[Show abstract][Hide abstract] ABSTRACT: Extensive evidence links youth mental health to family functioning, highlighting the need to document causal pathways. This will require longitudinal studies, but traditional methods for longitudinal clinical research have several limitations, including high cost and resource demands, underrepresentation of fathers, and attrition bias. We tested whether an online alternative might address limitations of—and thus provide a useful complement to—traditional methods. We used the Mechanical Turk (MTurk) survey program to obtain reports from parents (N=177) on family functioning, the parents’ own symptoms, their children’s behavioral and emotional problems, and parenting stress, with assessments in three consecutive months. Parents provided largely high-quality data (e.g., passed consistency checks); measures showed acceptable psychometrics at each time-point; and correlations among study measures paralleled those observed in prior research. Compared to prior studies using traditional longitudinal methods, the MTurk method was (a) much lower in cost and resource requirements, (b) successful in enrolling fathers, (c) comparable in participant attrition, and (c) similar in attrition bias, participant race/ethnicity, and enrollment of single parents. Overall, findings suggest that MTurk is a viable tool with its own set of strengths and limitations, and a potentially useful complement to traditional longitudinal methods. In particular, MTurk might be a cost-effective first step in generating causal hypotheses about family processes and youth mental health, for later testing via more traditional methods.
Journal of Child and Family Studies 01/2015; in press. · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study expands upon the Chorpita et al. (J Consult Clin Psychol 81:999-1009, 2013) findings by examining the impact of treatment protocol on youths' service utilization up to 2 years after starting an episode of: standard manualized treatment (Standard); modular treatment (Modular); or usual care (UC). Results showed that youths who received Modular accessed fewer service settings at their one-year follow-up relative to youths who received Standard or UC. Findings suggest that modular treatment may offer an advantage over standardized treatment manuals and UC in terms of sustained clinical benefits, and highlight the importance of treatment design considerations for service systems.
Administration and policy in mental health. 01/2015;
[Show abstract][Hide abstract] ABSTRACT: This study tested whether family income and stress in the parent-youth relationship might mediate links between parent symptoms and youth problems, and whether the process might differ for youth externalizing versus internalizing problems. We used a multiple mediation technique to test pathways by which family income and stress in the parent-child relationship might relate to parent-youth symptom associations in a sample of clinically-referred 7-13 year-olds (32 % female; M age = 10.16 years). Family income and stress jointly mediated the relation between parent symptoms and youth externalizing problems but not between parent symptoms and youth internalizing problems. Future longitudinal research should investigate whether low income and parent-youth stress may deplete the parental resources needed to manage youth externalizing behavior. This study extends existing literature by suggesting a specific pattern by which two identified risk factors for youth problems may operate jointly, and by showing specificity to externalizing problems.
Child Psychiatry and Human Development 01/2015; · 1.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
Youth in war-affected regions are at risk for poor psychological, social, and educational outcomes. Effective interventions are needed to improve mental health, social behavior, and school functioning. This randomized controlled trial tested the effectiveness of a 10-session cognitive-behavioral therapy (CBT)-based group mental health intervention for multisymptomatic war-affected youth (aged 15-24) in Sierra Leone.
War-affected youth identified by elevated distress and impairment via community screening were randomized (stratified by sex and age) to the Youth Readiness Intervention (YRI) (n=222) or a control condition (n=214). After treatment, youth were again randomized and offered an education subsidy immediately (n=220) or waitlisted (n=216). Emotion regulation, psychological distress, prosocial attitudes/behaviors, social support, functional impairment, and posttraumatic stress disorder (PTSD) symptoms were assessed at pre- and post-intervention and at six-month follow-up. For youth in school, enrollment, attendance, and classroom performance were assessed after eight months. Linear mixed-effects regressions evaluated outcomes.
The YRI showed significant post-intervention effects on emotion regulation, prosocial attitudes/behaviors, social support, and reduced functional impairment, and significant follow-up effects on school enrollment, school attendance, and classroom behavior. In contrast, education subsidy was associated with better attendance but had no effect on mental health or functioning, school retention, or classroom behavior. Interactions between education subsidy and YRI were not significant.
YRI produced acute improvements in mental health and functioning as well as longer-term effects on school engagement and behavior, suggesting efficacy in preparing war-affected youth for educational and vocational opportunities.
