a result,
McLoone and Rapee concluded that “the results of the study do not
clearly indicate whether either of these approaches was effective in
the treatment of child anxiety due to the apparent conflicting
reports from different informants” (p. 239).
In 2007, Chalfant, Rapee, and Carroll investigated the efficacy
of an adaptation of Cool Kids program for youth with high func-
tioning autism (HFA). While maintaining the core content of the
program, specific modifications were made “to account for the
visual and concrete learning style of HFA children” (p. 1848).
Progress in the adapted Cool Kids group was compared with that
of similar HFA youth randomized to a waiting list condition. At
posttreatment, 20 of 28 youth in the adapted Cool Kids condition
no longer met diagnostic criteria for a current primary anxiety
disorder versus 0 of 19 in the control group.
Hudson and colleagues (2009) questioned whether efficacy is
because of the so-called active components of a CBT intervention,
or simply because of nonspecific factors. To test this, the authors
randomly assigned youth to either group-based Cool Kids groups
or Group Support and Attention groups. Though findings differed
somewhat according to reporter, results according to diagnostic
interviews indicated greater efficaciousness for Cool Kids in terms
of there being a greater percentage no longer meeting criteria for
a principal anxiety disorder.
Rapee, Abbott, and Lyneham (2006) examined the efficacy of
self-help for youth anxiety disorders delivered via the modality of
bibliotherapy guided by parents; this was done by comparing
outcomes to a waitlist control group as well as an active compar-
ison condition consisting of group treatment based on the Cool
Kids program. Results were mixed depending on level of analysis
(e.g., “completer” vs. intent-to-treat [ITT]) as well as by reporter,
though generally tended to support bibliotherapy as significantly
better than waitlist, though with Cool Kids group treatment out-
performing other groups.
In the context of disseminating treatment to rural and remote
families via bibliotherapy, Lyneham and Rapee (2006) sought to
explore differences in incremental added benefit across various
modes of enhancing therapist-family contact (e.g., scheduled
phone calls, scheduled e-mails, or as-needed client initiated con-
tact). Of note, when families were asked to report how many
weeks of the program they attempted, it seemed that the nature of
structured contact with therapist (e.g., scheduled phone calls,
scheduled e-mails, or families responsible for initiating contact
themselves) influenced engagement. Despite variations in program
engagement, data demonstrated that active treatment conditions
outperformed waitlist at posttreatment in terms of presence of
anxiety disorders as well as anxious symptomatology, with gains
maintained or improved by 12-month follow-up.
Though already developed to be appropriate for adolescents,
subsequent adaptational work led to the creation of the Cool Teens
program (Cunningham, 2008), tailored specifically for that devel-
opmental period. A comprehensive description of the creation and
 META-ANALYSIS OF COOL KIDS INTERVENTION
structure of this intervention is reported elsewhere for the inter-
ested reader (Cunningham, Rapee, & Lyneham, 2007; Cunning-
ham & Wuthrich, 2007). In 2009, Cunningham et al. conducted a
pilot case series of the Cool Teens CD-ROM program for adoles-
cent anxiety. Citing barriers to care and associated low treatment
utilization rates, along with an underrepresentation of adolescents
in prior intervention trials, the authors note that a different modal-
ity of treatment delivery might hold promise for youth at this
developmental stage. Cunningham and colleagues assert that
“There are no existing published studies on computer-based ther-
apy programs for adolescents with anxiety” (p. 126), and thus it is
from this base that such a program—the Cool Teens CD-ROM—
was evaluated. At posttreatment, two of the five (e.g., 40%) no
longer met criteria for at least one of the preexisting anxiety
disorder; two other participants showed some indications of im-
provement in other areas. In 2012, Wuthrich et al. conducted the
first randomized controlled trial of the Cool Teens CD-ROM
program. By posttreatment, findings indicated that, “compared
with waitlist, adolescents using the Cool Teens program demon-
strated significant improvements both in terms of clinician re-
ported severity of anxiety as well as both self- and parent-reported
measures” (p. 267).
In the first Cool Kids study to be conducted outside of Australia,
Lundkvist-Houndoumadi and Thastum (2013) conducted a pilot
study case-series in Denmark. “Based on data derived from stan-
dardized diagnostic standardized interviews, self-report measures,
and qualitative interview material—four of the six children ob-
tained CGI-I ratings that classified them as responders at the
15-month follow-up” (p. 249). Following up on this study, Arendt,
Thastum, and Hougaard (2015) conducted the first randomized
wait-list controlled trial of Cool Kids in Denmark. Following use
of a Danish version of the intervention, results indicated that a
substantially larger (48.2%) proportion of youth receiving Cool
Kids was diagnosis-free at postintervention as compared with only
5.7% in the waitlist condition. Gains were either maintained or
extended to 3-month and 12-month follow-up periods. Continuing
this line of research, J␱´ nsson, Thastum, Arendt, and Sørensen
(2015) conducted an effectiveness trial of a Danish version of the
Cool Kids program in Denmark by investigating implementation in
community centers. However, as many comparison group individ-
uals were already represented in other trials (e.g., Arendt et al.,
2015), the data for these individuals are not included in the
meta-analysis below so as to preserve the assumption of indepen-
dence. Encouraging results from the community centers suggested
that this program is indeed transportable beyond research-based
settings, which adds support for the value of dissemination to a
wider selection of individuals.
Recently, Hudson and colleagues (2014) sought to investigate
the role of parental anxiety on the treatment outcomes of anxious
offspring, comparing a more conventional delivery of the Cool
Kids program with another group that received the identical inter-
vention combined with five 45-min, brief parental anxiety man-
agement (BPAM) sessions. Although there were no significant
differences across either comparison when examining by principal
anxiety disorder, a main effect was found for parental anxiety
status when looking at whether participants became free of any
(e.g., principal or comorbid secondary diagnoses) anxiety disorder,
such that those with nonanxious parents were significantly more
107
likely to be free of any anxiety disorder diagnosis; the same results
were found at 6-month follow-up.
Seeking to extend the application of the Cool Kids program even
farther, Sciberras and colleagues (2015) conducted a pilot random-
ized control trial of the intervention for youth with ADHD and a
comorbid anxiety disorder. Of particular note, to “cater to the
needs of children with ADHD” (p. 2), this was the only study that
applied an individual-, as compared with group-, format of inter-
vention delivery. While the primary outcome assessment was
“feasibility and acceptability of the intervention” (p. 2), secondary
analyses revealed that by assessment at 5 months, 3 of the 6 youth
in the Cool Kids program were free of an anxiety disorder diag-
nosis whereas this was not the case for any of the individuals in the
usual care group.
