Children and Youth Services Review

29 (2007) 823 839

www.elsevier.com/locate/childyouth

Can cognitive-behavioral therapy increase self-esteem

among depressed adolescents? A systematic review
Tatiana L. Taylor , Paul Montgomery
Centre for Evidence-Based Intervention, Department of Social Policy and Social Work,
University of Oxford, United Kingdom

Received 28 November 2006; received in revised form 14 January 2007; accepted 22 January 2007
Available online 20 February 2007

Abstract

This systematic review evaluates the efficacy of cognitive-behavioral therapy (CBT) in improving self-
esteem among depressed adolescents aged 1318 years. A search identified 265 references, 33 articles were
acquired, of which two papers met the inclusion criteria. Two excluded studies are also discussed. A total of
82 participants from two trials were included in the meta-analysis. The data suggest CBT may be an
effective treatment for increasing global and academic self-esteem when compared to wait-list controls.
However, more research is needed due to the limited number of studies conducted in this area and the need
for further investigation into the long-term effects of CBT.
2007 Elsevier Ltd. All rights reserved.

Keywords: Cognitive-behavioral therapy; Self-esteem; Depression

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 825
2.1. Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 825
2.2. Search strategy for identification of studies . . . . . . . . . . . . . . . . . . . . . . 825
2.3. Search terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826
2.4. Criteria for considering studies for this review . . . . . . . . . . . . . . . . . . . . . 826
2.5. Assessment of methodological quality . . . . . . . . . . . . . . . . . . . . . . . . . 826
2.6. Data abstraction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826

Corresponding author. Department of Social Policy and Social Work, University of Oxford, Barnett House,
32 Wellington Square, Oxford, OX1 2ER, United Kingdom.
E-mail address: tatiana.taylor@gmail.com (T.L. Taylor).

0190-7409/$ - see front matter 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.childyouth.2007.01.010
824 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839

2.7. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826

2.8. Multiple treatment arms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
3. Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
3.1. Trial flow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
3.2. Methodological quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 828
3.3. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 828
3.4. Depression: Cognitive-behavioral therapy versus wait-list control . . . . . . . . . . . 829
3.5. Self-esteem: Cognitive-behavioral therapy versus wait-list control . . . . . . . . . . . 832
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 832
4.1. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 837
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 837

1. Introduction

Depression is one of the most common forms of adolescent psychopathology. Worldwide

estimates of the disorder range from 0.48.3% (Anderson & McGee, 1994; Fleming & Offord,
1990; Kashani, Beck, Hoeper et al., 1987; Kashani, Carlson, Beck et al., 1987; Lewinsohn,
Clarke, Seeley, & Rhode, 1994; Lewinsohn, Duncan, Stanton, & Hautziner, 1986; Lewinsohn,
Hops, Roberts, Seeley, & Andrews, 1993) with prevalence increasing with age, creating a
sharp rise around the onset of puberty. Unlike childhood depression, adolescent depression is
similar to adult depression in both symptoms and gender prevalence (Carlson & Kashani,
1988; Fleming & Offord, 1990; Kessler et al., 1994; Kolvin, Barrett, & Bhate, 1991;
Lewinsohn et al., 1994). These similarities have led researchers to believe that adult
depression often begins during adolescence (Ryan et al., 1987). Due to the prevalence and
impact of the disorder, much research has been conducted to better understand depression and
find effective ways to treat it. Cognitive-behavioral therapy (CBT) has become the most
widely used and researched psychotherapy for the disorder (Fennell, 1989; Harrington,
Whittaker, & Shoebridge, 1998).
Cognitive-behavioral therapy attempts to positively manipulate an individual's interpre-
tation of various situations in order to bring about desired changes outside of a clinical
setting. Evidence suggests that CBT reduces relapse rates better than anti-depressants
(Evans et al., 1992; Hollon, Shelton, & Loosen, 1991). The intervention has shown promise
among adolescent patients, reducing both depressive symptoms and the risk of relapse
(Curry & Reinecke, 2003). Although CBT is effective, the mechanism through which it is
able to decrease depression is unclear. Harter (1999) concluded self-image to be cognitively
based. This belief in a cognitive connection between illogical thought patterns and
unhealthy self-esteem has caused some researchers to posit that CBT may have the ability to
alter cognition and promote positive self-esteem in adults as well as adolescents. Therefore,
it is possible that self-esteem may act as a mechanism for controlling depressive symptoms
through CBT.
Self-esteem has the ability to affect both mental and physical processes and has the
potential to become a risk factor for a variety of maladaptive behaviors and negative outcomes.
Self-esteem has been negatively correlated with eating disorders, such as anorexia nervosa and
bulimia nervosa, in adolescent females (Fisher, Schneider, Pegler, & Napolitano, 1991),
susceptibility to peer pressure, a decline in academic achievement, and increased alcohol use
(Zimmerman, Copeland, Shope, & Dielman, 1997). Susceptibility to unhealthy changes in
 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839 825

