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Randomized Controlled Trial of a

Cognitive–Behavioral Therapy for At-risk
Korean Male Adolescents
Myung-Sun Hyun, Kyoung A. Nam, and Myung-Ah Kim

This study examined the effects of cognitive behavioral therapy (CBT) aimed
at enhancing the resilience of high-risk adolescents with alcohol-dependent
parents in Suwon, South Korea. The study used a randomized control group
pretest and posttest design. The experimental group participated in 10 ses-
sions of CBT, and the scores on resilience increased significantly after the
intervention, whereas the scores of self-concept and depression did not
change. In the control group, none of the scores of outcome variables chan-
ged significantly after the intervention period. The results indicate that the
developed CBT program might be effective for improving the resilience of
adolescents with alcohol-dependent parents.
Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved.

C HILDREN CAN BE at risk of various

problems related to their parents' depression,
psychopathology, or alcohol use (Johnson & Leff,
2006). The Korea National Statistical Office (2007)
reported that 73.2% of the adult Korean male
population consumed alcohol, and 22% had alcohol
dependence or alcoholism. It was also reported that
30% of Korean children have been exposed to an
alcohol-dependent parent (Kim, 2005).
In a study of Korean adolescents, Park, Kim,
Joung, Kim, and Oh (2007) reported that parental
drinking was one of the factors influencing
psychosocial outcomes among adolescents. Chil-
From the College of Nursing, Ajou University, Suwon,
South Korea; Division of Nursing, College of Medicine,
Hallym University, Chuncheon, South Korea;
Department of Nursing, College of Medicine, Pochon
CHA University, Sungnam, South Korea.
Corresponding author: Myung-Sun Hyun, RN, PhD,
College of Nursing, Ajou University, San 5, Wonchon-
dong Yeongtong-gu, Suwon 443-721, South Korea.
E-mail addresses: mhyun@ajou.ac.kr,
namka@hallym.ac.kr, myungahk@hanmail.net.
Crown Copyright © 2010 Published by Elsevier Inc.
All rights reserved.
0883-9417/1801-0005$34.00/0
doi:10.1016/j.apnu.2009.07.005
dren of alcoholics (COAs) are clearly at a high risk
of maladaptive behavior or adverse health problems
during their lives (Christensen & Bilenberg, 2000;
Tuttle, Campbell-Heider, & David, 2006), such as
depression or low self-esteem due to parental
conflict or deficits in appropriate role models and
social support (Andra et al., 2002; Johnson & Leff,
2006; Rice, Dandreaux, Handley, & Chassin,
2006). Therefore, at-risk children such as COAs
need to be identified and their health risks managed
to prevent adverse outcomes and promote their
mental health (Lee, Kim, Kweon, Chai, & Jeong,
2004; Park et al., 2007).
However, because not all COAs develop adverse
health problem, some studies have focused on
identifying the protective factors rather than the risk
factors (Lieberman, 2000). Subsequently, it has
been noted that the protective factors for COAs,
such as resilience, can moderate the effects of
stressors caused by an alcohol-dependent parent
(Lee & Cranford, 2008).
Resilience is an especially important protective
resource for healthy adjustments of COAs who
usually have experienced chronic family stress such
as divorce, family conflict, parental psychopathol-
ogy, and poverty (Rice et al., 2006). Cognitive–