The goal of the present meta-analysis was to review and aggre-
gate the data from all available investigations of the Cool Kids
Program, which have been briefly summarized above. Although
some of these studies are represented in prior reviews, a compre-
hensive review specifically focused on this particular program
does not yet exist. It should be noted that reviews with similar
objectives—to synthesize the data from a single specific psycho-
therapy intervention— have already been published in high-quality
outlets. For instance, Brunwasser, Gillham, and Kim (2009) con-
ducted a meta-analytic review of the Penn Resiliency Program’s
(PRP) effect on depressive symptoms for youth. Additionally,
Briesch, Hagermoser Sanetti, and Briesch (2010) evaluated the
evidence base for the FRIENDS for Life Program. Lastly, though
not exhaustively, Cuijpers and colleagues (2011) conducted a
meta-analysis of Interpersonal Therapy (IPT) for depression. Thus,
especially within the contemporary context of evidence-based
practice, there is a strong precedent for evaluating the usefulness
of specific intervention programs. It is therefore believed that
the present review makes a similarly important contribution to
the field. The central purpose of this analysis will be to deter-
mine the overall mean effect size produced by the Cool Kids
intervention in terms of reducing anxiety; this effect will be
compared with that of controlled conditions to identify whether
Cool Kids results in significantly greater reductions in anxiety
symptoms than those not receiving the program.
An individual’s tendency to interpret events as stable, negative,
and global comprises the cognitive triad that has been demon-
strated to underlie depression (Abramson, Alloy, & Metalsky,
1989). As negatively valenced self-statements have been identified
as contributing to the manifestation of internalizing difficulties, a
secondary goal of this review was to determine whether the Cool
Kids program might also be able to create a more healthy shift in
this pattern of cognitive style.
Method
For the purposes of this review, an intervention was defined as
a program of content delivered to youth by individuals trained in
its implementation with the purpose of either (a) preventing the
onset or exacerbation of anxiety symptoms or disorders, or (b)
alleviating the symptoms and/or severity of already-existing anx-
iety disorders and associated symptomatology. Thus, both preven-
tion and treatment applications of the Cool Kids program were
included.
108 MYCHAILYSZYN
Searching
Studies for the present meta-analysis were identified through the
use of several search strategies. First, computerized searches were
conducted using the PsycINFO and PubMed research databases.
The search term of “Cool Kids” was utilized to identify potentially
appropriate studies. This specific search term was entered because
it was assumed that any relevant publication on this intervention
would have referenced the program by name, and/or would have
cited its forerunners. The final online search date was 11/06/2015.
Additionally, the reference sections of articles found via comput-
erized searches as well as those of previously conducted meta-
analyses were reviewed to ensure that potentially relevant studies
not identified by computerized search were included. The flow of
study selection is illustrated in Figure 1.
Selection
Studies were selected as appropriate for inclusion if they met the
following criteria. First, the study had to explore the outcome of an
application of the Cool Kids program (or one of its forerunners,
such as the Coping Koala program, or derivatives, such as the Cool
Figure 1. Flow chart of study inclusion. See the online article for the color version of this figure.
Teens program). Second, participants had to be youth enrolled in
Grades K through 12. Third, the size of the samples under inves-
tigation had to be sufficiently large (e.g., not single-case studies)
enough to allow for the types of statistical analyses required for
meta-analytic purposes. Fourth, the study had to provide quanti-
tative analyses of outcome data, with specific statistical informa-
tion needed for the calculation of effect sizes, or author contact
information to obtain the additional data needed. Last, although the
content of the intervention may have been delivered in any lan-
guage, the study must have been written in English. To preserve
assumptions of independence, studies were excluded if the sample
under investigation overlapped either in whole or in part with the
sample of participants from another study which met inclusion
criteria.
Validity Assessment
The rigorous standards of the peer-review process have led to
the speculation that studies which have made it to print are more
likely to have obtained statistically significant findings as com-
pared with those that were never published (Sterling, 1959). This
issue has become known as the “File Drawer Problem” (Rosenthal,
 META-ANALYSIS OF COOL KIDS INTERVENTION
1979), and refers to the well-supported notion that the studies
capable of being retrieved and subsequently making it into a
meta-analysis may not likely be a random sample of all studies
actually conducted to explore a particular content area (Rosenthal,
1993). The result of this “file drawer problem” is the emergence of
publication bias, whereby smaller studies which have insufficient
power to detect an effect or are deemed less important are omitted
and not included in the calculation of a mean effect size.
In the present meta-analysis, the file-drawer problem was ad-
dressed first by not restricting studies to only those evaluations
which have been published and second through the calculation of
Orwin’s (1983) adaptation to the “Fail-Safe N”, which reflects the
exact number of studies needed to shift a significant overall p
value beyond a predetermined critical value into the range of
nonsignificance (Rosenthal, 1979).
Data Abstraction
All variables of interest were captured using a codebook devel-
oped by the article author via an iterative process, and then
transposed into an SPSS file; the codebook is available upon
request to the article author. Quantitative data from measures to be
analyzed in this review were entered into a Microsoft Excel
(Microsoft Corp., Redmond, WA) database, with algorithms pro-
grammed in to calculate effect sizes (ESs). When data necessary
for the computation of ESs or related variables of interest were not
presented in manuscripts, an effort was made to obtain the needed
information directly from study authors. Consistent with the study
selection criteria described above, if missing quantitative data for
effect sizes could not be obtained through communication with
authors, that study was excluded.
Measures
With the exception of the FSSC-R (see McCathie & Spence,
1991; Muris et al., 2002), all measures described on below are
considered to be assessing trait- (as opposed to state-) level vari-
ables.
Youth Self-Report of Anxiety
Spence Children’s Anxiety Scale (SCAS; Spence, 1998). By
far, the most commonly used measure across studies evaluating the
Cool Kids program, Spence (1998) has found this measure to
demonstrate strong psychometric properties, with a coefficient
alpha of 0.92, a 6-month test–retest reliability of 0.60, and it
correlates well with other measures of anxiety.
Revised Children’s Manifest Anxiety Scale (RCMAS;
Reynolds & Richmond, 1978). With 37 items that assess
chronic or trait anxiety, the RCMAS has been found to have good
reliability (Reynolds & Paget, 1983) and reasonable construct
validity (Reynolds, 1982).
Fear Survey Schedule for Children—Revised (FSSC-R;
Ollendick, 1983). The FSSC-R comprises 80 items (each of
which are responded to on a 3-point scale) and demonstrates good
test–retest reliability and internal consistency (Ollendick, Matson,
& Helsel, 1985).
109
Parent-Report of Anxiety
Spence Children’s Anxiety Scale—Parent Report (SCAS-P;
Nauta et al., 2004). The parent-report form is considered to be
identical to the child self-report version, excepting that it is the
parental perspective of youth anxiety that is queried.
Child Behavior Checklist (CBCL; Achenbach & Edelbrock,
1991). A 118 item scale evaluating particular child behaviors
from the caregiver perspective. As the present meta-analysis was
focused on anxiety reduction, only the Internalizing dimensional
score was utilized—indeed, this was consistent with many of the
studies that implemented this measure.
