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The Unified Protocol for Transdiagnostic Treatment of Emotional

Disorders in Adolescents (UP-A) Adapted as a School-Based
Anxiety and Depression Prevention Program: An Initial Cluster
Randomized Wait-List-Controlled Trial
Julia García-Escalera
Rosa M. Valiente
Bonifacio Sandín
Universidad Nacional de Educación a Distancia
Jill Ehrenreich-May
University of Miami
Antonio Prieto
Paloma Chorot
Universidad Nacional de Educación a Distancia

the development of both anxiety and depression using a single

Anxiety and depression are common debilitating conditions
that show high comorbidity rates in adolescence. The Unified
Protocol for Transdiagnostic Treatment of Emotional Disor-
ders in Adolescents (UP-A; Ehrenreich-May et al., 2018) is one
of the few existing resources aimed at applying transdiagnostic
treatment principles across the core dysfunctions implicated in
The authors would like to thank the secondary school that
participated in the study (IES Jaime Vera, Madrid, Spain), its
teachers, students, the school principal (Dimas Rodríguez), and the
school counselor (María Teresa Andreu). The authors would also
like to thank Victoria Espinosa, who helped provide the program.
This work was supported by the Spanish Ministry of Economy,
Industry and Competitiveness grant (PSI2013-4480-P) awarded to
RMV, BS, and PC, and by the Spanish Ministry of Education,
Culture and Sport grants (FPU13/03315) awarded to JGE and
(FPU13/05914) to AP. The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the
manuscript.
The study was granted ethical approval from the Research Ethics
Committee of Universidad Nacional de Educación a Distancia,
Madrid, Spain. The study was registered at Clinicaltrials.gov
(NCT03123991).
Address correspondence to Rosa M. Valiente, Ph.D., Facultad de
Psicología, Universidad Nacional de Educación a Distancia, Juan
del Rosal, 10, Madrid, Spain; e-mail: rmvalien@psi.uned.es.
0005-7894/© 2019 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
protocol. This is the first known controlled study to examine
the efficacy of the UP-A adapted as a nine-session universal
preventive intervention program delivered in a school setting. A
total of 151 students (mean age: 15.05) participated in this
randomized wait-list-controlled trial conducted in Madrid,
Spain. An unexpected decline in anxiety and depression levels
from pre- to posttreatment and follow-up was found in both
groups (p = .009, d = –0.22), and overall differences between
conditions did not reach significance. Exploratory analyses of
baseline emotional symptom severity as a potential predictor
trended toward a significantly greater decrease in symptoms of
depression for those with greater baseline emotional symptoms
in the UP-A group compared to the wait-list-control group.
Future trials with larger samples are justified to estimate the
effect of the UP-A adapted as a selective prevention program for
anxiety and depression.
Keywords: universal prevention; Unified Protocol for Transdiagnostic
Treatment of Emotional Disorders; adolescents; anxiety; depression
DEPRESSION AND ANXIETY DISORDERS are highly
prevalent conditions in children and adolescents
(Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015)

Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
2 g a r c ı́ a - e s c a l e r a e t a l .
and are associated with increased risk of subse-
quent mental health problems in adulthood, edu-
cational underachievement, and difficulties in
relationships with peers (Ahlen, Lenhard, &
Ghaderi, 2015). Despite this chronic and concern-
ing level of impairment, only a small percentage of
youth with anxiety or depressive disorders ever
receives mental health services (Essau, 2005).
One possible way to address this problem is by
means of early preventive actions. Preventive
programs—that is, programs designed to reduce
the onset of disorders by reducing risk factors and
promoting protective processes—are commonly
classified into three categories: universal, selective,
and indicated interventions (Mrazek & Haggerty,
1994). Universal preventive interventions are those
applied to all individuals within an identified
population regardless of risk. Even though indicat-
ed and selective programs tend to yield larger effect
sizes than universal programs (Sanchez et al., 2018;
Werner-Seidler, Perry, Calear, Newby, & Chris-
tensen, 2017), several meta-analyses have pointed
out a number of advantages associated with
universal prevention programs, including the fol-
lowing: relatively low dropout rates, avoiding the
stigma of singling out individuals for intervention,
removal of the need for screening as well as
avoiding current limitations as to how to screen,
and enabling a greater reach to children or
adolescents who have limited access to treatment
services or who may not have been identified as
needing services (Ahlen et al., 2015; Horowitz &
Garber, 2006; Werner-Seidler et al., 2017). Addi-
tionally, universal prevention programs developed
for children and adolescents to help them cope with
anxiety and depression symptoms can teach rele-
vant strategies to all individuals, not only the ones
currently experiencing symptoms or who are at risk
(Ehrenreich-May & Bilek, 2011).
Employing the school system as the context for
implementation of prevention programs is a natural
way to provide young people with many of the
skills and strategies that may protect against the
onset of emotional problems (Ehrenreich-May &
Bilek, 2011). Some recent meta-analyses have
examined the efficacy of school-based prevention
programs on anxiety and depression for children
and adolescents (Ahlen et al., 2015; Werner-Seidler
et al., 2017), or for children only (Sanchez et al.,
2018), based either on randomized controlled trials
(RCTs) or cluster RCTs. The review of Werner-
Seidler et al. (2017) reported data of 81 studies
evaluating targeted or universal prevention pro-
grams. The authors concluded by stating that
school-based prevention programs have a small
beneficial effect (g ≤ 0.23) on depressive and
Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
anxiety symptoms when compared to a control
condition. The positive effect was stronger at
posttreatment than at follow-up, although the
reduced effect over time could be influenced by a
loss of statistical power due to smaller samples
being retained over protracted periods. Modest
effects of universal school-based prevention pro-
grams have also been reported in other recent meta-
analyses (Ahlen et al., 2015; Sanchez et al., 2018).
Anxiety and depression are frequently comorbid in
children and adolescents (Axelson & Birmaher, 2001)
and share vulnerability and maintenance factors, such
as negative affect, trouble tolerating unpleasant
emotions, and maladaptive emotion regulation strat-
egies (Ehrenreich-May et al., 2018). Despite this,
school-based universal prevention studies have mostly
applied cognitive-behavioral intervention protocols
aimed to target primarily anxiety or depression. For
example, in the meta-analysis of Werner-Seidler et al.
(2017), only 17 out of the 81 included studies targeted
both anxiety and depression. Similarly, in the meta-
analysis of Ahlen et al. (2015), only 7 studies out of 30
targeted both disorders.
However, a transdiagnostic approach may yield
larger and more long-lasting benefits regarding a
wider range of disorders and symptoms than
disorder-specific preventive interventions, since
transdiagnostic interventions target underlying vul-
nerability and maintenance factors across a group of
commonly comorbid disorders, such as anxiety and
depression disorders, instead of focusing on risk
factors specific to only one condition (Bentley et al.,
2017). Additionally, applying transdiagnostic pre-
ventive interventions would be more cost-effective
since it would not be needed to deliver as many
consecutive preventive interventions (Bentley et al.,
2017). This would especially be of interest for
schools, which usually lack enough human, finan-
cial, and time resources to work on mental health
promotion and prevention (Cefai & Cavioni, 2015).
Despite the potential benefits of transdiagnostic
preventive interventions there are only two trans-
diagnostic theory-driven cognitive-behavioral ther-
apy (CBT) protocols to prevent anxiety and
depression, and both were developed and prelim-
inarily evaluated for young children: (a) EMO-
TION: “Coping Kids” Managing Anxiety and
Depression (Kendall, Stark, Martinsen, O’Neil, &
Arora, 2013) and (b) Super Skills for Life (Essau &
Ollendick, 2013). Thus, there is a critical need for
the development, evaluation, and dissemination of
transdiagnostic CBT universal preventive interven-
tions for anxiety and depression in adolescents.
The Unified Protocols for Transdiagnostic Treat-
ment of Emotional Disorders in Children and
Adolescents (UP-C and UP-A, respectively;
 the up-a adapted as a prevention program
Ehrenreich-May et al., 2018) are a downward
extension of the Unified Protocol for Transdiag-
nostic Treatment of Emotional Disorders (UP;
Barlow et al., 2018), modified for children and
adolescents, and are based, as is the UP, on a
transdiagnostic theoretical model. The UP-A targets
adolescents ages 12–17 presenting with any prima-
ry emotional disorder, which encompasses an array
of anxiety, depressive, obsessive-compulsive, and
stress-related disorders and problem areas. One
might conceptualize the UP-A techniques as com-
prising the efficacious elements of CBTs (e.g.,
emotion education, cognitive reappraisal, behav-
ioral activation, exposure, and relapse prevention),
along with motivational enhancement and aware-
ness, and mindfulness techniques for emotional
disorders in youth.
As we have previously discussed (García-Escalera et
al., 2019), we believe the UP-A may be particularly
well suited for adaptation as a universal preventive
program for various reasons, apart from the advan-
tages discussed above in relation to transdiagnostic
preventive interventions: (a) the UP-A is a manualized
treatment protocol that has provided support in
mitigating symptoms of both anxiety and depression
(Ehrenreich-May et al., 2017; García-Escalera,
Chorot, Valiente, Reales, & Sandín, 2016; Queen,
Barlow, & Ehrenreich-May, 2014); (b) its emphasis
on addressing emotion regulation may be especially
well suited to effectively prevent the onset of and to
reduce the symptoms of a wide range of psychological
disorders since deficits in emotion regulation in youth
have been found to play a role in the development and
maintenance of numerous psychological disorders,
including anxiety, depression, substance use, and
eating disorders (Sloan et al., 2017); (c) it has a
flexible nature—that is, the clinician is advised to vary
the length of any given module based on the needs of
each particular patient—this flexibility along with a
reduced number of core modules (eight) makes this
treatment protocol a good candidate to potentially be
easily adapted as a universal preventive intervention;
and (d) there is preliminary evidence of the feasibility
of delivering the UP-A as a preventive intervention
since the UP-C was initially developed and evaluated
as a universal anxiety and depression prevention
program applied in a summer camp setting
(Ehrenreich-May & Bilek, 2011).
Due to the lack of school-based transdiagnostic
universal programs for the prevention of anxiety
and/or depression in adolescents, our group recent-
ly adapted the UP-A as a school-based prevention
program (García-Escalera et al., 2017) and report-
ed the results associated with an uncontrolled trial
(García-Escalera et al., 2019). In line with previous
research, the results of this study showed that
Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
3
participation in the program was associated with
modest reductions in anxiety (d ≥ –0.41) and no
significant results were observed for depressive
symptoms. However, the uncontrolled nature of
the study, its small sample size, and the lack of a
follow-up period made it difficult to draw firm
conclusions on the efficacy of the UP-A adapted as a
universal school-based prevention protocol.
The first aim of the present study was to examine
whether the adapted UP-A was more effective than
a wait-list-control group (WLCG) in reducing the
symptoms of anxiety and depression at posttreat-
ment and 3-month follow-up. According to the
literature, we expected slight beneficial effects of the
program on depressive and anxiety symptoms at
postintervention and follow-up. The second aim
was to conduct exploratory analyses of baseline
emotional symptom severity as a potential predic-
tor. Based on reports that have suggested stronger
effects of targeted prevention compared to universal
prevention (Sanchez et al., 2018; Werner-Seidler et
al., 2017) and on studies that showed significant
reductions in anxiety and depression symptoms
only for the most symptomatic participants (Ahlen,
Hursti, Tanner, Tokay, & Ghaderi, 2018; Gillham
et al., 2012), we expected greater reductions in
anxiety and depression in the most symptomatic
participants of the UP-A group compared to the
WLCG. The third and last aim of the study was to
assess the feasibility and acceptability of imple-
menting UP-A in a preventive group format and in a
school setting in Spain.
Method
PARTICIPANTS
The sample consisted of 151 adolescents, 90 in the
UP-A group and 61 in the WLCG, from three ninth-
grade classes (3° ESO in the Spanish educational
system) and two tenth-grade classes (4° ESO) from
an urban secondary school in the city of Madrid,
Spain. Table 1 presents the sociodemographic
characteristics broken down per condition. The
mean age of the total sample was 15.05 (SD = 1.14),
and the sample comprised 82 girls (54.3%) and 69
boys (45.7%). The inclusion criteria for the
participants were (a) both the adolescent and at
least one parent or legal guardian provided written,
informed consent, and (b) having Spanish profi-
ciency based on teacher reporting. No incentives
were provided for participating in this project either
to the adolescents or the school.
PROCEDURE
Fig. 1 shows a flowchart of the participants through
each stage of this two-arm cluster RCT with an
4 g a r c ı́ a - e s c a l e r a e t a l .