202 Archives of Psychiatric Nursing, Vol. 24, No. 3 (June), 2010: pp 202–211
CBT FOR HIGH-RISK ADOLESCENTS
Behavioral therapy (CBT) can improve resilience
by challenging one's perception of the circum-
stance (Gillham, Hamilton, Freres, Patton, &
Gallop, 2006) and developing adaptive coping
strategies (Steinhardt & Dolbier, 2008). It has
been reported to be an effective intervention for
depressed adolescents (Rohde, Clarke, Mace,
Jorgensen, & Seeley, 2004) and COAs (Thush
et al., 2007).
Therefore, the purpose of this study was to
develop and examine the effectiveness of a CBT
program aimed at enhancing the resilience of COAs
who are at risk of mental health problems.
LITERATURE REVIEW
COAs in South Korea
Alcoholism is one of the most prevalent mental
health problems and social issues in Korea. The
lifetime prevalence of alcohol use disorders for
Korean adults was 22% (Korean Alcohol Research
Foundation, 2006). In Korean society, alcohol
drinking has been recognized as important in
forming social relationships, and the amount of
alcohol drinking is valued as one's capacity in
active social life (Kim, 2005). Consequently,
people with alcohol drinking problems are less
likely to seek treatment (Choi et al., 2006).
Alcoholism is not only an individual disease but
also a family disease because the family members,
especially the children, face increased risks of a
variety of mental health problems, including
alcohol problems (Yang & Lee, 2005). A range
of genetic, psychosocial, and environmental fac-
tors in the family context can influence the
occurrence of alcohol drinking in adolescence
(Cha, 2004). Lee, An, Kim, and Shin (1999)
reported that 46.9% of hospitalized adult patients
with alcohol dependency noted that one or both of
their parents had alcohol dependency.
The findings in several Korean studies have
shown that COAs have low self-esteem or
negative self-concept by negative role modeling
of their parents (Kim, 2005) and due to the deficit
of their parents' healthy approval (Nho & Huh,
2003). In addition, compared with non-COAs,
COAs experience more emotional problems such
as depression or anxiety because they are exposed
to negative parenting such as demand, criticism,
and mistreatment (Cha, 2004; Kim, Kwon, Ahn, &
Shin, 2004).
203
In Korea, several investigators have emphasized
the importance of protective resources such as
resilience for at-risk populations in designing
interventions based on the result that resilient
COAs are less likely to develop maladaptive
behavior (Choi & Kim, 2001; Nam & Kim,
2003). In a study of Korean adolescents, Lee and
Cranford (2008) reported that resilience moderates
the association between parental problem drinking
and their children's problem behaviors.
In summary, COAs have recently become the
focus of research, and preventive programs have
been established to promote mental health for
COAs in Korea.
Cognitive–Behavioral Therapy
CBT is a treatment approach based on the general
assumption that psychological disorders and mal-
adaptive behaviors are caused by a dysfunctional
thinking pattern and lack of adaptive coping
strategies (O'Connor & Creswell, 2008). It has
been widely applied to adults as well as adolescents
and children with emotional and behavioral pro-
blems and suggested as an effective approach for at-
risk children of parents with alcohol problems or
depressive disorders (Thush et al., 2007).
In cognitive theory, the distorted cognitions or
interpretations of the self, the environment, and
the future lead to the development of depression
(Taylor & Montgomery, 2007). Taylor and
Montgomery (2007) indicated that CBT induces
depressed patients to logically challenge their
distorted thinking patterns and thereby reduce
their depression. The effectiveness of CBT in the
treatment of depression among adolescents has
been demonstrated in several studies (Chen, Lu,
Chang, Chu, & Chou, 2006; Rohde et al., 2004).
CBT can contribute to the improvement of
adolescents' self-concept, which is strongly and
negatively correlated with depression. Empirical
studies showed that CBT can promote self-esteem
through activities such as altering one's distorted
thinking toward oneself (Taylor & Montgomery,
2007) and identifying one's strengths (Schochet
et al., 2001). Evidence has been presented that CBT
can promote self-esteem among depressed patients
(Chen et al., 2006) and adolescents (Hyun, Chung,
& Lee, 2005).
CBT also can help to promote resilience by
changing one's perception of the situation (Stein-
hardt & Dolbier, 2008), which is associated with
204
adaptation to the situation (Gillham et al., 2006).
Several investigators noted that CBT may promote
resilience in adolescents exposed to risk through
activities on developing internal assets that affirm
their strengths (Schochet et al., 2001) and activities
such as role-playing and behavioral homework
assignment (Fergus & Zimmerman, 2005). How-
ever, little evidence has been reported in this area
in Korea.
RESEARCH HYPOTHESIS
Our research hypotheses were as follows:
• The self-concept levels of the participants
who received CBT would increase at post-
treatment, compared with the control group.
• The depression levels of the participants who
received CBT would decrease at posttreat-
ment, compared with the control group.
• The resilience levels of the participants who
received CBT would increase at posttreat-
ment, compared with the control group.
METHODS
Design
The experimental design comprised a random-
ized control group with a pretest and a posttest.
Participants and Procedures
Eligible participants were all first-grade students
(12 or 13 years old) attending one middle school in
a metropolitan city in the Kyounggi area of South
Korea. Among the total 327 students, 317 agreed to
participate, of whom 47% (n = 150) were boys and
53% (n = 167) were girls.
We administered the Children of Alcoholics
Screening Test (CAST) to the 317 participants to
select the at-risk adolescents who were eligible to
participate in the experimental study. Based on the
inclusion criterion for study participation of a
CAST score higher than 6 points, 24.8% of the
boys (n = 36) and 24.5% of the girls (n = 39)
were selected.
Our research team included only male students in
the experimental study for the following reasons. In
terms of feasibility, students in the school are
segregated into same-gender classes. Subsequently,
the school principal and coordinator teacher
advised us to include only either male or female
students in the program due to feasibility issues
HYUN, NAM, AND KIM
such as availability of rooms and coordinator
teacher's arrangement role. Therefore, because
male students are more vulnerable to alcohol
drinking and behavioral problems than female
students (Cha, 2004), we only included the 36
male students in the experimental study.
Among the 36 students, 2 refused to participate,
and the remaining 34 were randomly assigned to
either the experimental (n = 17) or the control (n =
17) group. The experimental group was thereafter
divided into two subgroups of 8 and 9 participants
because group therapy is most effective in groups of
5–10 members (Yalom & Leszcz, 2005). The level
of self-concept, depression, and resilience of the
subjects in each experimental group were assessed
at the first session (pretest) of the 10-week
treatment program.
The intervention sessions, which consisted of
10 weekly sessions, were provided by two
members of our research team who were trained