Strengths and Difficulties Questionnaire—Parent Report
(SDQ-P; Goodman, Meltzer, & Bailey, 1998). This measure is
comprised of 25 items and has demonstrated sound psychometrics
(Goodman, 2001; Goodman & Scott, 1999). Given the focus of the
Cool Kids family of interventions on anxiety, only scores from the
Emotional Symptoms Subscale were used in the present review to
reflect measurement of internalizing symptomatology.
Youth-Report of Automatic Thoughts: Children’s
Automatic Thoughts Scale (CATS; Schniering &
Rapee, 2002)
A secondary analysis of this review sought to examine whether
the Cool Kids program could significantly alter patterns of auto-
matic thoughts. This measure has demonstrated good discriminant
validity for each of its subscales across youth disorders, as well as
good convergent validity with related anxiety scales (Schniering &
Lyneham, 2007).
Quantitative Data Synthesis
It was often the case that individual studies utilized and reported
on more than one measure for the construct of anxiety. However,
treating multiple measures of a unitary construct as distinct entities
would violate assumptions of independence that underlie the sta-
tistical process of meta-analysis (Rosenthal, 1984). Following the
recommendations of Lipsey and Wilson (2000) and consistent with
the approach taken by authors of recently published high quality
meta-analyses (e.g., Stewart & Chambless, 2009), to address this
issue, multiple effect sizes for a particular construct within indi-
vidual studies were averaged. This was done prior to synthesis
with effect sizes from other studies so as to ensure that each study
would only contribute one single effect of anxiety for each study.
Effect Size
The present meta-analysis utilized two different forms of effect
size to investigate the aggregated success of the acquired collec-
tion of Cool Kids studies. The first is what has been referred to as
the standardized mean difference (SMD; Lipsey & Wilson, 2000)
and is the analytical approach most frequently employed to eval-
uate intervention outcomes as compared with control groups in
those studies that implemented the latter. As a number of studies
did use control groups, this review sought to make such compar-
isons. Additionally, the standardized mean gain (SMG; Becker,
1988) effect size was also applied; this strategy explores changes
in continuous measures of constructs over time (e.g., baseline to
posttreatment). This author believes that the SMG makes a unique
110 MYCHAILYSZYN
contribution in the following manner: it allows for control groups
to be taken into account by comparing a summary effect size for
intervention groups with one for control groups to determine
whether the former is statistically significantly greater than the
latter. In this way, findings are not limited to knowing only whether
intervention groups have lower scores than control groups at a sin-
gular posttreatment timepoint. Rather, use of SMG allows for the
determination of whether an intervention group truly yields statisti-
cally significantly greater change in scores over time as compared
with a control group, which takes baseline scores into account. By
conducting both SMD and SMG analyses, it is hoped that the most
comprehensive picture of outcomes will be provided. Analyses were
completed following procedures outlined by Borenstein, Hedges,
Higgins, and Rothstein (2009), developers of the software program
Comprehensive Meta-Analysis, which has been utilized in other
recent metaanalytical investigations published in top-tier journals
(e.g., Brunwasser, Gillham, & Kim, 2009; Hofmann, Sawyer, Witt,
& Oh, 2010). Additional analyses were conducted using the SPSS
Version 23.0 for Windows statistical software package (SPSS,
Inc., Chicago, IL).
Results
Study Characteristics
A total of 16 studies evaluating the Cool Kids program were
identified using the search criteria and inclusions/exclusion criteria
described above. A total of 1579 youth were involved in these
investigations, and they ranged from 7–16 years in age, though
most were in the range of middle childhood (see Table 1). Partic-
ipant attrition can pose a challenge to meta-analysis of data when
different sample sizes are reported at different timepoints; fortu-
nately, in the present review, only one study (Sciberras et al.,
2015) reported differential sample sizes at baseline and postinter-
vention, and this was only a drop in 1 individual. Eleven of the 16
studies utilized control groups, which were mostly waitlist con-
trols. All except two of the studies were at the intervention level of
treatment, as enrolled youth underwent diagnostic interviews and
were found to meet criteria for one or more anxiety disorders; the
remaining two (McLoone & Rapee, 2012; Mifsud & Rapee, 2005)
fell into the classification of “indicated” prevention— both were
school-based studies where screenings with questionnaires led to
identification of youth whose scores reflected elevated anxiety;
such studies might also be deemed ‘early intervention,’ as such
symptom levels often reflect subclinical levels of disorder al-
though it is likely that other enrolled youth would meet sufficient
criteria for disorder if administered a diagnostic interview. Across
studies, the program was delivered in multiple modalities (e.g., in
clinic-based group therapy, via CD-ROM, Bibliotherapy) and was
implemented in different ways (e.g., by psychologists, graduate
students under psychologist supervision, by parents, or via com-
puter program).
Effect Size Distribution: Homogeneity Analysis
Statistical tests utilizing the Q-statistic (Borenstein et al., 2009)
were conducted. The Q-statistic evaluates the null hypothesis that
all studies share a common effect size. For the collection of studies
reviewed, from the SMG perspective, the null hypothesis that all
studies share a common effect size was rejected and it was con-
cluded that the true effects vary according to child-report (Q ⫽
90.28, p ⬍ .001) as well as according to parent-report (Q ⫽
128.80, p ⬍ .001). The homogeneity results thus support the a
priori decision to conduct the meta-analysis according to a random
effects model.
Quantitative Data Synthesis
Standardized mean difference effect size. For the 11 studies
evaluating the Cool Kids program that utilized control groups, the
aggregated effect size (Hedge’s g) comparing intervention groups
against control groups (e.g., SMD) was significant at 0.54 (95% CI
[0.19, 0.88], p ⬍ .01) in terms of decreases of child-reported
anxiety-related symptoms. Results were similarly significant ac-
cording to parent-report, though even more pronounced; specifi-
cally, the aggregated effect size (Hedges g) comparing intervention
groups to control groups yielded a value of 0.84 (95% CI [0.45,
1.23], p ⬍ .001). Thus, analysis according to postintervention
scores provide support for the Cool Kids program according to
both child- and parent-report.
Standardized mean gain effect size. For the 16 studies in
total evaluating the Cool Kids program that had baseline and
posttreatment data, the summary pre–post (e.g., SMG) effect
size estimate (Hedge’s g) for those youth receiving the inter-
vention was significant at 0.65 (95% CI [0.50, 0.79], p ⬍ .001)
for reducing anxious symptomatology according to child-report
measures (see Table 1). From the studies acquired, 11 utilized
control groups of various designs (e.g., waitlist, supportive
attention, etc.), for which the summary pre–post effect size
estimate was significant at 0.35 (95% CI [0.19, 0.51], p ⬍ .001)
in terms of a decrease in anxiety symptoms over time. As can
be seen from the aggregated effect sizes and accompanying
confidence intervals, individuals receiving the Cool Kids inter-
vention demonstrated statistically significant decreases in anx-
ious symptomatology from baseline to the end of the interven-
tion. While those in control groups similarly demonstrated
significant reductions in anxiety, direct comparison of these
summary effect sizes illustrates a significance between the two
(Z ⫽ 2.70, p ⬍ .01) with intervention groups demonstrating
statistically significantly greater reductions in anxiety from
baseline-to-postintervention than controls.