self-esteem is often triggered by stressful or traumatic events. The maintenance of a healthy

self-esteem becomes increasingly difficult during adolescence (Reinecke, Dattilio, & Freeman,
2003).
Ellis (1977) argues that people often hold both positive and negative irrational beliefs about
themselves and the way in which their actions affect their environment. Individuals with positive
self-perception are more accepting of themselves (Burns, 1979) and, as a result, are better able to
handle stressful situations, while adolescents operating under negative self-perceptions possess
significantly higher rates of maladjustment than peers maintaining positive self-esteem (Engel,
1959). Adolescents with low self-esteem also exhibit less consistent behavior compared to their
peers (Burns, 1979), making them more easily influenced and prone to succumbing to peer
pressure. Self-esteem's ability to influence the way individuals process and participate with the
world around them may provide it with the potential to increase or decrease susceptibility to
maladjustment.
Recent literature has begun to strengthen the idea of a relationship between cognition and
self-esteem in which individuals' illogical and negative mental associations cause decreased
belief in personal abilities and a negative overall view of themselves (Shirk, Burwell, &
Harter, 2003). Evidence exists that self-esteem is not only a predictor of various outcomes
but that it also functions as a mediator and/or moderator for a variety of clinical problems
(Shirk et al., 2003). In a study conducted by Khale, Kulka, and Klingel (1980), self-esteem
was found to be an effective predictor of later interpersonal problems. Bidirectionality of the
findings was not substantiated. Twamley and Davis (1999) found self-esteem to serve as a
moderator between body dissatisfaction and disordered eating, creating a negative cor-
relation between self-esteem and eating patterns. In 1986, Harter demonstrated self-esteem's
role as a mediator of children's relationships between perceived social support and competence
and academic motivation. Low self-esteem can be connected to schematic processing biases or
cognitive distortions, making it an important focus for CBT interventions (Shirk et al., 2003).
Through a reassessment and analysis of the literature concerning CBT interventions among
depressed adolescents which include the measurement of self-esteem outcomes, it may be
possible to determine whether or not self-esteem is the mechanism by which CBT helps
adolescents suffering from depression. The format of this review is designed to follow the
Quality of Reporting of Meta-analyses (QUORUM) statement (Moher et al., 1999).

2. Methods

2.1. Objective

To assess the efficacy of cognitive-behavioral interventions in improving self-esteem among

depressed adolescents aged 1318 years.

2.2. Search strategy for identification of studies

The following electronic databases were searched: PsychINFO (1872-June 2005); CINAHL
(1982-May 2005); EMBASE (1980-April 2005); MEDLINE (1966-July 2005); ERIC OCLC First
Search; ArticlesFirst OCLC First Search; PapersFirst OCLC First Search. Reference lists of
articles identified through database searches were examined to identify further relevant studies.
Bibliographies of systematic review and meta-analysis articles were also examined. All reports of
identified studies were independently inspected and assessed by two reviewers.
826 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839

2.3. Search terms

Search terms pertaining to self-esteem, youth and adolescence, depression and depressive
symptoms, and cognitive-behavioral therapy were used to isolate randomized controlled
trials.