in the CBT program and had experience in
counseling adolescents and working in a psychi-
atric unit. One of them had a doctoral degree, and
the other was studying in a doctoral course in
nursing science. The posttest was conducted at the
final session. The average attendance was 8.4
sessions per subject (range, 6–10 sessions), and
60% of the participants who attended each session
had completed the homework assignments, 20%
had only partly finished them, and 20% had not
started them. As for the control group, we
performed the pretest and posttest at the same
time as the experimental group and provided a
brief education on mental health for them after
the posttest.
Of the 34 male adolescents who were enrolled in
the study, 6 were excluded from the analyses (2 in
the experimental group and 4 in the control group)
because they had moved to another school or were
absent at the posttest. Hence, the experimental and
control groups were composed of 15 and 13
subjects, respectively, at the posttest (Figure 1).
Ethical Considerations
Because there was no institutional review board
for research in 2005 when this study was
conducted in Korea, we submitted the study
proposal, including the purpose, procedures,
benefits and risks of the study, and the right
of the subjects to refuse to participate and
CBT FOR HIGH-RISK ADOLESCENTS
Fig 1. Flowchart of the trial.
discontinue participation at any time, to the school
teaching committee for approval.
After school committee approval, the principal
sent a letter that described the study and enclosed
the written consent form to all the parents of the
first-grade students. This letter informed the
parents that a questionnaire survey for mental
health was to be performed to the students. The
parents who permitted the study participation
returned the written informed consent to the
school. Then, we obtained written informed
consents from the participants whose parents
had permitted the study before distributing the
CAST questionnaire.
For the experimental study, the coordinator
teacher explained to the parents of the selected
participants the study purpose and procedure by
telephone and then asked whether they permitted
their children to participate in the study. The
205
teacher confirmed that the raw data would be
recorded in an unidentifiable manner to protect
the confidentiality of the participants and that
accessibility to them would be rigorously limited
to the researchers. The teacher also assured that
the participants could withdraw from the study at
any time and that there were no disadvantages to
the parents or the participants for not participating
in the study. However, the coordinator teacher
did not inform the parents of their children's
CAST scores unless they asked for it because the
teacher was not sure how this information would
affect the parents' relationship with their children.
None declined their children's participation in the
study. The coordinator teacher received permis-
sion from the parents verbally. When the children
themselves were asked for permission to partic-
ipate in the study, two students declined due to
their after-school activities. Finally, we received
206
written consent from the 34 participants at the
pretest session.
Instruments
CAST was used to select the participants, and
three outcome variables (self-concept, depression,
and resilience) were assessed to examine the effects
of the CBT developed in this study.
Children of Alcoholics Screening Test
CAST was developed as a tool for identifying
children or adolescents living in families with
alcohol-dependent parents by Jones (1983) and
translated into Korean by Kim, Chang, and Kim
(1995). This inventory consists of 30 items, with
“yes” (score = 1) or “no” (score = 0) responses to
each item. A cutoff score of 6 was reported to identify
100% of COAs (Jones, 1983). The internal consis-
tency reliabilities in studies of Korean adolescents in
middle (Lee et al., 2004) and high (Cha, 2004)
schools were reported as .89 and .95, respectively. In
this study, Cronbach's alpha was .86.
Self-concept
To measure the level of self-concept, the Self-
Perception Profile for Children developed by Harter
(1985) and translated into Korean by Lee and Gwak
(1999) was used. This inventory consists of 36 items
containing positive and negative statements of self-
perception. The scale consists of six subscales
(academic competence, social acceptance, athletic
competence, appearance perception, behavior per-
ception, and global self-worth). Higher scores
indicate positive self-concept, with recoding of the
negative statements. Lee and Gwak reported a
Cronbach's alpha for this inventory of .89 in a study
of Korean adolescents. In this study, Cronbach's
alpha was .83.
Depression
The level of depression was measured by
Reynolds Adolescent Depression Scale -II devel-
oped by Reynolds (2002). The Korean version has
been validated with Korean adolescents (Hyun,
Nam, Kang, & Reynolds, 2009). This inventory
consists of 30 items measuring depressive symp-
toms with a 4-point scale. Higher scores indicate a
high depression level. Reynolds noted a cutoff
score of 66, which indicates depressive symptom-
HYUN, NAM, AND KIM
atology. Hyun et al. (2009) reported a reliability of
.90 among Korean adolescents. Cronbach's alpha
in this study was .86.
Resilience
The level of resilience was measured using the
Korean Adolescent Resilience Scale (Lee, 2003).
This scale was developed originally by Kim (2002),
with 32 items to measure the level of resilience of
adolescents with chronic illness, and was revised by
Lee (2003) to 31 items to increase the applicability
of the scale to adolescents with alcohol-dependent
parents. The inventory consists of three domains:
intrapersonal characteristics (positive self-under-
standing), characteristics of coping (self-reliance
and resourcefulness), and interpersonal character-
istics (perceptions of positive interpersonal relation-
ships). This inventory is scored with a 4-point scale.
Higher scores indicate a high level of resilience.
Reported values of Cronbach's alpha were .91
(Kim, 2002) and .93 (Lee, 2003), as compared to
.89 in this study.
The CBT Program
We developed the CBT program based on the
guidelines provided by Friedberg and McClure
(2002) and the modules described by Free (1999).
The CBT program consisted of five parts (the three
topics covered, plus opening and closing parts)
based on the modules developed by Free. The
effectiveness of the developed CBT for adolescents
living in shelters has been reported previously by
Hyun et al. (2005).
The program consisted of sessions that integrated
cognitive (increasing self-consciousness and iden-
tifying dysfunctional coping) and behavioral com-
ponents (developing healthy coping strategies;
Table 1). Free (1999) recommended 6 or 12 CBT
sessions, whereas Scott (2001) suggested 8.
Considering these recommendations and the feasi-
bility of collecting our study participants during the
program, we structured the program with 10
sessions, including the pretest in the first session
and the posttest in the last session. Each 50-minute
session in a quiet classroom was divided into the
following five or six major activities based on the
session structure suggested by Friedberg and
McClure (2002): warm up, presenting homework
(if applicable), explanation of the objectives of the
current session (by the group leader), filling out the
CBT FOR HIGH-RISK ADOLESCENTS 207