Amongst the studies included in the present review, all also
utilized one or more measures of parent report. Thus, in these 16
studies, according to parent report, the summary pre–post (e.g.,
SMG) effect size estimate (Hedge’s g) for youth receiving the
Cool Kids program was fairly consistent with that of child-report,
being significant at 0.84 (95% CI [0.66, 1.02], p ⬍ .001) for
reducing anxious symptomatology. As above, 11 of these studies
employed control groups, which produced a nonsignificant pre–
post effect size estimate of 0.17 (95% CI [⫺0.01, 0.38], p ⬎ .05)
for improving anxiety symptoms. A direct comparison between the
conditions reveals that youth receiving the Cool Kids intervention
experienced significant greater reductions (Z ⫽ 4.84, p ⬍ .001) in
anxiety according to parent ratings than did youth in control
groups.
For the calculation of a fail-safe N, a criterion effect size of 0.20
was selected as the level at which results would no longer be
considered meaningful, as this represents what Cohen’s standards
 META-ANALYSIS OF COOL KIDS INTERVENTION 111

Table 1
Characteristics of Studies

SMG
Number of Nature of control effect size
Study Country N Mean age (years) sessions group Measures analyzed (g)

Arendt, Thastum, and Denmark 109 11.78 10 Waitlist SCAS-C C ⫽ 1.069

Hougaard (2015) SCAS-P P ⫽ 1.166
Barrett, Dadds, and Rapee Australia 79 mnr (7–14 yrs) 12 Waitlist RCMAS C ⫽ .607
(1996) FSSC-R P ⫽ 1.231
CBCL
Chalfant, Rapee, and Carroll Australia 47 10.80 12 Waitlist RCMAS C ⫽ 3.053
(2007) SCAS-C P ⫽ 2.824
SCAS-P
SDQ-P
CATS
Cunningham et al. (2009) Australia 5 mnr (14–16 yrs) 8 No control SCAS-C C ⫽ ⫺.513
SCAS-P P ⫽ .139
CATS
Hudson et al. (2009) Australia 112 10.20 10 Placebo therapy SCAS-C C ⫽ 3.237
SCAS-P P ⫽ 1.295
SDQ-C
SDQ-P
Hudson et al. (2014) Australia 209 9.43 10 No control SCAS-C C ⫽ .700
SCAS-P P ⫽ .922
Jónsson et al. (2015) Denmark 87 11.18 10 No controla SCAS-C C ⫽ .477
SCAS-P P ⫽ .793
Lundkvist-Houndoumadi and Denmark 6 9.00 10 No control SCAS-C C ⫽ .171
Thastum (2013) SCAS-P P ⫽ .214
Lyneham and Rapee (2006) Australia 100 9.42 12 Waitlist RCMAS C ⫽ .757
SCAS-C P ⫽ 1.114
SCAS-P
CBCL
CATS
McLoone and Rapee (2012) Australia 152 9.11 10 Waitlist SCAS-C C ⫽ .413
SCAS-P P ⫽ .369
CATS
Mifsud and Rapee (2005) Australia 91 9.50 8 Waitlist SCAS-C C ⫽ .364
SCAS-P P ⫽ .435
CATS
Rapee (2000) Australia 95 10.47 9 Waitlist RCMAS C ⫽ .749
FSSC-R P ⫽ 1.077
CBCL
Rapee (2003) Australia 165 10.80 9 No control RCMAS C ⫽ .834
FSSC-R P ⫽ .525
CBCL
Rapee, Abbott, and Lyneham Australia 267 9.50 9 Waitlist SCAS-C C ⫽ .358
(2006) SCAS-P P ⫽ .621
CBCL
CATS
Sciberras et al. (2015) Australia 12 11.0 20 Treatment as SCAS-C C ⫽ .789
usual SCAS-P P ⫽ .617
SDQ-P
Wuthrich et al. (2012) Australia 43 15.17 8 Waitlist SCAS-C C ⫽ .803
SCAS-P P ⫽ .660
SDQ-P
CATS
Note. SMG ⫽ standardized mean gain; A “—” indicates that data were not reported or could not be obtained through communication with the authors;
“mnr” ⫽ mean not reported; “C” ⫽ Child-report measures; “P” ⫽ Parent-report measures.
a
In this study, the comparison group comprised individuals already represented in other studies included in this meta-analysis; they were thus excluded
to prevent a violation of the assumption of independence in meta-analysis.

for effect size interpretation suggest are small effect sizes (Cohen,
1988). Using this value, and based on child-report, results indicate
that 35 additional investigations of the Cool Kids program with an
effect size of zero would have to remain unidentified (“in the file
drawer”) to reduce the summary effect size for anxiety interven-
tions from 0.64 to 0.20 according to child report of symptoms.
Parent-report led to even more robust results, as 53 studies was
obtained as the Fail-Safe N value. These findings therefore suggest
that the obtained summary effect sizes are relatively robust, would
not be considerably altered by presence of a few unidentified
studies reaching null effects, and thus are an accurate representa-
tion of the research base.
112 MYCHAILYSZYN
Outcomes Over Time
As intervention trials often deliver the program to control
groups following the main evaluation, the SMD effect size be-
comes less applicable for follow-up analysis as there is frequently
no longer a control group to compare to. As such, the SMG effect
size was focused on here for analyzing maintenance of gains over
time. There were seven studies that assessed outcomes 3 months
after the end of the Cool Kids intervention. These trials showed not
only a maintenance, but an extension of gains, with a significant
mean SMG effect size from baseline to 3-month follow-up of 0.80
(95% CI [0.48, 1.11], p ⬍ .001). A similar trend was identified
when looking at longer-term maintenance. There were 6 studies
that reported outcomes at 12 months, and for these investigations,
there was a significant mean SMG effect size of 1.07 (95% CI
[0.77, 1.37], p ⬍ .001).
Secondary Analyses
Intervention effects on related constructs. This meta-
analysis also sought to determine whether the Cool Kids program’s
targeting of anxiety led to improvements in related constructs. The
range of associated variables assessed was limited, with only one
construct being evaluated and reported in more than a couple of the
studies. Data on this construct is reported below.
Automatic thoughts. Seven of the included studies examined
changes in the presence of unwanted cognitions by administering
the Children’s Automatic Thoughts Scale (Schniering & Rapee,
2002). The mean pre–post (e.g., SMG) effect size estimate for
those receiving the Cool Kids intervention was 0.56 (95% CI [0.32,
0.80], p ⬍ .001). Of these studies, 6 out of 7 implemented control
groups, for which the summary pre–post effect size estimate was
0.21 (95% CI [0.01, 0.41], p ⬍ .05). A comparison of aggregated
effect size estimates indicates that those receiving the Cool Kids
program demonstrated statistically significantly greater improve-
ments in the presence of automatic thoughts than did those in
control groups (Z ⫽ 2.19, p ⬍ .05).