2.4. Criteria for considering studies for this review

Studies included in the review are randomized controlled and quasi-randomized (e.g.
alternate allocation, sequential number allocation) trials of all forms of CBT among participants
with a mean age ranging from 13 to 18 years. The mean age range of 13 to 18 years was selected
because individuals in this range are, developmentally, similar. Studies must have measured
self-esteem and depression, using psychometrically sound and validated scales (e.g. the
Rosenberg Self-Esteem Scale [RSES] Rosenberg, 1965). Outcomes were divided, where
possible, into immediate post-treatment, short-term follow-up (up to 3 months after treatment),
medium-term follow-up (3 to 6 months after treatment), and long term follow-up (more than
6 months after treatment).

2.5. Assessment of methodological quality

Quality assessment was made of all included studies by both reviewers, independently, to
consider the following questions:

Was the assignment to treatment groups truly random?

Was allocation adequately concealed?
How complete was follow-up?
How were the outcomes considered for people who withdrew?
Were they included in the analysis?
Were those assessing outcomes blind to the treatment allocation?

It is known that a strong relationship between the potential for bias in the results and allocation
concealment exists (Higgins & Green, 2005).

2.6. Data abstraction

Data was extracted and compared using data extraction sheets and entered independently into
meta-analytic software (Review Manager [RevMan], 2002).

2.7. Data synthesis

Clinical and methodological heterogeneity between studies was found. Since self-esteem and
depression (at immediate post-treatment) are continuous outcomes, and were measured with
similar, but not identical, instruments across studies, standardized mean differences (SMD)
were calculated. Depression and global self-esteem at short-term follow-up and academic self-
concept at post-treatment and short-term follow-up were calculated using weighted mean
differences (WMD). The area to the right of the line of no effect indicates a favorable outcome
for CBT.
 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839 827

2.8. Multiple treatment arms

No included studies contained more than one eligible CBT therapy versus a control group.
Where studies contained more than one treatment group, comparisons were only assessed
between the CBT group and the wait-list control.

3. Results

3.1. Trial flow

Following database searches, 265 references were located. Titles and abstracts were examined
and 33 articles were acquired. After searching reference lists of acquired articles, 15 were
examined. Two trials met the inclusion criteria (Reynolds & Coats, 1986; Rossell & Bernal,
1999). For more information on trial flow see Fig. 1.

Fig. 1. Trial flow.

828 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839

3.2. Methodological quality

The authors of studies were contacted in order to obtain the details of randomization and
allocation concealment since no information was provided within the published papers. No
response has been received regarding methods of randomization and allocation concealment from
either study. The specific details of both included and excluded studies are reported in Tables 1
and 2, respectively.

3.3. Study characteristics

Included studies were published between 1986 and 1999 (Reynolds & Coats, 1986; Rossell
& Bernal, 1999). Participants were recruited from schools (Reynolds & Coats, 1986) and clinics
(Rossell & Bernal, 1999). The included studies were small, with a total of 101 participants.
Eighty-two subjects provided information on outcomes relevant to this review and were used in
the analysis. Neither study asserted that it had correctly gauged the power for the number of
participants needed for the study to produce statistically significant results.
The stated purpose of each included study was to reduce depression in adolescents through
cognitive-behavioral interventions or other techniques. All included studies' participants were
excluded if they were taking psychotropic medications. Both studies excluded participants who
were receiving any other type of treatment for a disorder. Rossell and Bernal (1999) included