Table 1. The CBT Program for At-risk Adolescents
Part Session content
Opening Session 1: general orientation
Raising Session 2: reviewing and reflecting
self-consciousness on oneself
Session 3: reviewing family
and environment
Identifying Session 4: education on
dysfunctional coping dysfunctional thinking–
emotion–behavior cycle
Session 5: identifying distorted
thinking patterns
Session 6: identifying distorted
thinking–emotion–behavior cycle
Developing healthy Session 7: developing alternative
coping strategies thinking
Session 8: practicing stress
management
Session 9: identifying one's
strengths and potential
Closing Session 10: writing a letter
to a significant other
material specifically prepared for each session,
presenting and sharing experiences and information
with one another, and a summary.
Part I of the program consisted of a one-session
general orientation to the program and introduction
to the other participants. The topic of Part II was
increasing self-consciousness by identifying the
good and bad elements in their character and
describing the effects of family and environmental
factors on their lives. The topic of Part III was
identifying dysfunctional coping. Participants were
guided to understand how thought distortion was
associated with negative emotional states that
consequently led to maladaptive behaviors. They
were then directed to identify their own distorted
thinking patterns and recognize the negative
emotional states associated with those thinking
patterns through homework. The homework in-
cluded recording unpleasant events experienced
during the previous week and their thoughts
resulting from them. The topic of Part IV was
developing healthy coping strategies. Sessions
focused on the development of alternative healthy
thinking patterns. They practiced stress manage-
ment, including pleasant activities and relaxation
techniques. The participants were guided to identify
their own strengths and potentials through home-
work and then shared them with others by recalling
the most satisfying and successful experiences of
their lives. They also were encouraged to make
plans for the future and present their vision of future
life. In the last session, the participants wrote letters
to significant others and took the posttest.