As indicated above, 6 of the available studies in the current
collection of studies collected self-report data from both interven-
tion and available control groups in terms of Automatic thoughts.
For those 6 studies, the aggregated effect size (Hedge’s g) com-
paring intervention groups against control groups (e.g., SMD) was
significant at 0.94 (95% CI [0.28, 1.59], p ⬍ .01) in terms of
decreases in the presence and severity of automatic thoughts
related to anxiety.
Discussion
The present meta-analysis yielded general support for the primary
hypothesis: For the 16 identified studies implementing applications of
the Cool Kids program, mean change (SMG) effect sizes were statis-
tically significantly for intervention groups, which outperformed con-
trol groups according to both child- and parent-report measures. In a
similar fashion, Cool Kids outperformed control groups according to
both child- and parent-report measures when utilizing a standardized
mean different effect size. According to effect sizes based on both
child- and parent-report, fail-safe N calculations indicated that 35–53
additional investigations of the Cool Kids program—all with effect
sizes of zero—would have to remain unidentified “in file drawers” to
reduce the obtained summary effect sizes to a criterion level of 0.20
(e.g., a “small” effect size according to Cohen’s standards). As such,
because the present review’s rigorous study identification efforts only
revealed 16 published studies of this particular intervention package,
the present summary effects can be interpreted as robust insofar as it
is unlikely that such a number of additional unpublished studies all
with an effect size of zero actually exist somewhere ‘in file drawers.’
The extant literature contains a number of examples of reviews of
specific intervention programs. Brunwasser and colleagues (2009)
reviewed the Penn Resiliency Program (PRP). They reported evi-
dence suggesting that PRP significantly reduces depressive symp-
toms. Briesch et al. (2010) report that findings on the Friends for Life
program suggest that there is promise of its use in school-based
settings at both the universal and target intervention levels for reduc-
ing anxious symptomatology. Additionally, Cuijpers and colleagues
(2011) meta-analyzed interpersonal therapy for depression (IPT) and
concluded that it efficaciously treats depression, either as a stand-
alone treatment or in combination with medication. The meta-analytic
results presented here fit well within this context, demonstrating initial
evidence that the Cool Kids program leads to meaningful reductions
in youth anxiety according to parent-report by either (e.g., SMG or
SMD) framework, as well as by child-report when considering an
SMD approach.
The current findings reflect an important contribution to the
existing literature, especially in the present day when selection of
treatment protocols it to be ethically guided by standards of
evidence-based practice. This review summarizes the available
research on the Cool Kids program, a well-known cognitive–
behavioral intervention, and results from this meta-analysis aggre-
gate and quantify its overall effects as compared with control
groups. Along with the above-referenced analyses that consider
publication bias (e.g., Fail-Safe N calculations), the present review
indicates that the combined results of all Cool Kids interventions
are consistent with substantial reductions in anxiety—as well as
improvements in dysfunctional automatic thoughts—for youth,
and that this program should be considered a viable option for
family based group-therapy treatment of youth anxiety disorders.
Preliminary findings would suggest that this program can be
implemented in schools for those identified as ‘at-risk’ for anxiety
disorders. However, as it has not yet been tested as a universal
intervention, it is not yet certain whether Cool Kids can be suc-
cessful in this modality. In any event, given the potential negative
sequelae of youth anxiety, this author would endorse more regular/
standardized screenings for anxiety and other psychological diffi-
culties within the context of school mental health services, in
hopes that those who are experiencing— or just beginning to
exhibit— behavioral and emotional problems can be served appro-
priately according to their developmental level.
Limitations
The present review strove for comprehensiveness in terms of re-
viewing the available literature on the Cool Kids program. As such,
studies were included even if they did not utilize control groups.
Although this was an a priori intended goal of the project, the author
also acknowledges that noncontrolled studies possess less method-
ological rigor; however, as there were only 5 studies without control
groups (as operationally defined for this review), and as these results
are aggregated along with the rest while being weighted according to
 META-ANALYSIS OF COOL KIDS INTERVENTION
sample size, this helps to buffer against the existence of any outlier
results unduly influencing overall conclusions.
Additionally, in the present review, parent-report was restricted
to data provided by mothers. This decision was made based on the
sparseness of father-report data available across studies. Indeed,
even in studies where input from both parents was actively sought
out, difficulties were often encountered. For instance, Rapee
(2000) noted that “Because relatively few fathers returned data,
inclusion of their questionnaires in this analysis would have un-
duly reduced total numbers” (p. 126). Additionally, Lyneham and
Rapee (2006) reported that “father’s data were not available in
26% of the sample” (p. 1293). As such, because the convention in
other included studies (e.g., Hudson et al., 2009) was to gather data
only from mothers, the present review focused on mother-report.
This was admittedly discouraging, and unfortunately is consistent
with prior research citing a lack of attention paid to the role of
fathers in treatment for youth internalizing disorders, particularly
anxiety disorders (Bögels & Phares, 2008; Podell & Kendall,
2011). As such, an exhortation to reverse this trend and build a
greater understanding of fathers’ roles should be considered as a
recommendation for future research.
Lastly, too few studies in this collection included teacher-report
of youth anxiety. This is discouraging, as teachers represent one of
the most consistent adult points of contact that children and ado-
lescents have each day for 9 –10 months of the year or more. It
would be valuable for future research on the Cool Kids program to
more reliably seek out teacher perceptions of how students are
getting along in the classroom, as this would lend an added level
of ecological validity in terms of the degree to which students
experience improved emotional functioning in one of the most
central environmental settings of their daily lives.
Future Directions: “Cool Little Kids”
In seeking to downward extend the benefits of the Cool Kids
program, Rapee and colleagues have sought to apply the interven-
tion’s success to an even younger cohort of individuals at risk for
struggles with anxiety—a program known as Cool Little Kids, which
is an intervention delivered to parents of preschool-age youth, rather
than the children themselves. Based on existing research that with-
drawn and inhibited temperament is known to be the greatest risk
factor for anxiety disorders later in youth, it would be important to
determine whether it is possible to alter this developmental trajectory
through prevention efforts. “In a recent systematic review of early
interventions to improve social, emotional and behavioral outcomes,
Bayer and colleagues (2009) identified Cool Little Kids as the only
preschool age prevention program to successfully prevent anxiety
disorders” (Beatson et al., 2014, p. 651). Two randomized controlled
trials have demonstrated the of this program thus far (Kennedy,
Rapee, & Edwards, 2009; Rapee, Kennedy, Ingram, Edwards, &
Sweeney, 2010), and a large-scale new population-based trial (Bayer
et al., 2011) of the Cool Little Kids program was recently completed,
with data to be published in the near future. Thus, research of the
overall family of Cool Kids-based interventions continues to grow. It
has been developmentally translated for adolescents via computer-
based technology, and for preschoolers via parent-based intervention.