Table 1
Characteristics of included studies
Study Reynolds and Coats (1986)
Methods Randomized controlled trial
Participants 30 participants (mean age of 15.65; SD not provided). Participants were included if they had a Beck
Depression Inventory (BDI) score of 12 or greater, Reynolds Adolescent Depression Scale (RADS) of 72
or greater, Bellevue Index of Depression (BID) score of 20 or greater
Interventions Treatment 1: Cognitive-behavioral therapy (CBT); Treatment 2: Relaxation training (RT); Treatment 3:
Wait-list control (WL)
Outcomes BDI; RADS; BID; Rosenberg Self-Esteem Scale (RSES); the high school version of the Academic Self-
Concept Scale (ASCS-HS); State-Trait Anxiety Inventory (STAI)
Notes Subjects received 10, 50-minute group treatments (at the high school) over the course of 5 weeks; Initial
intake was 30; 24 completed post-treatment assessments; 21 completed 5-week follow-up; Drop-out
proportions (30%) were tested and found insignificant; No intent-to-treat
Allocation B
concealment

Study Rossell and Bernal (1999)

Methods Randomized controlled trial
Participants 71 participants (mean age of 14.70; SD = 1.40). Participants were included if met the DSM-III diagnosis
for major depressive disorder, dysthymia, or both and were 13 to 18 years of age.
Interventions Treatment 1: Interpersonal therapy (IPT); Treatment 2: CBT; Treatment 3: WL
Outcomes Children's Depression Inventory (CDI); Piers-Harris Children's Self-Concept Scale (PHCSCS); Social
Adjustment Scale for Children and Adolescents (SASCA); Family Emotional Involvement and Criticism
Scale (FEICS); adolescent and parent Child Behavior Checklist (CBCL)
Notes Subjects received 12 one-hour individual sessions over 12 weeks; Initial intake was 71; 58 completed
post-treatment assessments; 20 completed 3-month follow-up; WL was unavailable for follow-up
(eligible to receive therapy); Drop out rate: 18.31%; No intent-to-treat
Allocation B
concealment
 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839 829

Table 2
Characteristics of excluded studies
Stark et al.This randomized controlled-trial of self-control, behavioral problem-solving, and wait-list control included
(1987) participants with a mean age of 11.17 years. The main findings showed both treatments to be significantly
effective in decreasing depression. Results were maintained at 8-week follow-up. Self-Esteem as measured
by the Coopersmith Self-Esteem Inventory (Coopersmith, 1975) increased with time in all groups. However,
only subjects in the self-control arm reported a significant improvement in self-esteem at both post-treatment
and follow-up.
Wood et al. This randomized-controlled trial of cognitive-behavioral therapy (CBT) and relaxation training (RT; used as
(1996) a control) included participants with a mean age of 14.20 years. Data concerning participant flow was
unavailable. The trial found CBT to be more effective than RT in increasing self-esteem at post-treatment and
3-month and 6-month follow-up.

subjects ranging from 13 to 18 years of age. Reynolds and Coats (1986) included high school
aged adolescents.
Included subjects were screened and found to be depressed using a variety of measures.
Reynolds and Coats (1986) screened a high school population using the Beck Depression
Inventory (BDI [Beck, Ward, Mendelson, Mock, & Erbaugh, 1961]) and the Reynolds
Adolescent Depression Scale (Reynolds, 1986). Rossell and Bernal (1999) screened adolescents
referred to a clinic using DSM-III-R (American Psychiatric Association, 1994) criteria for major
depressive disorder, dysthmia or both. Individuals were excluded from for a variety of reasons
such as: known learning disabilities, emotional disturbances (other than affective disorders) or
mental retardation (Reynolds & Coats, 1986) and serious imminent suicidal risk, psychotic
features, bipolar disorder, organic brain syndrome, marked hyper aggression, need for immediate
treatment or hospitalization, currently receiving psychotropic medication or psychotherapy or
legal involvement (Rossell & Bernal, 1999).
Rossell and Bernal (1999) compared two treatment conditions (CBT and interpersonal
therapy) to a wait-list control. Reynolds and Coats (1986) compared two treatment conditions
(CBT and relaxation training) to a wait-list control. Full descriptions of each study's outcome
measures are included in Table 1.
Follow-up data were sought after 5 weeks (Reynolds & Coats, 1986) and three months
(Rossell & Bernal, 1999). In one study (Rossell & Bernal, 1999), follow-up data for the wait-
list control group were unavailable because the control group was allowed to receive treatment
after post-treatment assessments. Attrition rates of studies included were found to range from
18.31% (Rossell & Bernal, 1999) to 30% (Reynolds & Coats, 1986). Many of the studies
included in systematic reviews concerning the use of CBT for depression (Compton et al., 2004;
Harrington, Whittaker, Shoebridge, & Campebell, 1998) contain a large proportion of high
attrition rates such as 14.50% (Lewinsohn, Clarke, Hops, & Andrews, 1990), 21.95% (Clarke,
Rhode, Lewinsohn, Hops, & Seeley, 1999), and 27.10% (Brent et al., 1997). This high range of
rates mirrors those found in studies focusing on adult populations (37.06%, Elkin et al., 1989;
27.08%, Murphy, Simons, Wetzel, & Lustman, 1984). Therefore, these rates are not unusual in
depression research concerning CBT.