Table 1
Demographic Information for Each Condition at Time 1
Variable UP-A WLCG χ2 p Total
(n = 88) (n = 59) (n = 147)
n (%) n (%) n (%)
Gender a 0.043 .835
Female 50 (55.6%) 32 (52.5%) 82 (54.3%)
Male 40 (44.4%) 29 (47.5%) 69 (45.7%)
Grade 2.548 .110
9 (3°ESO) 59 (67.0%) 31 (52.5%) 90 (61.2%)
10 (4°ESO) 29 (33.0%) 28 (47.5%) 57 (38.8%)
Child’s length of residence in Spain 2.284 .516
Born in Spain 34 (38.6%) 23 (39.0%) 57 (38.8%)
A year or less 19 (21.6%) 10 (16.9%) 29 (19.7%)
2 – 5 years 17 (19.3%) 17 (28.8%) 34 (23.1%)
More than 5 years 18 (20.5%) 9 (15.3%) 27 (18.4%)
Family affluence b 0.767 .682
Low 25 (28.7%) 21 (35.6%) 46 (31.5%)
Medium 39 (44.8%) 24 (40.7%) 63 (43.2%)
High 23 (26.4%) 14 (23.7%) 37 (25.3%)
Note. UP-A = UP-A group; WLCG = Waitlist control group. Family affluence assessed by the Family Affluence Scale.
a
n = 151.
b
n = 146