Considering the promising results thus far, future researchers are
encouraged to continue exploring applications and to continue eval-
uating the efficacy and effectiveness of the program in new contexts.
113
Résumé
Réaliser une méta-analyse visant à faire le sommaire de la recher-
che actuelle sur le programme Cool Kids, une intervention
cognitivo-comportementale pour les troubles anxieux chez les
jeunes, et évaluer son efficacité globale quant à la symptomatolo-
gie anxieuse. Une recherche dans les bases de données en ligne, le
dépouillement des listes de références et des échanges avec des
prestataires et des concepteurs du programme, ont permis de cerner
16 études ayant analysé les effets du programme Cool Kids lui-
même (N ⫽ 1579), de ses ancêtres et de ses dérivés. Les analyses
se sont centrées sur les réponses des enfants et des parents au sujet
de l’anxiété, l’ampleur des effets ayant été combinée selon un
modèle à effets aléatoires et calculée en tant que différence entre
les mesures de post-traitement des groupes ayant eu des interven-
tions et celles des groupes témoins (différence des moyennes
standardisées), de même qu’en tenant compte des changements
dans les scores entre deux temps de mesure (gain moyen stan-
dardisé). Les analyses ont révélé une amélioration supérieure chez
les jeunes bénéficiant des interventions du programme Cool Kids,
comparativement aux groupes témoins, selon les analyses de la
différence des moyennes standardisées, pour les réponses à la fois
des enfants et des parents, et selon les analyses du gain moyen
standardisé, pour les réponses des parents, mais non pour celles
des enfants, en dépit d’une ampleur des effets combinée quasi
identique; cette différence était attribuable à de plus grands gains
rapportés par les jeunes de groupes témoins; des analyses secon-
daires suggèrent également une amélioration supérieure sur le plan
des pensées automatiques parmi les participants au programme.
Cette intervention a été mise en vigueur selon différentes formules,
elle est prometteuse et, dans le contexte actuel de la pratique axée
sur les preuves, elle peut être perçue comme ayant une solide base
empirique.
Mots-clés : anxiété, jeunes, Cool Kids, méta-analyse, revue
systématique.
References
References marked with an asterisk (ⴱ) indicate studies included in the
meta-analysis.
Abramson, L. Y., Alloy, L. B., & Metalsky, G. I. (1989). Hopelessness
depression: A theory-based subtype of depression. Psychological Re-
view, 96, 358 –372. http://dx.doi.org/10.1037/0033-295X.96.2.358
Achenbach, T. M., & Edelbrock, C. S. (1991). Manual for the Child
Behavior Checklist and Profile. Burlington, VT: University of Vermont.
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety
disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology
(2nd ed., pp. 279 –329). New York, NY: Guilford Press.
ⴱ
Arendt, K., Thastum, M., & Hougaard, E. (2015). Efficacy of a Danish
version of the Cool Kids program: A randomized wait-list controlled
trial. Acta Psychiatria Scandinavica, 1–13.
ⴱ
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. http://dx.doi.org/10.1037/0022-006X.64.2
.333
Bayer, J., Hiscock, H., Scalzo, K., Mathers, M., McDonald, M., Morris, A.,
. . . Wake, M. (2009). Systematic review of preventive interventions for
children’s mental health: What would work in Australian contexts?
Australian and New Zealand Journal of Psychiatry, 43, 695–710. http://
dx.doi.org/10.1080/00048670903001893
114 MYCHAILYSZYN
Bayer, J. K., Rapee, R. M., Hiscock, H., Ukoumunne, O. C., Mihalopoulos,
C., Clifford, S., & Wake, M. (2011). The Cool Little Kids randomised
controlled trial: Population-level early prevention for anxiety disorders.
BMC Public Health, 11, 11. http://dx.doi.org/10.1186/1471-2458-11-11
Beatson, R. M., Bayer, J. K., Perry, A., Mathers, M., Hiscock, H., Wake,
M., . . . Rapee, R. M. (2014). Community screening for preschool child
inhibition to offer the ‘Cool Little Kids’ anxiety prevention programme.
Infant and Child Development, 23, 650 – 661. http://dx.doi.org/10.1002/
icd.1863
Becker, B. J. (1988). Synthesizing standardized mean-change measures.
British Journal of Mathematical and Statistical Psychology, 41, 257–
278. http://dx.doi.org/10.1111/j.2044-8317.1988.tb00901.x
Bögels, S., & Phares, V. (2008). Fathers’ role in the etiology, prevention
and treatment of child anxiety: A review and new model. Clinical
Psychology Review, 28, 539 –558. http://dx.doi.org/10.1016/j.cpr.2007
.07.011
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009).
Introduction to meta-analysis. West Sussex, UK: Wiley. http://dx.doi
.org/10.1002/9780470743386
Briesch, A. M., Hagermoser Sanetti, L. M., & Briesch, J. M. (2010).
Reducing the prevalence of anxiety in children and adolescents: An
evaluation of the FRIENDS for Life Program. School Mental Health, 2,
155–165. http://dx.doi.org/10.1007/s12310-010-9042-5
Brunwasser, S. M., Gillham, J. E., & Kim, E. S. (2009). A meta-analytic
review of the Penn Resiliency Program’s effect on depressive symptoms.
Journal of Consulting and Clinical Psychology, 77, 1042–1054. http://
dx.doi.org/10.1037/a0017671.supp
Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a
neglected population: Prevalence of anxiety disorders in pre-adolescent
children. Clinical Psychology Review, 26, 817– 833. http://dx.doi.org/10
.1016/j.cpr.2005.12.002
ⴱ j.janxdis.2015.06.009
Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Treating anxiety disor-
ders in children with high functioning autism spectrum disorders: A
controlled trial. Journal of Autism and Developmental Disorders, 37,
1842–1857. http://dx.doi.org/10.1007/s10803-006-0318-4
Chavira, D. A., Stein, M. B., Bailey, K., & Stein, M. T. (2004). Child
anxiety in primary care: Prevalent but untreated. Depression and Anxi-
ety, 20, 155–164. http://dx.doi.org/10.1002/da.20039
Cohen, J. (1988). Statistical power analysis for the behavioral sciences
(2nd ed.). Hillsdale, NJ: Erlbaum.