3.4. Depression: Cognitive-behavioral therapy versus wait-list control

Depression was used as an outcome measure (BDI and Children's Depression Inventory) in
both studies at immediate post-treatment analysis (n = 55) in Fig. 2 (Reynolds & Coats, 1986;
Rossell & Bernal, 1999) and in one study at short-term follow-up (n = 16 [Reynolds & Coats,
 830
T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839
Fig. 2. Comparison of cognitive-behavioral therapy and wait-list control groups concerning depressive symptoms at immediate post-treatment.
 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839
Fig. 3. Comparison of cognitive-behavioral therapy and wait-list control groups concerning depressive symptoms at short-term follow-up.

831
832 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839

1986]) in Fig. 3. The overall SMD random effect estimate at immediate post-treatment was 0.75
(95% Confidence Interval [CI] = 0.25, 1.76) in favor of CBT. However, this result was not
significant ( p = 0.14). After five weeks, the overall WMD random effect estimate at short-term
follow-up as reported in one study had significantly improved (14.20; 95% CI = 6.20, 22.20;
p = 0.0005) in favor of the intervention treatment (CBT).

3.5. Self-esteem: Cognitive-behavioral therapy versus wait-list control

Global self-esteem was measured as an outcome (Rosenberg Self-Esteem Scale and Piers
Harris Children's Self-Concept Scale) at immediate post-treatment (n = 55) in both studies
(Reynolds & Coats, 1986; Rossell & Bernal, 1999) and at short-term follow-up ([n = 15]
Reynolds & Coats, 1986) in one study as shown in Figs. 4 and 5, respectively. At immediate post-
treatment, the SMD random effect was found to be slightly in favor of CBT (0.13; 95% CI =
0.55, 0.81). However, this result did not reach significance ( p = 0.71). Five weeks later, CBT
effectiveness had increased with a WMD of 2.86 (95% CI = 1.73, 7.45) but this effect was still
insignificant ( p = 0.22).
The domain specific outcome of academic self-concept (high school version of the Academic
Self-Concept Scale) was measured both at post-treatment (n = 16; Fig. 6) and short-term follow-up
(n = 15; Fig. 7) in one study (Reynolds & Coats, 1986). The WMD fixed effect of 6.01 (95% CI =
4.06, 16.08) was found to favor CBT over the control at immediate post-treatment. This was not
significant ( p = 0.24). However, five weeks after treatment, the effect more than doubled with a
WMD of 12.41 (95% CI = 3.75, 21.07), showing a highly significant effect ( p = 0.005) in favor of
CBT.