intervention condition and a WLCG. The trial
included three measurement points along the
2016–2017 school year: Time 1 (T1; November
2016; 1 week before the UP-A group started the
intervention), Time 2 (T2; January 2017; 1 week
after the UP-A group finished the intervention), and
Time 3 (T3; April 2017; 3 months after the UP-A
group finished the intervention and 1 week before
the WLCG started the intervention). Times 1, 2,
and 3 assessments and intervention sessions were
conducted at the school during school hours. The
WLCG received the intervention after the T3
assessment was completed (results of the program
for these participants can be found in García-
Escalera et al., 2019).
Each participating class (cluster) was randomly
allocated 1:1 to the preventive intervention or the
WLCG by a researcher not involved in the current
project, using a computerized random number
generator and a balanced design, resulting in
approximately the same number of classes in each
of the preventive intervention groups and the WLCG
(Fig. 1). Random assignment occurred before the T1
measurements took place because the research ethics
committee requested that the parents/guardians and
the participants knew whether the student was going
to be in the UP-A group or the WLCG when they
provided informed consent.
INTERVENTION
The school-based intervention was the Spanish
version of the UP-A modified for delivery as a
weekly 55-minute, nine-session universal preven-
tive intervention. Each session targeted one of the
eight UP-A core modules except for Module 5
(addressing cognitive distortions and problem-
solving skills), which was targeted in Sessions 5
and 6. The first adaptation to the original treatment
protocol was to reduce the number of sessions per
module, especially in regard to Module 2 that
targets psychoeducation about emotions (two or
three suggested sessions), and Module 7 that targets
situational emotion exposures (more than two
suggested sessions; Ehrenreich-May et al., 2018).
The module “Parenting the Emotional Adolescent”
was not implemented in this preventive adaptation
of the UP-A.
Furthermore, some handouts of the UP-A were
adapted from the original treatment model for use
in a universal prevention setting. For instance, the
Weekly Activity Planner handout (Module 3) was
adapted to plan and report not only enjoyable
activities and emotional levels, but also school-
work. Additionally, some cultural adaptations were
made for application of the UP-A in the Spanish
cultural context. For example, some of the activities
in the “List of Commonly Enjoyed Activities” that
are not common in a Spanish context (e.g., playing
lacrosse or yard work) were exchanged for others
that are common in a Spanish context (e.g., going to
the gym or going for a walk). Finally, in this
preventive adaptation of the UP-A, each session
began with a short quiz regarding core concepts
learned in the previous session.

Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
 the up-a adapted as a prevention program 5

Assessed for eligibility (N = 5, n = 157)

Excluded:

• Did not speak fluent Spanish

(N = 0, n = 5)

Randomized (N = 5, n = 152)

Allocated to UP-A group Allocated to control group

(N = 3, n = 90) (N = 2, n = 62)
Allocation

Received allocated intervention Received allocated intervention

(N = 3, n = 90) (N = 2, n = 61)

Did not receive allocated Did not receive allocated

intervention (N = 0, n = 0) intervention (N = 0, n = 1)

Lost to follow up Lost to follow up

Follow up

T1 (N = 0, n = 2); T2 (N = 0, n = 10); T1 (N = 0, n = 1); T2 (N = 0, n = 4);

T3 (N = 0, n = 17) T3 (N = 0, n = 13)