Costello, E. J., Egger, H., & Angold, A. (2005). 10-year research update
review: The epidemiology of child and adolescent psychiatric disorders:
I. Methods and public health burden. Journal of the American Academy
of Child & Adolescent Psychiatry, 44, 972–986. http://dx.doi.org/10
.1097/01.chi.0000172552.41596.6f
Cuijpers, P., Geraedts, A. S., van Oppen, P., Andersson, G., Markowitz,
J. C., & van Straten, A. (2011). Interpersonal psychotherapy for depres-
sion: A meta-analysis. The American Journal of Psychiatry, 168, 581–
592. http://dx.doi.org/10.1176/appi.ajp.2010.10101411
Cunningham, M. (2008). Overview of design approaches in the Cool Teens
CD and other computer programs for adolescent anxiety. E-Journal of
Applied Psychology, 4, 6 –11. http://dx.doi.org/10.7790/ejap.v4i2.116
Cunningham, M., Rapee, R., & Lyneham, H. (2007). Overview of the Cool
Teens CD-ROM for anxiety disorders in adolescents. The Behavior
Therapist, 30, 15–19.
Cunningham, M., & Wuthrich, V. (2007). The Cool Teens CD-ROM
program: An anxiety management program for young people. Journal of
Family Studies, 13, 104 –108.
ⴱ
Cunningham, M. J., Wuthrich, V. M., Rapee, R. M., Lyneham, H. J.,
Schniering, C. A., & Hudson, J. L. (2009). The Cool Teens CD-ROM for
anxiety disorders in adolescents: A pilot case series. European Child &
Adolescent Psychiatry, 18, 125–129. http://dx.doi.org/10.1007/s00787-
008-0703-y
Goodman, R. (2001). Psychometric properties of the strengths and diffi-
culties questionnaire. Journal of the American Academy of Child &
Adolescent Psychiatry, 40, 1337–1345. http://dx.doi.org/10.1097/
00004583-200111000-00015
Goodman, R., Meltzer, H., & Bailey, V. (1998). The Strengths and Diffi-
culties Questionnaire: A pilot study on the validity of the self-report
version. European Child & Adolescent Psychiatry, 7, 125–130. http://
dx.doi.org/10.1007/s007870050057
Goodman, R., & Scott, S. (1999). Comparing the Strengths and Difficulties
Questionnaire and the Child Behavior Checklist: Is small beautiful?
Journal of Abnormal Child Psychology, 27, 17–24. http://dx.doi.org/10
.1023/A:1022658222914
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect
of mindfulness-based therapy on anxiety and depression: A meta-
analytic review. Journal of Consulting and Clinical Psychology, 78,
169 –183. http://dx.doi.org/10.1037/a0018555
ⴱ
Hudson, J. L., Newall, C., Rapee, R. M., Lyneham, H. J., Schniering,
C. C., Wuthrich, V. M., . . . Gar, N. S. (2014). The impact of brief
parental anxiety management on child anxiety treatment outcomes: A
controlled trial. Journal of Clinical Child and Adolescent Psychology,
43, 370 –380. http://dx.doi.org/10.1080/15374416.2013.807734
ⴱ
Hudson, J. L., Rapee, R. M., Deveney, C., Schniering, C. A., Lyneham,
H. J., & Bovopoulos, N. (2009). Cognitive-behavioral treatment versus
an active control for children and adolescents with anxiety disorders:
A randomized trial. Journal of the American Academy of Child &
Adolescent Psychiatry, 48, 533–544. http://dx.doi.org/10.1097/CHI
.0b013e31819c2401
ⴱ
Jónsson, H., Thastum, M., Arendt, K., & Juul-Sørensen, M. (2015). Group
cognitive behavioural treatment of youth anxiety in community based
clinical practice: Clinical significance and benchmarking against effi-
cacy. Journal of Anxiety Disorders, 35, 9 –18. http://dx.doi.org/10.1016/
Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a
randomized clinical trial. Journal of Consulting and Clinical Psychol-
ogy, 62, 100 –110. http://dx.doi.org/10.1037/0022-006X.62.1.100
Kendall, P. C., Brady, E. U., & Verduin, T. L. (2001). Comorbidity in
childhood anxiety disorders and treatment outcome. Journal of the
American Academy of Child & Adolescent Psychiatry, 40, 787–794.
http://dx.doi.org/10.1097/00004583-200107000-00013
Kendall, P. C., Safford, S., Flannery-Schroeder, E., & Webb, A. (2004).
Child anxiety treatment: Outcomes in adolescence and impact on sub-
stance use and depression at 7.4-year follow-up. Journal of Consulting
and Clinical Psychology, 72, 276 –287. http://dx.doi.org/10.1037/0022-
006X.72.2.276
Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009). A selective
intervention program for inhibited preschool-aged children of parents
with an anxiety disorder: Effects on current anxiety disorders and
temperament. Journal of the American Academy of Child & Adolescent
Psychiatry, 48, 602– 609. http://dx.doi.org/10.1097/CHI.0b013e31
819f6fa9
Lipsey, M. W., & Wilson, D. B. (2000). Applied Social Research Methods
Series: Vol. 49. Practical meta-analysis. Thousand Oaks, CA: Sage.
ⴱ
Lundkvist-Houndoumadi, I., & Thastum, M. (2013). A “Cool Kids”
cognitive-behavioral therapy group for youth with anxiety disorders: Pt.
2, analysis of the process and outcome of responders versus nonre-
sponders. Pragmatic Case Studies in Psychotherapy, 9, 179 –274.
ⴱ
Lyneham, H. J., & Rapee, R. M. (2006). Evaluation of therapist-supported
parent-implemented CBT for anxiety disorders in rural children. Behav-
iour Research and Therapy, 44, 1287–1300. http://dx.doi.org/10.1016/j
.brat.2005.09.009
Manassis, K., & Monga, S. (2001). A therapeutic approach to children and
adolescents with anxiety disorders and associated comorbid conditions.
Journal of the American Academy of Child & Adolescent Psychiatry, 40,
115–117. http://dx.doi.org/10.1097/00004583-200101000-00024
 META-ANALYSIS OF COOL KIDS INTERVENTION
Mathers, C. D., & Loncar, D. (2006). Projections of global mortality and
burden of disease from 2002 to 2030. PLoS Medicine, 3, e442. http://
dx.doi.org/10.1371/journal.pmed.0030442
McCathie, H., & Spence, S. H. (1991). What is the revised Fear Survey
Schedule for Children measuring? Behaviour Research and Therapy, 29,
495–502. http://dx.doi.org/10.1016/0005-7967(91)90134-O
ⴱ
McLoone, J. K., & Rapee, R. M. (2012). Comparison of an anxiety
management program for children implemented at home and school:
Lessons learned. School Mental Health, 4, 231–242. http://dx.doi.org/
10.1007/s12310-012-9088-7
Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S.,
Cui, L., . . . Swendsen, J. (2010). Lifetime prevalence of mental disor-
ders in U.S. adolescents: Results from the National Comorbidity Survey
Replication—Adolescent Supplement (NCS-A). Journal of the Ameri-
can Academy of Child & Adolescent Psychiatry, 49, 980 –989. http://dx
.doi.org/10.1016/j.jaac.2010.05.017
ⴱ
Mifsud, C., & Rapee, R. M. (2005). Early intervention for childhood
anxiety in a school setting: Outcomes for an economically disadvantaged
population. Journal of the American Academy of Child & Adolescent
Psychiatry, 44, 996 –1004. http://dx.doi.org/10.1097/01.chi.0000173294
.13441.87
Muris, P., Merckelbach, H., Ollendick, T. H., King, N. J., Meesters, C., &
van Kessel, C. (2002). What is the Revised Fear Survey Schedule for
Children measuring? Behaviour Research and Therapy, 40, 1317–1326.