Journal of the American Academy of Child & Adolescent Psychiatry 12/2014; · 6.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Compared to youths who believe personal traits are malleable, those who believe personal traits are fixed experience more academic and self-regulatory distress. Recently, studies have begun to explore relations between beliefs about the malleability of personal traits, or implicit theories, and youth mental health problems. We synthesized this emerging body of research in youths (ages 4-19) across 45 effect sizes from 17 research reports. Studies were included if they assessed youth mental health and implicit theories and did not manipulate implicit theory or affective/behavioral states prior to measuring these variables. Our random-effects meta-analysis using clustered data analysis techniques (i.e., effect sizes nested within samples) revealed that youths holding entity theories—the belief that personal traits are fixed—showed more pronounced mental health problems. This association between entity theories and mental health problems was evident across methodological factors and problem types (internalizing versus externalizing; psychopathology versus general distress). Limitations include the small number of eligible studies, insufficient data to test further demographic moderators, and few longitudinal studies on this topic. Overall, findings support the value of parsing the implicit theory-mental health link in youths. Implicit theories may prove to be promising targets for treatment and prevention of youth mental health problems.
Clinical Psychology Review 11/2014; in press. · 7.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Observational measures to assess implementation integrity (the extent to which components of an evidence-based treatment are delivered as intended) are needed. The authors evaluated the reliability of the scores and the validity of the score interpretations for the Therapy Process Observational Coding System for Child Psychotherapy-Revised Strategies scale (TPOCS-RS; McLeod, 2010) and assessed the potential of the TPOCS-RS to assess treatment differentiation, a component of implementation integrity. The TPOCS-RS includes 5 theory-based subscales (Cognitive, Behavioral, Psychodynamic, Client-Centered, and Family). Using the TPOCS-RS, coders independently rated 954 sessions conducted with 89 children (M age = 10.56, SD = 2.00; age 7-15 years; 65.20% White) diagnosed with a primary anxiety disorder who received different treatments (manual-based vs. nonmanualized) across settings (research vs. practice). Coders produced reliable ratings at the item level (M intraclass correlation coefficient = .76, SD = .18). Analyses support the construct validity of the Cognitive and Behavioral subscale scores and, to a lesser extent, the Psychodynamic, Family, and Client-Centered subscale scores. Correlations among the TPOCS-RS subscale scores and between the TPOCS-RS subscale scores and observational ratings of the alliance and client involvement were moderate suggesting independence of the subscale scores. Moreover, the TPOCS-RS showed promise for assessing implementation integrity as the TPOCS-RS subscale scores, as hypothesized, discriminated between manual-guided treatment delivered across research and practice settings and nonmanualized usual care. The findings support the potential of the TPOCS-RS Cognitive and Behavioral subscales to assess treatment differentiation in implementation research. Results for the remaining subscales are promising, although further research is needed. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
[Show abstract][Hide abstract] ABSTRACT: Identifying factors that promote sustained implementation of evidence-based treatments (EBTs) after
therapists receive training is critical for professional psychology. To address the field’s minimal
knowledge in this area, we interviewed community-based therapists (N � 23) who had completed
intensive training in cognitive– behavioral therapy (CBT) for either anxiety or depression as part of a
randomized effectiveness trial (Southam-Gerow et al., 2010; Weisz et al., 2009). Therapists were
interviewed 3 to 5 years after completion of the initial trial, representing one of the longest-term
follow-ups of therapist practices after training. Therapists viewed each protocol and their individual CBT
strategies as effective and appropriate for the majority of their current anxiety and depression caseloads.
However, therapists used parts of each protocol much more frequently than the protocol as a whole (i.e.,
78.5% used parts of the Coping Cat, and 7.5% used the whole protocol; 58.6% used parts of the PASCET,
and 20% used the whole protocol). Therapists reported using problem-solving the most and exposure
exercises the least for current anxious cases; they used cognitive restructuring the most and homework
the least for current depression cases. Interventions that were more difficult to implement in usual care
settings appeared less likely to be sustained. Future efforts should evaluate the characteristics and
structure of EBTs that are most acceptable to therapists and should investigate which kinds of ongoing
learning supports will maintain therapist skills in and continued use of EBTs.
