evidence Base
Most evidence supporting the efficacy of PST for youth is indirect,
deriving from studies evaluating multimodal treatments that include
it as one component (see Table 4.1 for a summary of PST applications
in evidence-based treatment manuals for internalizing disorders in
youth).More specifically, in efforts to identify evidence-based treat-
ments, PST is a component of those labeled as "well established" for
depression (David-Ferdon & Kaslow, 2008), "probably efficacious" for
bipolar disorder (Fristad & McPherson, 2014), and "probably effica-
cious" for anxiety disorders (Freeman et al., 2014; Silverman, Pina, et
al., 2008). In the closest approximation of a stand-alone evaluation, Stark
and his colleagues compared behavioral problem-solving therapy
(BPS), self-control therapy (SC), and waitlist conditions in a sample
of 29 children (mean age = 11.17 years) scoring in the moderately to
severely depressed range on a self-report measure of depression (Stark
et al., 1987). The initial four sessions of both active 12-session group
treatments were quite similar (e.g., rationale, self-monitoring, group4. Problem-Solving Training
& Goldfried, 1971; D'Zurilla & Nezu, 2010). Negative thinking patterns
may make it more difficult for depressed youth to be objective and
specific when addressing their problems (Nezu, 1987). For example, an
adolescent who tends to blame him- or herself for everything will be
less able to accurately define a problem, identify its true source, and
generate possible solutions. The generation of alternatives stage involves coming up with pos-
sible solutions to a particular problem in a way that maximizes the
likelihood that the most effective response is included among them
(D'Zurilla & Goldfried, 1971). Depression is associated with the genera-
tion of a restricted range of response alternatives that results in ineffec-
tive responding (Nezu, 1987). The goal of the decision-making stage is to
select the most effective response alternative. Effective responses alter
the situation, maximizing positive consequences while minimizing
negative ones. Depression hampers decision making. Cognitive biases,
such as selectively attending to the negative, can lead to the inaccurate
assessment of response alternatives and their potential consequences
(Nezu, 1987). Of course, having fewer quality response options to
choose from makes ineffective responding more likely for depressed
youth regardless of their decision-making abilities. The final stage of problem solving occurs after the chosen response
alternative has been enacted. Verification, later referred to as solution
implementation and verification (D'Zurilla & Nezu, 1982), involves an
assessment of the actual outcome and whether any self-correction is
needed (D'Zurilla & Goldfried, 1971). The key question is whether the
actual consequences of a solution match those anticipated during the
decision-making stage (Nezu, 1987). For youth experiencing depres-
sion, biased thinking may preclude objectivity in assessing outcomes. They may focus on the negative, set very high expectations for them-
selves, and be more swayed by the short-term, rather than long-term,
consequences of their actions (Nezu, 1987; Rehm, 1977). Overall, despite ample evidence relating depression and more gen-
eral problem-solving deficits in child and adolescent samples (e.g., Mul-
lins, Siegel, & Hodges, 1985; Sacco & Graves, 1984), there is surprisingly
little empirical support for the particular stage-related deficits pro-
posed by Nezu (1987) other than that found for orientation variables in
studies of adolescents. Positive problem orientation has been found to
moderate the relation between negative life stress and depression, and,
conversely, negative problem orientation and impulsive and avoid-
ant response styles predict depression (e.g., Frye & Goodman, 2000;
Reinecke, DuBois, & Schultz, 2001). Beyond that, there is some evidencelinking depressive symptoms and the generation of fewer solutions
(Frye & Goodman, 2000; Levendosky, Okun, & Parker, 1995). Though
the types of deficits proposed by Nezu (1987) may well exist, research-