Complete case analysis Participants Complete case analysis Participants

Analysis

with data for: T1 and T2 (N = 3, with data for: T1 and T2 (N = 2,

n = 78); T1, T2 and T3 (N = 3, n = 67) n = 56); T1, T2 and T3 (N = 2, n = 46)

FIG. 1 CONSORT Flow Diagram. N = cluster (classrooms); n = students; T1 = Time 1; T2 = Time 2; T3 = Time 3

The intervention was administered by JGE and a
master’s student in clinical psychology and was
supervised by RMV, BS, and PC. The intervention
sessions were implemented during “Tutorías,”
which are 1-hour weekly sessions intended to
address issues taking place within the school
context (e.g., providing academic support).
Teachers in the WLCG were instructed to maintain
their normal class schedules without any planned
socioemotional focus.
A detailed description of the content of each UP-A
session has been comprehensively described elsewhere
(García-Escalera et al., 2017, 2019)—therefore, they
are only briefly outlined here. In the first session, the

Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
6 g a r c ı́ a - e s c a l e r a e t a l .
adolescents were introduced to the group rules and
provided their three top problems and a goal for each.
In the second session, the adolescents were taught
emotional education, and the “before, during, and
after” framework (a functional assessment of emo-
tional experiences) was introduced. In the third
session, the adolescents learned about the cycle of
avoidance and, after reflecting on their current use of
free time, compiled a list of enjoyed activities with
which to engage in opposite actions for sadness. In the
fourth session, the adolescents learned about physical
sensations associated with emotions and conducted
interoceptive exposures in class to demonstrate that
physiological sensations are normal and harmless. In
the fifth session, the concept of cognitive reappraisal
was introduced, and the adolescents learned how to
address thinking traps using detective thinking skills.
In the sixth session, the adolescents learned how to
overcome problems using problem-solving skills and
reviewed skills learned thus far in the program. In the
seventh session, they practiced present-moment
awareness skills using nonemotional stimuli. In the
eighth session, the cycle of avoidance was reviewed,
the adolescents were provided with psychoeducation
about emotional exposures, and exposure homework
was assigned. Finally, in the ninth session, the
adolescents reviewed the strategies learned in the
program and created an individualized postprogram
plan to practice skills.
The participants were encouraged to practice the
skills learned in the sessions by completing the
structured home-learning assignments that were
discussed at the beginning of each session (with the
exception of the first). Session materials included
PowerPoint slides and handouts.
MEASURES
Primary Outcome Measures
Revised Child Anxiety and Depression Scale–30
(RCADS-30). The RCADS-30 (Sandín, Chorot,
Valiente, & Chorpita, 2010) is a self-report
questionnaire widely used to measure anxiety and
depressive symptoms in children and adolescents.
The scale comprises six subscales derived from the
fourth and fifth editions of Diagnostic and Statis-
tical Manual of Mental Disorders (DSM-IV and
DSM-5, respectively) criteria. In the current sample,
the six individual subscales demonstrated adequate-
to-good internal consistency at all assessments (α
range = .66–.86) and on the total anxiety and
depression scale (α range = .92–.93).
Depression Questionnaire for Children (Cuestionario
de Depresión para Niños; CDN). The CDN (Sandín,
Chorot, & Valiente, 2016) is a self-reported ques-
Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
tionnaire that assesses the symptoms described in the
DSM-IV/DSM-5 for major depressive disorder and
dysthymic disorder in children and adolescents. The
CDN comprises 16 items, although in this study the
two items targeting suicidal ideation were not
included at the request of school personnel. The
CDN demonstrated good internal consistency at all
assessment points (α range = .87–.89).
Anxiety Scale for Children (Escala de Ansiedad
para Niños; EAN). The EAN (Sandín et al., 2016)
is a 10-item questionnaire that assesses anxiety
symptoms in children and adolescents during the
prior few weeks. In the current sample, the EAN
scale demonstrated excellent internal consistency at
all assessments (α range = .91–.94).
Measures Completed at Postintervention Only
Satisfaction With the Program Questionnaire.
Program satisfaction was assessed using a question-
naire containing 10 items. A 10-point scale from 1
(least or none) to 10 (a lot) was employed for six
questions, whereas a 2-point scale, with 1 (yes) and 2
(no), was used for another three questions. Last, the
adolescents were asked an open question (“What did
you like best and worst about the program?”). Six of
the 10 questions were extracted from Rapee et al.’s
(2006) Satisfaction Questionnaire (see Table 3) and,
in the current sample, had only fair internal
consistency at T2 (α = .59).
Discipline Problems During Sessions Question-
naire. Due to the large size of the groups, the
students themselves (and not the group leaders)
answered six questions about how often they
demonstrated certain behaviors during the sessions
using a 4-point Likert-type scale with scores
ranging from 1 to 4. Specific items are shown in
Table 4 (e.g., “I have talked to my classmates when
I should not have”). In the current sample, this
questionnaire demonstrated only fair internal
consistency at the T2 assessment (α = .68).
Measures Completed at Postintervention and
Follow-Up
Curriculum Knowledge Questionnaire. This
questionnaire consisted of two open-ended ques-