Table 2. Comparison of Participants' Characteristic Between the Experimental and Control Groups
Characteristic Category Experimental group (n = 17) Control group (n = 17) χ2 (P)/U (P)

Age, M (SD) 12.60 (0.51) 12.47 (0.52) 97.0 (.472)

Religion Christianity 7 (46.7) 5 (33.3) 3.242 (.198)
Buddhism 4 (26.7) 2 (13.3)
None 3 (20.0) 8 (53.3)
Living with parents Both 12 (85.7) 13 (86.6) 1.340 (.512)
Only mother 0 (0.0) 1 (6.7)
Only father 2 (14.3) 1 (6.7)
Relationship with parents Poor 0 (0.0) 1 (7.7) 1.198 (.753)
Moderate 4 (28.6) 4 (30.8)
Good 4 (28.6) 3 (23.1)
Very good 6 (42.8) 5 (38.4)
Relationship with siblings Poor 0 (0.0) 3 (21.4) 3.635 (.304)
Moderate 4 (30.8) 2 (14.3)
Good 5 (38.4) 5 (35.7)
Very good 4 (30.8) 4 (28.6)
Familial economic High 3 (21.4) 2 (13.3) 0.333 (.564)
Status⁎ Moderate 11 (78.6) 13 (86.7)
Troubles experienced Relationship with friends 0 (0.0) 3 (21.5) 5.048 (.168)
Dates 1 (7.1) 1 (7.1)
Relationship with parents 2 (14.3) 0 (0.0)
School grades 11 (78.6) 10 (71.4)
NOTE. The values represent number (percentage) unless otherwise indicated.
⁎ Fisher's exact test.
208 HYUN, NAM, AND KIM

Table 3. Homogeneity of Outcome Variables at the Pretest Between the Two Groups
Variable Experimental group (n = 17) Control group (n = 17) U P