Professional Psychology Research and Practice 10/2014; · 1.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: Research has examined the effects of parental psychopathology, family functioning, and caregiver strain on treatment response in anxious youths. Although these variables have shown individual links to youth treatment response, theoretical models for their combined effects remain unexplored. This study tested the hypothesis that improvements in family functioning and reductions in caregiver strain explained the effects of parental psychopathology on youth treatment outcome in an anxiety treatment trial. Method: A multiple mediation technique was used to test the proposed model across independent evaluator (IE), parent, and youth informants in 488 youths, aged 7-17 years (50% female; mean age = 10.7) meeting Diagnostic and Statistical Manual of Mental Disorders criteria for social phobia, separation anxiety, and/or generalized anxiety disorder. Youths were randomized to receive 12 weeks of cognitive-behavioral treatment (Coping Cat), medication (sertraline), their combination, or a pill placebo. At pre- and posttreatment, parents completed self-report measures of global psychopathology symptoms, family functioning, and caregiver strain; parents, youths, and IEs rated youths' anxiety symptom severity. Results: Changes in family functioning and caregiver strain jointly explained relations between parental psychopathology and reductions in youth anxiety. Specifically, across IE and parent informants, families with higher pretreatment parental psychopathology showed more improvement in family functioning and caregiver strain, which in turn predicted greater youth anxiety reductions. Further, higher pretreatment parental psychopathology predicted greater caregiver strain reductions and, in turn, greater youth anxiety reductions, based on youths' reports of their own anxiety. Conclusions: Findings suggest that improvements in family functioning and reductions in caregiver strain can influence treatment outcomes for anxious youths, especially among youths with more distressed parents. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Journal of Consulting and Clinical Psychology 09/2014; · 4.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pediatric inflammatory bowel disease (IBD) is associated with high rates of depression. This study compared the efficacy of cognitive behavioral therapy (CBT) to supportive nondirective therapy (SNDT) in treating youth with comorbid IBD and depression.
Journal of the American Academy of Child and Adolescent Psychiatry 07/2014; 53(7):726-35. · 6.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Parent-teacher cross-informant agreement, although usually modest, may provide important clinical information. Using data for 27,962 children from 21 societies, we asked the following: (a) Do parents report more problems than teachers, and does this vary by society, age, gender, or type of problem? (b) Does parent-teacher agreement vary across different problem scales or across societies? (c) How well do parents and teachers in different societies agree on problem item ratings? (d) How much do parent-teacher dyads in different societies vary in within-dyad agreement on problem items? (e) How well do parents and teachers in 21 societies agree on whether the child's problem level exceeds a deviance threshold? We used five methods to test agreement for Child Behavior Checklist (CBCL) and Teacher's Report Form (TRF) ratings. CBCL scores were higher than TRF scores on most scales, but the informant differences varied in magnitude across the societies studied. Cross-informant correlations for problem scale scores varied moderately across societies studied and were significantly higher for Externalizing than Internalizing problems. Parents and teachers tended to rate the same items as low, medium, or high, but within-dyad item agreement varied widely in every society studied. In all societies studied, both parental noncorroboration of teacher-reported deviance and teacher noncorroboration of parent-reported deviance were common. Our findings underscore the importance of obtaining information from parents and teachers when evaluating and treating children, highlight the need to use multiple methods of quantifying cross-informant agreement, and provide comprehensive baselines for patterns of parent-teacher agreement across 21 societies.
[Show abstract][Hide abstract] ABSTRACT: Links between parents' psychiatric symptoms and their children's behavioral and emotional problems have been widely documented in previous research, and the search for moderators of this association has begun. However, family structure (single versus dual-parent households) has received little attention as a potential moderator, despite indirect evidence that risk may be elevated in single-parent homes. Two other candidate moderators-youth gender and age-have been tested directly, but with inconsistent findings across studies, perhaps in part because studies have differed in whether they used youth clinical samples and in which informants (parents vs. youths) reported on youth problems. In the present study, we examined these three candidate moderators using a sample of exclusively clinic-referred youths (N = 333, 34 % girls, aged 7-14,) and assessing youth problems through both parent- and youth-reports. Both family structure and youth gender emerged as robust moderators across parent and youth informants. Parent symptoms were associated with youth internalizing and externalizing problems in single-parent but not dual-parent homes; and parent symptoms were associated with youth internalizing problems among boys, but not girls. The moderator findings suggest that the risks associated with parent psychopathology may not be uniform but may depend, in part, on family structure and youth gender.
