Common Practice Elements in Treatment Programs for Adolescents with Externalizing and Internalizing Problems: A Meta-Analysis

Figures & data

Table 1. Included primary studies, treatment setting, and outcome measurements.

Author (year)	Intervention	Treatment setting	Duration: weeks (sessions/week)	Internalizing measurement	Externalizing measurement
Ahrens and Rexford (2002)	Cognitive Processing Therapy (CPT)	Juvenile Justice/corrections (“youth facility for adolescent offenders”)	8 (1)	PTSD Symptom Scale Self-Report (PSS-SR); Beck Depression Inventory (BDI)	N/A
Bunford (2017)* ^a	Interpersonal Skills Group – Corrections Modified (ISG-CM)	Juvenile Justice/corrections (Perry Multi-County Juvenile Facility for “detained juvenile offenders”)	7 (1.7)	Difficulties in Emotion Regulation (DERS)	Disruptive Behavior Disorders Rating Scale-Parent report (DBD); Modified Overt Aggression Scale (MOAS); Disruptive Behavior Disorders Rating Scale DBD-Teacher
Cianciolo (1989)* ^a	Skills Training groups (problem solving, cognitive reappraisal, behavioral rehearsal, and relaxation) to reduce “acting out behavior”	Juvenile Justice/corrections (New York State youth facility, adolescents “placed there by the court system”)	6 (2)	State Trait Anxiety Inventory	Behavioral Measures: Incident Reports
Cohen-Kahn (1995) *	“Muscle Max” tailored weight-training program, using graded mastery to reduce depression	Mental health (“residential treatment center” for adolescent inpatients)	8 (3)	Beck Depression Inventory (BDI); Multiple Affect Adjective Check List MAACL-R (depression)	N/A
Coleman et al. (1992) ^a	Aggression Replacement Training (ART)	Mental health/Child welfare (“residential treatment center” for adolescents with behavioral disorders. 54% of study sample were under state custody)	10 (5)	N/A	The Behavior Incident Report (BIR); Self-Control Rating Scale (SCRS)
Ellmann (2002)* ^a	Problem Solving, Cognitive Restructuring, and Combined Problem Solving/Cognitive Restructuring	Mental health (“residential treatment center” for adolescents with conduct disorders and ADHD)	4 (2)	N/A	The State-Trait Anger Expression Inventory (STAXI): Anger Expression Subscale; Child Behavior Checklist; Belief in Hostility/Aggression test
Gest et al. (2015)	Combined wake and light therapy (COWALI) to reduce depressive symptoms	Mental health (psychiatric hospital for adolescent psychiatric inpatients)	2 (5)	Beck Depression Inventory-II (BDI-II); The Strength and Difficulties Questionnaire (SDQ);	N/A
Goldstein et al. (2018) ^a	Juvenile Justice Anger Management (JJAM)	Juvenile Justice/corrections (“three residential juvenile justice facilities»)	8 (2)	N/A	The Novaco Anger Scale and Orovocation Inventory (NAS-PI); Aggression Questionnaire (AQ); The Intent Attributions and Feelings of Distress Measure (IAFD, Hostile Attributions subscale)
Hawkins et al. (1991) ^a	Intensive Skills Training Program (skills training, social network development & involvement in prosocial activities)	Juvenile Justice/corrections (a Washington state juvenile correctional facility housing adjudicated delinquent adolescents)	10 (2)	N/A	Adolescent Problem Situation Inventory (APSI): Drug and Alcohol Avoidance, social and problem solving, and self-control subscales
Hein et al. (2020)	Social problem-solving training (SPST)	Juvenile Justice/corrections	10 (1)	N/A	The State-Trait Anger Expression Inventory-2nd edition (STAXI); The Delinquency Reduction Outcome Profile (DROP)
Jackson (1991)* ^a	Aggression Replacement Training (ART)	Mental health (private psychiatric hospital, adolescents admitted for 28-day intensive treatment)	2 (5)	N/A	The Aggressive Behavior Checklist (ABC)
Jarden (1995)* ^a	Problem-Solving Group Therapy (PSGT) & Problem-solving group therapy with generalization procedures (PSGT-GP)	Mental health/Child welfare (“comprehensive treatment center offering residential services” for adolescents with disruptive behavior disorder, referred by state departments of human services)	18 (1)	Child Behavior Checklist (CBCL); internalizing problems subscales	Child Behavior Checklist (CBCL); hyperactive, aggression, and delinquent subscales
Jewell and Elliff (2013) ^a	Relaxation Skills Violence Prevention (RSVP)	Juvenile Justice/corrections (“juvenile justice detention center”)	1 (5)	N/A	Anger and Coping Questionnaire (ACQ)
Klatt (2008)*	Forgiveness intervention addressing previous victimization to reduce aggressive behavior through the healing of past wounds.	Juvenile justice/corrections (“incarcerated youth at a juvenile treatment facility”)	12 (1)	N/A	Aggression Questionnaire (AQ); Behavior observations
Ladley (1997) ^a	Attributional-Intention Training to reduce anger and aggression	Mental health/Child welfare (“Residential treatment program” with average duration of ½-1 year, for adolescents “in placement” with socio-emotional difficulties and behavioral problems)	5 (2)	N/A	Teacher Checklist (TC): aggression subscale; Self-Control Rating Scale (SCRS)
Macmahon And Gross (1988)	Aerobic exercise to reduce depression	Juvenile Justice/corrections (“incarcerated adolescents in juvenile detention facilities”)	12 (3)	Beck Depression Inventory (BDI)	N/A
Mitchell et al. (2011)	Cognitive Behavior Therapy with Motivational Interview and Narrative Therapy to treat “common mental health problems”	Juvenile Justice/corrections (“four secure children’s homes and a young offender institution”)	2–28 (1)	Youth Self Report (YSR): Internalizing; Difficulties and Coping Profile (DCP): depressive symptoms and anxiety	Youth Self Report (YSR): Externalizing; Difficulties and Coping Profile (DCP): aggressive behavior
Pereira et al. (2020)	“Wave by wave” surf program with resilience-promoting components targeting self-esteem, self-regulation, healthy habits, and prosocial skills	Child welfare (adolescents living in residential childcare institutions)	21 (1)	Strengths and Difficulties Questionnaire (SDQ); Revised Children’s Anxiety and Depression Scale (RCADS)	Strengths and Difficulties Questionnaire (SDQ)
Riemann et al. (2013)	Computerized Attention Modification (AMP), directing attention away from threatening stimuli.	Mental health (“residential treatment facility specializing in CBT for severe and complicated cases of anxiety disorders”)	Notreported (7)	Screen for Child Anxiety Related Disorders (SCARED); Beck Depression Inventory II (BDI-II)	N/A
Rohde et al. (2004)	“Coping Course” Group-based CBT to enhance general coping and problem-solving skills	Juvenile Justice/corrections (“Youth Correctional Facility providing closed custody care to male juvenile offenders»)	8 (2)	Beck Depression Inventory II (BDI-II); Youth Self-Report (YSR): Internalizing	Youth Self-Report (YSR): Externalizing
Schlichter and Horan (1981) ^a	Stress Inoculation through role-played provocations to reduce anger and aggression	Juvenile Justice/corrections (“Adjudicated delinquents committed to a correctional facility”)	5 (2)	N/A	Institutional behavior ratings: Physical and verbal aggression
Schuurmans et al. (2018) ^a	“Dojo” emotion-evoking videogame with instructions in CBT-based relaxation techniques, positive thinking, and guided imagery	Mental health (Conducted in residential institutions that provide “secure youth care”)	4 (2)	Spence Children’s Anxiety Scale (SCAS): Child	Strengths and Difficulties Questionnaire (SDQ); externalizing subscales ‘conduct problems,’ ‘hyperactivity-inattention,’ and ‘peer-problems.’
Stein et al. (2011)	Motivational interviewing (MI) to reduce depression and alcohol and marijuana consumption	Juvenile Justice/corrections (“state juvenile correctional facility»)	8 (2)	N/A	The risks and Consequences Questionnaire (RCQ)
Vohra et al. (2019)	Mindfulness based-stress reduction (MBSR) to enhance relations with peers, adaptive skills, and emotion regulation.	Mental health (Voluntary treatment for youth “in need of intensive care”)	8 (1)	Behavior Assessment System for Children (BASC-2): Internalizing problems,	Behavior Assessment System for Children (BASC-2): Externalizing problems