Self-concept M (SD) 93.73 (10.23) 88.85 (16.09) 71.50 .230

Mean rank 16.23 12.50
Sum of ranks 243.50 162.50
Depression M (SD) 49.86 (8.78) 54.40 (14.78) 89.50 .712
Mean rank 13.97 15.12
Sum of ranks 209.50 196.50
Resilience M (SD) 91.60 (10.50) 99.07 (12.95) 66.0 .088
Mean rank 12.40 17.79
Sum of ranks 186.00 249.00

Data Analysis ship with parents and siblings, familial economic

The nonparametric test was used because the
study sample was too small to assume normally
distributed study variables. The homogeneity of
demographics and outcome variables at the pretest
was analyzed between the experimental and control
groups using chi-square test, Fisher's exact prob-
ability test, and the Mann-Whitney U test. We used
the Wilcoxon's signed rank test to analyze changes
in outcome variables between pretest and posttest
within each group.
RESULTS
Comparison of Participants' Characteristics
Between the Experimental and Control
Groups
There were no significant differences between
the two groups in the participants' characteristics in
terms of age, religion, living with parents, relation-
status, and troubles experienced (Table 2).
Homogeneity Between the Two Groups in
Outcome Variables
There were no significant differences between
the two groups in self-concept, depression, and
resilience at the pretest (Table 3).
Effects of the CBT Program
There were no significant changes in self-
concept (z = −1.736, P = .083) and depression
(z = −0.085, P = .932) in the experimental group
after the intervention. However, the resilience in the
experimental group significantly increased after the
intervention (z = −2.420, P = .016). Although the
level of total self-concept did not change signifi-
cantly after the intervention in the experimental
group, one of the subscales of self-concept, the
level of self-worth, was significantly increased at

Table 4. Comparison of Outcome Variables Between Pre- and Posttests in the Two Groups
Variable Experimental group (n = 15) Control group (n = 13)

Self-concept Pretest, M (SD) 93.73 (10.23) 88.85 (16.09)