4. Discussion

The objective of this review was to assess the efficacy of cognitive-behavioral therapy in
improving self-esteem among adolescents aged 1318 years. Cognitive-behavioral therapy
appears to be a potentially effective treatment in increasing self-esteem. Overall findings suggest
that the use of CBT for adolescents suffering from unhealthy, low levels of self-esteem may be
appropriate.
Cognitive-behavioral therapy has been shown to be the most effective and widely used
intervention for the treatment of depression (Fennell, 1989; National Institute of Mental Health,
2000). The results of this meta-analysis show CBT to be significantly more effective in decreasing
depressive symptoms when compared to a control group at short-term follow-up (up to three
months post-treatment). The effect of CBT on global self-esteem and academic self-concept did
not reach significance at post-treatment ( p = 0.71 and 0.24, respectively). At five weeks post-
treatment, cognitive-behavioral therapy's effect on global self-esteem increased, although still did
not reach significance ( p = 0.22). A highly significant effect was found in regard to academic self-
concept at five weeks post-treatment ( p = 0.005).
Cognitive-behavioral therapy's delayed effect may, in part, be due to the aim of the treatment.
It is not intended to be an immediate cure. The goal of the therapy in relation to depression is to
arm the client with the skills to logically challenge extreme negative thoughts. Like all things
learned, these skills increase with time, making the individual better able to handle depression
with time. Studies (Scott & Stradling, 1990) examining the effect of CBT on depression show that
in long-term follow-up, CBT significantly decreases depressive symptoms. It is important to note
that CBT may positively affect self-esteem in the long term rather than in the months immediately
 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839
Fig. 4. Comparison of cognitive-behavioral therapy and wait-list control groups concerning global self-esteem at immediate post-treatment.

833
 834
T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839
Fig. 5. Comparison of cognitive-behavioral therapy and wait-list control groups concerning global self-esteem at short-term follow-up.
 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839
Fig. 6. Comparison of cognitive-behavioral therapy and wait-list control groups concerning academic self-concept at immediate post-treatment.

835
 836
T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839
Fig. 7. Comparison of cognitive-behavioral therapy and wait-list control groups concerning academic self-concept at short-term follow-up.
 T.L. Taylor, P. Montgomery / Children and Youth Services Review 29 (2007) 823839 837

following the end of treatment. The two included studies show that CBT's effect on increasing
self-esteem came closer to significance five weeks after the end of treatment. Furthermore, two
studies excluded from the meta-analysis for participant mean age (Stark, Reynolds, & Kaslow,
1987) and the unavailability of essential unpublished data (Wood, Harrington, & Moore, 1996)
also found CBT to be effective in increasing self-esteem at post-treatment and both short- and
medium-term follow-up (for further details see Table 2).
Both physicians and parents resist medicating children and adolescents. The results of this
study provide evidence that CBT may be a viable alternative to medication. If self-esteem is at the
root of depression, CBT may be used as a treatment to prevent depression among youth and to
minimize the effects of the disorder as well as other disorders connected to self-esteem (e.g. eating
disorders).

4.1. Limitations

The results of this systematic review should be considered in light of its limitations. Firstly, this
meta-analysis is very small with the largest outcome having a total n of 27 in the intervention arm
and 28 in the control arm. This presents a considerable lack of statistical power which needs to be
considered. Furthermore, differences exist between cognitive-behavioral therapies, their method,
and the quality of therapist delivery. Publication bias may also limit available research. Had more
studies been available for inclusion, a funnel plot would have been performed. Included studies
showed high attrition rates. Although the rates are not unusual in this area of research (Brent et al.,
1997; Clarke et al., 1999; Lewinsohn et al., 1990), it can limit the generalization of the results.
Research on interventions that include and discuss adolescent self-concept is limited. This
review contains the data of only two studies fitting inclusion criteria. Therefore, it is imperative
that more research, both creating and assessing interventions focused on increasing adolescent
self-esteem, be carried out. Research must also extend follow-up times by including, at least, a
12 month follow-up in order to gain further understanding as to cognitive-behavioral therapy's
long-term effect on self-esteem. Only then will it be possible to more accurately assess cognitive-
behavioral therapy's effectiveness in increasing adolescent self-esteem.

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