tions and one multiple-choice question with three
possible answers (see the “Results” section for
specific items). It was created to assess the
participants’ knowledge of the core information
presented in the program.
Strategies Practiced Outside of the Session Ques-
tionnaire. We adapted the questionnaire used in a
previous study (Johnson, Burke, Brinkman, &
Wade, 2016). The students were asked at
 the up-a adapted as a prevention program
posttreatment and follow-up how much they
practiced each of eight techniques rated on a 5-
point Likert-type scale from 1 (never) to 5 (three
times or more each week). The specific questions
can be found elsewhere (García-Escalera et al.,
2017), but a shorter version of them is shown in
Table 5. In the current sample, this questionnaire
demonstrated adequate-to-good internal consisten-
cy at T2 (α = .82) and T3 (α = .85).
STATISTICAL ANALYSES
The data were analyzed using the linear mixed-
models (LMMs; MIXED) procedure implemented
in SPSS 24.0 with full-information maximum
likelihood estimation. This procedure allows for
the management of complex sample procedures in
which units of observations are nested in a
hierarchy and allows for the regulation of missing
data without eliminating individuals or inputting
scores (Campbell & Walters, 2014).
To test whether the program was effective in
reducing primary outcome measures, a three-level
random intercept hierarchical model (measurement
time within individual within class) was fitted to
account for within-subject and within-class corre-
lations. Separate LMMs (per test pre-alpha level =
.05) were run on each outcome to maximize the
likelihood of convergence. The randomized sample
size in this study was large enough to detect a
Cohen’s d effect of 0.30 with 80% power at the 5%
level of significance, allowing for an intracluster
correlation coefficient of 0.02 and a 10% partici-
pant dropout rate at follow-up. Effect sizes were
calculated employing the following formula
pffiffiffiffiffiffiffiffi
(Hedges, 2007): d = B/(SE n−1Þ.
Additionally, an exploratory analysis was under-
taken to explore differential effects of the program
as a function of the baseline level of anxiety and
depression symptoms. First, RCADS total score at
T1 was taken as a continuous predictor (entered as
a covariable in the LMMs) and separate analyses
were run to assess the effects of the program both at
T2 and T3. In addition, given that T scores above
65 are traditionally considered borderline clinical
or clinical in the literature (Maruish, 2018), we
transformed the raw RCADS total scores at T1 into
T scores to define two groups of participants: one
with elevated baseline anxiety and depression
symptoms (n = 16; 9 in the UP-A group) and
another one with nonelevated baseline anxiety and
depression symptoms (n = 132).
A triple interaction term was then added to the
above estimated regression models: Group (UP-A,
WLCG) × Time (T1, T2, T3) × Predictor (elevated or
nonelevated RCADS total score at T1). Separate
LMMs were run on each dependent variable (total
Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
7
scores of RCADS, CDN, and EAN) including a total
sample of 148—that is, all the adolescents who
completed the questionnaires at T1 and could be
classified as presenting nonelevated or elevated
emotional symptoms at baseline. Post hoc
Bonferroni-adjusted pairwise comparisons were run
when significant (alpha level b .05) or marginally
significant (alpha level b .10) three-way interactions
took place, and Cohen’s d (mean difference between
groups or conditions/standard deviation) was calcu-
lated for significant post hoc comparisons.
Results
BASELINE EQUIVALENCE
The baseline sociodemographic characteristics of the
students who completed the T1 assessment are
presented in Table 1. The chi-squared test for
categorical variables revealed no significant differ-
ences between the groups at T1 in terms of the
demographic variables. LMMs taking into account
the clustered nature of the data showed no significant
differences for the primary outcome measures
between the groups at T1 either (p N .21). The
average age (years) was 15.00 (SD = 1.20) for the UP-
A group and 15.13 (SD = 1.03) for the WLCG (t =
0.70, p = .49). A participant in the UP-A group was
found to be a consistent outlier at T2 in all outcome
measures (he had always answered the first available
answer choice in all questions)—therefore, his data at
T2 were excluded from the analyses.
INTERVENTION EFFECTS ON ANXIETY AND DEPRESSIVE
SYMPTOMS
At a descriptive level (see Table 2), between T1 and
T3, the reported anxiety and depression levels
declined for both the UP-A group and the WLCG.
Intracluster correlation coefficients (ICCs) for all
outcome measures ranged from 0.04 to 0.14.
Repeated LMMs measurements found a signifi-
cant main effect of time on the RCADS total score, B
= –1.90 (SE = 0.72), p = .009, 95% CI [–3.33, –0.48],
d = –0.22, and on the following RCADS subscales:
Separation Anxiety Disorder (SAD), B = –0.43 (SE
= 0.11), p b .001, 95% CI [–0.65, –0.21], d = –0.32;
Generalized Anxiety Disorder (GAD), B = –0.50 (SE
= 0.23), p = .031, 95% CI [–0.95, –0.05], d = –0.18;
and Obsessive Compulsive Disorder (OCD), B = –0.49
(SE = 0.19), p = .014, 95% CI [–0.87, –0.10], d = –0.21.
However, there were no significant Time × Group
interactions regarding the RCADS total score, B =
–0.88 (SE = 0.93), p = .346, 95% CI [–2.72, 0.96],
d = –0.08; CDN, B = –0.11 (SE = 0.40), p = .784,
95% CI [–0.90, 0.68], d = –0.02; or EAN, B = –0.29
(SE = 0.49), p = .577, 95% CI [–1.26, 0.68], d = –0.05.
Likewise, there were no significant Time × Group
interactions concerning any RCADS subscales: Major
8 g a r c ı́ a - e s c a l e r a e t a l .