Posttest, M (SD) 96.53 (11.11) 87.46 (17.20)
Sum of ranks (negative) 29.50 40.50
Sum of ranks (positive) 90.50 37.50
z (P) −1.736 (.083) −0.118 (.906)
Global Pretest, M (SD) 15.73 (2.89) 15.93 (4.36)
Self-worth Posttest, M (SD) 17.47 (2.92) 16.00 (5.52)
z (P) −2.187 (.029) −0.433 (.665)
Depression Pretest, M (SD) 49.86 (8.78) 54.40 (14.78)
Posttest, M (SD) 49.13 (8.39) 56.07 (16.58)
Sum of ranks (negative) 58.50 35.50
Sum of ranks (positive) 61.50 55.50
z (P) −0.085 (.932) −0.700 (.484)
Resilience Pretest, M (SD) 91.60 (10.50) 99.07 (12.95)
Posttest, M (SD) 98.00 (10.00) 96.92 (13.69)
Sum of ranks (negative) 14.00 46.50
Sum of ranks (positive) 91.00 44.50
z (P) −2.420 (.016) −0.070 (.944)
CBT FOR HIGH-RISK ADOLESCENTS
the posttest (z = −2.187, P = .029). However, in the
control group, there were no significant changes in
self-concept (z = −0.118, P = .906), depression (z =
−0.700, P = .484), or resilience (z = −0.070, P =
.944) between pretest and posttest (Table 4).
DISCUSSION
This study investigated the effectiveness of CBT for
at-risk adolescents. We hypothesized that in the CBT
group, the self-concept and resilience level would
increase and the depression level would decrease at
the posttest, as compared with the control group.
The study findings partly supported our hypoth-
eses, in that there was a significant increase in
resilience after the intervention in the experimental
group, as compared with the control group.
However, there were no significant changes in
self-concept or depression at the posttest. In the
control group, none of the outcome variables
changed significantly at the posttest.
Resilience has been suggested to be one of the
protective resources that facilitate successful coping
under conditions of adversity (Fergus & Zimmer-
man, 2005) and moderate the influence of negative
parental behaviors on children (Tuttle et al., 2006).
Hence, this study's finding that CBT may promote
the resilience of Korean COAs is encouraging. This
finding is consistent with a study of adolescents by
Steinhardt and Dolbier (2008). The component of
CBT that increased self-consciousness and identi-
fied good elements in their character would have
contributed to the improvement in resilience
exhibited by the participants in the experimental
group. The efforts to change distorted thinking
toward oneself and develop coping strategies
in CBT also would have promoted resilience in
this population.
Although the change in total scores of self-
concept was not significant after intervention, the
study results are also encouraging because there
was a significant improvement in self-worth, which
is one of the subscales of self-concept. These
findings partly agree with those reported by Hyun et
al. (2005) for male adolescents. Explicitly identi-
fying one's strengths and potential by oneself and
with others in CBT would have contributed to the
increased self-worth among the participants. The
participants received positive regard and feedback
from others (including the program provider) when
they presented their homework or their experiences,
which also may have increased their positive self-
209
worth. However, the scope of the CBT in the study
was apparently insufficient to change the level of
total self-concept. Given that self-concept generally
tends to increase gradually for children over time
(Taylor & Montgomery, 2007), future research
needs to investigate the dynamic processes under-
lying improvement of self-concept in adolescents.
CBT was expected to decrease depression, but
the study participants exhibited no significant
change. This finding is consistent with a study of
adolescent boys with mild depression by O'Kear-
ney, Gibson, Christensen, and Griffiths (2006). The
level of depression among the study participants (M
= 52.13) was within the normal range (Reynolds,
2002). O'Kearney et al. noted that the individuals
with severe depression were more responsive to
CBT than others with mild depression. Therefore,
we cautiously suggest that the low level of
depression among the participants was responsible
for the lack of CBT-induced effects. In addition, the
amount of treatment may have been a cause of this
finding. Various investigators have suggested
different numbers of CBT sessions (Free, 1999;
Scott, 2001), and Chen et al. (2006) suggested that
CBT requires 2 hours of treatment per week for 8–
15 weeks to be effective. Our intervention only
totaled 10 hours and may therefore have been
insufficient for the effective decrement of depres-
sion among the participants. Future studies with
longer CBT intervention are needed for effective
treatment of adolescents.
Although this study has enlarged the applicabil-
ity of school-based CBT for high-risk adolescents,
we present the limitations of this study and propose
several recommendations for future studies. First,
treatment diffusion may have been a possible
confounding factor because the subjects in the
experimental and control groups were selected at
the same site. Second, because of the small sample
size, the results may be descriptive rather than
predictive and must be interpreted carefully. A
replication study with a larger group of at-risk
adolescents needs to be conducted to confirm the
effectiveness of the CBT developed in this study.
Third, the inclusion of only male adolescents in this
study limited the generalizability of the findings.
Hence, future research needs to include female
adolescents and explore the gender difference in the
effectiveness of CBT among high-risk teens.
Finally, we did not control for potential mediators
such as family violence, family conflict, family
210
background, friend support, and life events. There-
fore, future research should attempt to detect the
potential mediating effects of these factors on
treatment outcome with a large sample from a
more diverse population.
CONCLUSION
The study findings suggest that the developed
CBT program can improve the resilience of
adolescents with alcohol-dependent parents. The
ongoing development and evaluation of interven-
tion programs for this at-risk population remain
important challenges for nurses. School nurses are
in an ideal position to provide integrated health care
services for promoting the mental health of at-risk
adolescents. As the CBT program presented here
provides structured and specific content in each
session, it might be useful to replicate the program
in other schools with larger study populations and
in other settings. Furthermore, the effectiveness of
this CBT program needs to be further validated by
replication studies with well-designed, random
controlled trials.
ACKNOWLEDGMENT
This work was supported by the Korea Research
Foundation Grant funded by the Korean Govern-
ment (MOEHD)(KRF-2004-204-E00076).
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