[Show abstract][Hide abstract] ABSTRACT: This study examined patterns of evidence-based treatment (EBT) implementation within community settings by evaluating integrity along separate dimensions of practice content (PC; a session included the prescribed procedure) and practice sequencing (a session occurred in the prescribed sequence) within a recent randomized effectiveness trial. We measured whether sessions showed integrity to PC and to flexible or linear practice sequences. Findings revealed that providers tended to incorporate content from the EBT protocol in most treatment sessions, but that the sequencing of the sessions was often modified, suggesting that providers are amenable to evidence-based procedures, but not necessarily their prescribed arrangement.
Administration and Policy in Mental Health and Mental Health Services Research 01/2014; · 3.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Decades of clinical psychological science have produced empirically supported treatments that are now undergoing dissemination and implementation (DI) but with little guidance from a science that is just taking shape. Charting a future for DI science (DIS) and DI practice (DIP), and their complex relationship, will be complicated by significant challenges—the implementation cliff (intervention benefit drops when tested practices are scaled up), low relevance of most clinical research to actual practice, and differing timetables and goals for DIP versus DIS. To address the challenges, and prepare the next generation of clinical psychological scientists, we propose the following: making intervention research look more like practice, solving the “too many empirically supported treatments” problem, addressing mismatches between interventions and their users (e.g., clients, therapists), broadening the array of intervention delivery systems, sharpening outcome monitoring and feedback, incentivizing high-risk/high-gain innovations, designing new professional tracks, and synchronizing and linking the often-insular practice and science of DI.
[Show abstract][Hide abstract] ABSTRACT: Background: Worldwide, over one billion children and adolescents live in war-affected regions. These youth represent a uniquely vulnerable population at heightened risk of developing mental health problems, interpersonal difficulties and impairments in daily functioning. This study tested the effectiveness of a stabilization and skills-focused mental health intervention for multi-symptomatic, war-affected youth. Methods: A randomized controlled trial was conducted in Freetown, Sierra Leone for youth (N=436, ages 15-24 years old) who exhibited psychological distress and functional impairments who were not enrolled in school. The Youth Readiness Intervention (YRI) is a group-based behavioral treatment targeting co-occurring emotion dysregulation/anger-management difficulties, deficits in interpersonal skills, psychological distress and functional impairments in war-affected youth. Participants were randomly assigned and enrolled in either the YRI (n=222) or a control condition (n=214). YRI participants received the group intervention once per week over a 10 week period and were assessed pre and post-YRI for emotion regulation/anger-management skills, functional impairment, psychological distress, and prosocial attitudes/behavior. Secondary outcomes were social support and post-traumatic stress (PTS) symptoms. Results. Post-intervention, YRI participants reported significant improvements in emotion regulation skills, prosocial attitudes/behaviors, and improvements in day-to-day functioning compared to controls. YRI participants also reported greater perceived social support. The two conditions showed similar levels of improvement in psychological distress and PTS symptoms. Conclusions. The YRI improved emotion regulation, prosocial skills, social supports and daily functioning among war-affected youth. Future research should investigate adding additional components to address PTS and depression symptoms and how to link such interventions to education and employment programs.
141st APHA Annual Meeting and Exposition 2013; 11/2013
[Show abstract][Hide abstract] ABSTRACT: This study examined the psychometric properties of the DSM-oriented scales of the Child Behavior Checklist (Achenbach, Dumenci, & Rescorla, 2003) using confirmatory factor analysis to compare the six-factor structure of the DSM-oriented scales to competing models consistent with developmental theories of symptom differentiation. We tested these models on both clinic-referred (N = 757) and school-based, nonreferred (N = 713) samples of youths in order to assess the generalizability of the factorial structures. Although previous research has supported the fit of the six-factor DSM-oriented structure in a normative sample of youths ages 7 to 18 (Achenbach & Rescorla, 2001), tripartite model research indicates that anxiety and depressive symptomology are less differentiated among children compared to adolescents (Jacques & Mash, 2004). We thus examined the relative fit of a six- and a five-factor model (collapsing anxiety and depression) with younger (ages 7-10) and older (ages 11-18) youth subsamples. The results revealed that the six-factor model fit the best in all samples except among younger nonclinical children. The results extended the generalizability of the rationally derived six-factor structure of the DSM-oriented scales to clinic-referred youths and provided further support to the notion that younger children in nonclinical samples exhibit less differentiated symptoms of anxiety and depression.