http://dx.doi.org/10.1016/S0005-7967(02)00007-4
Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H., &
Waters, A. (2004). A parent-report measure of children’s anxiety: Psy-
chometric properties and comparison with child-report in a clinic and
normal sample. Behaviour Research and Therapy, 42, 813– 839. http://
dx.doi.org/10.1016/S0005-7967(03)00200-6
Ollendick, T. H. (1983). Reliability and validity of the Revised Fear
Surgery Schedule for Children (FSSC-R). Behaviour Research and
Therapy, 21, 685– 692. http://dx.doi.org/10.1016/0005-7967(83)90087-6
Ollendick, T. H., Matson, J. L., & Helsel, W. J. (1985). Fears in children
and adolescents: Normative data. Behaviour Research and Therapy, 23,
465– 467. http://dx.doi.org/10.1016/0005-7967(85)90174-3
Orwin, R. G. (1983). A fail-safe N for effect size in meta-analysis. Journal
of Educational Statistics, 8, 157–159. http://dx.doi.org/10.2307/1164923
Podell, J. L., & Kendall, P. C. (2011). Mothers and fathers in family
cognitive-behavioral therapy for anxious youth. Journal of Child and
Family Studies, 20, 182–195. http://dx.doi.org/10.1007/s10826-010-
9420-5
ⴱ dren’s mental health: Problems and services. OTA-H-33. Washington,
Rapee, R. M. (2000). Group treatment of children with anxiety disorder:
Outcome and predictors of treatment response. Australian Journal of
Psychology, 52, 125–129. http://dx.doi.org/10.1080/000495300082
55379
ⴱ Disciplines, 26, 55–75. http://dx.doi.org/10.1111/j.1469-7610.1985
Rapee, R. M. (2003). The influence of comorbidity on treatment outcome
for children and adolescents with anxiety disorders. Behaviour Research
and Therapy, 41, 105–112. http://dx.doi.org/10.1016/S0005-7967
(02)00049-9
ⴱ American Academy of Child & Adolescent Psychiatry, 40, 1086 –1093.
Rapee, R. M., Abbott, M. J., & Lyneham, H. J. (2006). Bibliotherapy for
children with anxiety disorders using written materials for parents: A
randomized controlled trial. Journal of Consulting and Clinical Psychol-
ogy, 74, 436 – 444. http://dx.doi.org/10.1037/0022-006X.74.3.436
Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., & Sweeney, L.
(2010). Altering the trajectory of anxiety in at-risk young children. The
American Journal of Psychiatry, 167, 1518 –1525. http://dx.doi.org/10
.1176/appi.ajp.2010.09111619
Rapee, R. M., Wignall, A., & Hudson, J. L., & Schniering, C. A. (2000).
Treating anxious children: An evidence based approach. Oakland, CA:
New Harbinger.
115
Reynolds, C. R. (1982). Convergent and divergent validity of the Revised
Children’s Manifest Anxiety Scale. Educational and Psychological
Measurement, 42, 1205–1212. http://dx.doi.org/10.1177/0013164
48204200429
Reynolds, C. R., & Paget, K. D. (1983). National normative and reliability
data for the Revised Children’s Manifest Anxiety Scale. School Psy-
chology Review, 12, 324 –336.
Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel: A
revised measure of children’s manifest anxiety. Journal of Abnormal
Child Psychology, 6, 271–280. http://dx.doi.org/10.1007/BF00919131
Rosenthal, R. (1979). The “file drawer problem” and tolerance for null
results. Psychological Bulletin, 86, 638 – 641. http://dx.doi.org/10.1037/
0033-2909.86.3.638
Rosenthal, R. (1984). Meta-analytic procedures for social research. Ap-
plied Social Research Methods Series (Vol. 6). Beverly Hills, CA: Sage
Publications.
Rosenthal, R. (1993). Meta-analytic procedures for social research. New-
bury Park, CA: Sage.
Schniering, C. A., & Lyneham, H. J. (2007). The Children’s Automatic
Thoughts Scale in a clinical sample: Psychometric properties and clin-
ical utility. Behaviour Research and Therapy, 45, 1931–1940. http://dx
.doi.org/10.1016/j.brat.2006.09.009
Schniering, C. A., & Rapee, R. M. (2002). Development and validation of
a measure of children’s automatic thoughts: The children’s automatic
thoughts scale. Behaviour Research and Therapy, 40, 1091–1109. http://
dx.doi.org/10.1016/S0005-7967(02)00022-0
Sciberras, E., Mulraney, M., Anderson, V., Rapee, R. M., Nicholson, J. M.,
Efron, D., . . . Hiscock, H. (2015). Managing anxiety in children with
ADHD using cognitive-behavioral therapy: A pilot randomized con-
trolled trial. Journal of Attention Disorders. Advance online publication.
http://dx.doi.org/10.1177/1087054715584054
Spence, S. H. (1998). A measure of anxiety symptoms among children.
Behaviour Research and Therapy, 36, 545–566. http://dx.doi.org/10
.1016/S0005-7967(98)00034-5
Sterling, T. D. (1959). Publication decisions and their possible effects on
inferences drawn from tests of significance—Or vice versa. Journal of
the American Statistical Association, 54, 30 –34.
Stewart, R. E., & Chambless, D. L. (2009). Cognitive-behavioral therapy
for adult anxiety disorders in clinical practice: A meta-analysis of
effectiveness studies. Journal of Consulting and Clinical Psychology,
77, 595– 606. http://dx.doi.org/10.1037/a0016032.supp
United States Congress, Office of Technology Assessment. (1986). Chil-
DC: U.S. Government Printing Office.
Vikan, A. (1985). Psychiatric epidemiology in a sample of 1510 ten-year-
old children—I. Prevalence. Child Psychology & Psychiatry & Allied
.tb01628.x
Woodward, L. J., & Fergusson, D. M. (2001). Life course outcomes of
young people with anxiety disorders in adolescence. Journal of the
http://dx.doi.org/10.1097/00004583-200109000-00018
ⴱ
Wuthrich, V. M., Rapee, R. M., Cunningham, M. J., Lyneham, H. J.,
Hudson, J. L., & Schniering, C. A. (2012). A randomized controlled trial
of the Cool Teens CD-ROM computerized program for adolescent
anxiety. Journal of the American Academy of Child & Adolescent
Psychiatry, 51, 261–270. http://dx.doi.org/10.1016/j.jaac.2011.12.002
Received May 2, 2016
Revision received September 16, 2016
Accepted December 8, 2016 䡲