Note. N/A = Not applicable *Dissertation ^aStudy contained common practice elements significantly associated with increase in effect size

Figure 1. Common practice element frequencies for externalizing outcomes: winning groups and all trials.

Note: The bars represent the number of CPEs coded as “present” across comparisons. N = Total number of effect estimates for each comparison group. * p < .05 ** p < .01 *** p < .001

Figure 2. Common practice element frequencies for internalizing outcomes: winning groups and all trials.

Note: The bars represent the number of CPEs coded as “present” across comparisons. N = Total number of effect estimates for each comparison group. * p < .05 ** p < .01 *** p < .001

Table 2. Practice elements associated with stronger or weaker effects on externalizing symptoms.

Practice Element	Practice Element Present (k)	Practice Element Absent (k)	Mean Difference	ES with Practice Element	ES without Practice Element
1 Emotion recognition and differentiation	64	46	.325*	.464	.140
2 Preventing maladaptive behavioral responses to emotional distress	97	13	.323^†	.371	.048
3 Self-exploration/monitoring of thoughts and feelings	60	50	.075	.357	.282
4 Training in behavior regulation	29	81	.269	.522	.253
5 Mindfulness	35	75	−.005	.309	.314
6Training in cognitive skills	79	31	.044	.326	.282
7 Psychoeducation	71	39	.314*	.469	.155
8 Problem solving skills	84	26	−.086	.291	.377
9 Social skills training	39	71	−.143	.226	.368
10 Organizational skills	55	55	.271^†	.460	.189
11 Lifestyle	19	91	−.008	.246	.334

Note. Differences in effect sizes between programs with or without the practice element were significant at the level of *p < .05; ^†p < .10. k = number of comparisons. ES = effect size (Cohen’s d)

Table 3. Practice elements associated with stronger or weaker effects on internalizing symptoms.

Practice Element	Practice Element Present (k)	Practice Element Absent (k)	Mean Difference	ES with Practice Element	ES without Practice Element
1 Emotion recognition and differentiation	11	27	−.133	.182	.315
2 Preventing maladaptive responses to emotional distress	14	24	.052	.310	.259
3 Self-exploration/monitoring of thoughts and feelings	9	29	.157	.402	.245
4 Training in behavior regulation	8	30	.197	.438	.241
5 Mindfulness	12	26	.068	.326	.258
6 Cognitive skills training	23	15	−.034	.263	.297
8 Problem solving skills	17	21	−.086	.227	.312
9 Social skills training	16	22	−.202	.150	.351
10 Organizational skills	10	28	.130	.377	.247
11 Lifestyle	9	29	−.255	.083	.338

Note. Differences in effect sizes between programs with or without the practice element were significant at the level of *p < .05; ^†p < .10. k = number of comparisons. ES = effect size (Cohen’s d). Element 7 did not fulfil the criteria to be defined as a common element for internalizing outcomes.

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