ers have tended not to assess them, instead relying on self-reports of
more global attitudes and abilities. Research examining problem solving and anxiety is much less
advanced, but the Nezu (1987) formulation seems readily adaptable. Studies with adults have documented links between anxiety and less
effective problem solving (e.g., Dugas, Letarte, Rheaume, Freeston,
& Ladouceur, 1995) and evidence of a moderating role for problem-
solving ability in the relationship between negative life stress and
anxiety (Nezu, 1986). Anxious youth present with a range of cognitive
biases that would appear to adversely impact their problem-solving
ability. For example, Chorpita, Albano, and Barlow (1996) found that
anxious children had a distinct tendency to interpret ambiguous situ-
ations as threatening, endorse more avoidant plans in response, and
assign higher probability to the occurrence of threatening events. Problem situations are inherently ambiguous, and perceiving them as
threats may impede the ability to objectively define them, discourage
the generation of solutions, and prevent decision making and imple-
mentation (Dugas et al., 1995).TaBle 4.1 The Problem-solving Training element in representative eBT Manuals
Coping Cat (Kendall &
Hedtke, 2006)
o Problem solving is explicitly mentioned and integrated
throughout this treatment, with a specific session
dedicated to developing problem-solving skills. The
therapist is also encouraged to model problem solving
in anxiety-provoking situations of increasing intensity. C.A.T. Project (Kendall,
Choudhury, Hudson, &
Webb, 2002)
o As with Coping Cat, problem solving is integrated
throughout the treatment and is also the focus of a
particular session about coping and problem solving. The therapist is encouraged to help adolescents acquire
skills for problem solving in anxiety-provoking
situations. Family-Based Treatment for
Young Children with OCD
(Freeman & Garcia, 2009)
o Problem solving is explicitly incorporated into parental
scaffolding for teaching ERP in one section of the
treatment. o The parents also problem-solve potential barriers to
homework completion (child and parent assignments)
with the therapist. CBT of Childhood OCD:
It's Only a False Alarm
(Piacentini, Langley, &
Roblek, 2007)
o Although problem solving is not a specific skill taught
in this treatment, the parents and/or the therapists are
encouraged to help the youth use it in several places
throughout this treatment (e.g., in problem solving
obstacles to homework compliance or engaging in
exposure exercises). When Children Refuse School:
A CBT Approach (Kearney
& Albano, 2007): Chapters
4 and 5 on internalizing
symptoms
o Though covered in detail as part of parent-child
negotiation and contracting in a chapter devoted to
reward-based school refusal (Chapter 7), there is no
clear teaching of problem-solving skills in the two
chapters on internalizing symptoms. Treating Trauma and
Traumatic Grief in Children
and Adolescents (Cohen,
Mannarino, & Deblinger,
2006)
o Problem solving is explicitly mentioned, with one
section devoted to enhancing problem solving and
social skills, including related worksheets for youth to
complete. o Problem solving is also referenced at other points in the
treatment through the use of an acronym (i.e., CRAFTS)
for the types of problems addressed in treatment
(Cognitive, Relationship, Affective, Family, Traumatic
behavior, Somatic). Adolescent Coping with
Depression (Clarke,
Lewinsohn, & Hops, 1990)
o Problem solving is an explicit focus of this treatment,
with an entire section devoted to learning negotiation
and problem solving.TaBle 4.1. (continued)
Interpersonal Psychotherapy
for Depressed Adolescents,
2nd edition (Mufson,
Pollack Dorta, Moreau, &
Weissman, 2011)
o Teaching problem solving is an explicit component of
this treatment, with the therapist assisting the client in
each of the formal steps involved in problem solving. Treating Depressed Children:
Therapist Manual for "Taking
Action" (Stark & Kendall,
1996)
o Problem solving is explicitly discussed in this
treatment, with a specific section dedicated to it.