Development and Psychopathology 11/2013; 25(4pt1):1005-1015. · 4.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: This article reports outcomes from the Child STEPs randomized effectiveness trial conducted over a 2-year period to gauge the longer term impact of protocol design on the effectiveness of evidence-based treatment procedures. Method: An ethnoracially diverse sample of 174 youths ages 7- 13 (N = 121 boys) whose primary clinical concerns involved diagnoses or clinical elevations related to anxiety, depression, or disruptive behavior were treated by community therapists randomly assigned to 1 of 3 conditions: (a) standard, which involved the use of 1 or more of 3 manualized evidence-based treatments, (b) modular, which involved a single modular protocol (Modular Approach to Treatment of Children With Anxiety, Depression, or Conduct Problems; MATCH) having clinical procedures similar to the standard condition but flexibly selected and sequenced using a guiding clinical algorithm, and (c) usual care. Results: As measured with combined Child Behavior Checklist and Youth Self-Report Total Problems, Internalizing, and Externalizing scales, the rate of improvement for youths in the modular condition was significantly better than for those in usual care. On a measure of functional impairment (Brief Impairment Scale), no significant differences were found among the 3 conditions. Analysis of service utilization also showed no significant differences among conditions, with almost half of youths receiving some additional services in the 1st year after beginning treatment, and roughly one third of youths in the 2nd year. Conclusions: Overall, these results extend prior findings, supporting incremental benefits of MATCH over usual care over a 2-year period. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Journal of Consulting and Clinical Psychology 08/2013; · 4.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence-based treatments for child mental health problems are not consistently available in public mental health settings. Expanding availability requires workforce training. However, research has demonstrated that training alone is not sufficient for changing provider behavior, suggesting that ongoing intervention-specific supervision or consultation is required. Supervision is notably under-investigated, particularly as provided in public mental health. The degree to which supervision in this setting includes 'gold standard' supervision elements from efficacy trials (e.g., session review, model fidelity, outcome monitoring, skill-building) is unknown. The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practices and test the impact of systematic implementation of gold standard supervision strategies on treatment fidelity and clinical outcomes.Methods/design: The study has two phases. We will conduct an initial descriptive study (Phase I) of supervision practices within public mental health in Washington State followed by a randomized controlled trial of gold standard supervision strategies (Phase II), with randomization at the clinician level (i.e., supervisors provide both conditions). Study participants will be 35 supervisors and 130 clinicians in community mental health centers. We will enroll one child per clinician in Phase I (N = 130) and three children per clinician in Phase II (N = 390). We use a multi-level mixed within- and between-subjects longitudinal design. Audio recordings of supervision and therapy sessions will be collected and coded throughout both phases. Child outcome data will be collected at the beginning of treatment and at three and six months into treatment.
This study will provide insight into how supervisors can optimally support clinicians delivering evidence-based treatments. Phase I will provide descriptive information, currently unavailable in the literature, about commonly used supervision strategies in community mental health. The Phase II randomized controlled trial of gold standard supervision strategies is, to our knowledge, the first experimental study of gold standard supervision strategies in community mental health and will yield needed information about how to leverage supervision to improve clinician fidelity and client outcomes.Trial registration: NCT01800266.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE This study examined the extent to which therapists who participated in a randomized controlled trial (RCT) of evidence-based treatments continued to use them with nonstudy clients after the trial as well as the types of treatment used and the reasons for their continued use. METHODS Semistructured interviews and focus groups were conducted with 38 therapists, three clinical supervisors, and eight clinic directors three months after an RCT of evidence-based treatments for depression, anxiety, and conduct disorders among children and adolescents. The therapists had been assigned randomly to one of three conditions: modular (N=15), allowing flexible use and informed adaptations of treatment components; standard (N=13), using full treatment manuals; and usual care (N=10). Grounded-theory analytic methods were used to analyze interview transcripts. RESULTS Twenty-six therapists (93%) assigned to the modular or standard condition used the treatments with nonstudy cases. Of those, 24 (92%) therapists, including all but two assigned to the standard condition, reported making some adaptation or modification, including using only some modules with all clients or all modules with some clients; changing the order or presentation of the modules to improve the flow or to work around more immediate issues; and using the modules with others, including youths with co-occurring disorders, youths who did not meet the age criteria, and adults. CONCLUSIONS The results provide insight into the likely sustainability of evidence-based treatments, help to explain why the outcomes of the RCT favored a modular approach, and highlight the strengths and limitations of use of evidence-based treatments.