The therapist is also encouraged to model the use of
problem solving to overcome impediments the client
encounters.Treating Depressed Youth:
Therapist Manual for "Action"
(Stark et al., 2007)
o Problem solving is an explicit component of this
treatment, with a section focused on this skill and
the steps one takes to learn it, as well as a separate
appendix describing the steps. Psychotherapy for Children
with Bipolar and Depressive
Disorders (Fristad, Arnold, &
Leffler, 2011)
o Problem solving is explicitly discussed and integrated
throughout this treatment, including several related
activities and handouts. o Additionally, there are separate problem-solving skills
chapters intended to address parents' and children's
problem-solving deficits. Note. Some book titles are shortened to conserve space. See the References at the back of the book for
full titles. problem solving to increase frequency of pleasurable activities). The
remaining sessions in the BPS condition were devoted to teaching
problem-solving skills and developing strategies for increasing the
occurrence of pleasant activities. In the SC condition, the remaining
sessions targeted self-monitoring of pleasant activities and positive
self-statements, setting more realistic performance standards, adap-
tive attributions, and self-consequating. Both of the active treatments
were effective relative to the waitlist condition, producing statistically
and clinically significant improvements in depression. The BPS condi-
tion fared a bit better than the SC condition on the parent ratings, with
mothers reporting significant improvements in internalizing behavior
at posttreatment and in social withdrawal, depression, and internal-
izing behavior at an 8-week follow-up. Multimodal treatments that include PST as a component are effec-
tive in treating child and adolescent depression (e.g., Clarke et al., 1999;
Kahn, Kehle, Jenson, & Clark, 1990; Lewinsohn et al., 1990; Mufson
et al., 2004; Mufson, Weissman, Moreau, & Garfinkel, 1999). Most of
these are cognitive-behavioral treatments that also include psycho-
education, cognitive restructuring, pleasant events scheduling, and
skills training (e.g., coping, emotion regulation, and social skills). Forexample, in a study with 59 depressed adolescents (mean age = 16.23
years), Lewinsohn and colleagues compared adolescent-only and ado-
lescent and parent versions of their CWD-A (Lewinsohn et al., 1990). The CWD-A consisted of 14 group skills training sessions targeting
teaching of relaxation skills, increasing pleasant events, controlling
negative thoughts, and improving social skills, as well as a conflict
resolution component addressing communication and problem solv-
ing with parents. In the PST component, adolescents were taught to
concisely define problems, brainstorm alternative solutions, decide on
one or more mutually satisfactory solutions, and specify the details for
implementing the agreed-upon solution. In the adolescent-and-parent
version, seven parent sessions overviewing what was taught to the
teens were added to promote acceptance and support for the interven-
tion. Both versions resulted in significant reductions in depression that
were maintained at a 2-year follow-up assessment, whereas adolescents
in the waitlist control condition showed very little improvement. No
significant differences between the two versions of the CWD-A course
were found. PST is also included in the only "first line" psychosocial treat-
ment for pediatric bipolar disorders (Fristad & McPherson, 2014).Fristad et
al. (2009) conducted a randomized controlled trial (RCT) with youth
(N = 165; ages 8-12 years) meeting the criteria for depression or bipolar
disorder that compared multifamily psychoeducational psychother-
apy plus treatment as usual (MF-PEP + TAU) and waitlist control plus
treatment as usual (WLC + TAU) conditions.After two sessions devoted to psychoeducation, the remaining six ses-
sions targeted a variety of coping skills, including emotion regulation,
problem solving, and nonverbal and verbal communication. CBT for Social Phobia: Stand
Up, Speak Out (Albano &
DiBartolo, 2007)
o Problem solving is explicitly mentioned in a section on
"problem solving and skills training," a series of three
sessions, one of which is dedicated jointly to social
problem solving and cognitive restructuring (the other
two sessions focusing on social skills training and
assertiveness training).Fam-
ily psychoeducation plus skill building interventions provide families
with information on the symptoms, course, and treatment of bipolar
disorders while also teaching coping skills helpful in symptom man-
agement (e.g., Fristad, Verducci, K. Walters, & Young, 2009).MF-PEP was evaluated
as an adjunctive intervention, and all youth were allowed to continue
with TAU, including medication.The MF-PEP condition consisted of
eight 90-minute sessions with concurrent parent and child groups.