[Show abstract][Hide abstract] ABSTRACT: Sudden gains have been described as rapid, sizeable changes observed between treatment sessions and have been associated with improved treatment outcome in adults. The current study examined weekly sudden gains among children seeking treatment in the community mental health setting.
Participants were 161 children (age M = 10.58, SD = 1.73; 69.6% male; 47.8% Caucasian) and their parents who were randomized to one of three treatment modalities and were administered weekly and quarterly assessments throughout treatment.
When idiographic (youth- and parent-identified "top problems") and nomothetic measures (standardized checklists) were used to calculate sudden gains (i.e., gain must be large: in absolute terms, relative to prior session, and relative to changes in prior and subsequent sessions), 20-42% of participants experienced at least one sudden gain during treatment. Most sudden gains occurred early in treatment, and session content of relaxation was associated with sudden gain presence. Using a modified Bonferonni correction, sudden gains predicted overall symptom levels at final assessment (i.e., last assessment obtained following post-treatment) even after controlling for pre-treatment symptom levels and magnitude of the overall gain from pre- to post-treatment.
Suddenness of gains may have a direct effect on long-term treatment outcome among children in the community.
Behaviour Research and Therapy 06/2013; 51(9):564-572. · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE Research across more than 4 decades has produced numerous empirically tested evidence-based psychotherapies (EBPs) for psychopathology in children and adolescents. The EBPs were developed to improve on usual clinical interventions. Advocates argue that the EBPs should replace usual care, but this assumes that EBPs produce better outcomes than usual care. OBJECTIVE To determine whether EBPs do in fact produce better outcomes than usual care in youth psychotherapy. We performed a meta-analysis of 52 randomized trials directly comparing EBPs with usual care. Analyses assessed the overall effect of EBPs vs usual care and candidate moderators; we used multilevel analysis to address the dependency among effect sizes (ES) that is common but typically unaddressed in psychotherapy syntheses. DATA SOURCES We searched the PubMed, PsychINFO, and Dissertation Abstracts International databases for studies from January 1, 1960, through December 31, 2010. STUDY SELECTION We identified 507 randomized youth psychotherapy trials. Of these, the 52 studies that compared EBPs with usual care were included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS Sixteen variables (participant, treatment, outcome, and study characteristics) were extracted from studies, and ESs were calculated for all comparisons of EBP vs usual care. We used an extension of the commonly used random-effects meta-analytic model to obtain an overall estimate of the difference between EBP and usual care while accounting for the dependency among ESs. We then fitted a 3-level mixed-effects model to identify moderators that might explain variation in ESs within and between studies by adding study or ES characteristics as fixed predictors. MAIN OUTCOMES AND MEASURES Primary outcomes of our meta-analysis were mean ES estimates across all studies and for levels of candidate moderators. These ES values were based on measures of symptoms, functioning, and other outcomes assessed within the 52 randomized trials. RESULTS Evidence-based psychotherapies outperformed usual care. Mean ES was 0.29; the probability was 58% that a randomly selected youth would have a better outcome after EBP than a randomly selected youth after receiving usual care. The following 3 variables moderated treatment benefit: ESs decreased for studies conducted outside North America, for studies in which all participants were impaired enough to qualify for diagnoses, and for outcomes reported by informants other than the youths and parents in therapy. For certain key groups (eg, studies of clinically referred samples and youths with diagnoses), significant EBP effects were not demonstrated. CONCLUSIONS AND RELEVANCE Evidence-based psychotherapies outperform usual care, but the EBP advantage is modest and moderated by youth, location, and assessment characteristics. The EBPs have room for improvement in the magnitude and range of their benefit relative to usual clinical care.