Table 2
Descriptive Statistics for RCADS, CDN and EAN
UP-A group WLCG ICCs
n Mean SD T-scores n Mean SD T-scores
RCADS T1 88 26.39 15.65 49.40 60 28.57 13.61 50.87 0.07
T2 79 23.58 14.70 49.12 57 26.58 13.71 51.22 0.11
T3 73 20.56 14.24 48.73 48 25.06 13.40 51.94 0.13
CDN T1 88 8.63 5.34 49.72 60 9.00 5.51 50.41 0.04
T2 79 8.19 6.04 49.39 57 9.04 5.44 50.85 0.08
T3 73 8.40 5.84 49.85 48 8.60 5.21 50.22 0.11
EAN T1 88 7.61 7.10 49.77 60 8.00 6.16 50.34 0.04
T2 79 6.22 7.09 49.59 57 6.88 6.14 50.57 0.06
T3 73 5.64 6.62 49.09 48 7.10 6.12 51.36 0.14
Note. CDN = Depression Questionnaire for Children; EAN = Anxiety Scale for Children; ICCs = Intracluster Correlation Coefficients; RCADS
= Revised Child Anxiety and Depression Scale-30 Total Score; WLCG = Waitlist-control group.

Depressive Disorder, B = –0.04 (SE = 0.22), p = .845,
95% CI [–0.48, 0.39], d = –0.01; Panic Disorder, B =
–0.03 (SE = 0.21), p = .895, 95% CI [–0.45, 0.39], d =
–0.01; SAD, B = –0.20 (SE = 0.15), p = .181, 95% CI
[–0.49, 0.09], d = –0.11; GAD, B = –0.28 (SE = 0.30),
p = .343, 95% CI [–0.87, 0.30], d = –0.08; OCD, B =
–0.27 (SE = 0.25), p = .281, 95% CI [–0.77, 0.22],
d = –0.09; or Social Phobia, B = –0.09 (SE = 0.27),
p = .738, 95% CI [–0.63, 0.45], d = –0.03.
EXPLORATORY ANALYSES OF BASELINE SEVERITY AS
A POTENTIAL PREDICTOR
Results including RCADS at T1 as a continuous
predictor showed no significant differences between
groups neither at T2 nor at T3 for RCADS total
score, CDN or EAN.
Similarly, results using repeated measures LMMs
showed no Group (UP-A, WLCG) × Time (T1, T2,
T3) × Predictor (elevated or nonelevated RCADS
total score at T1) interactions for RCADS total
score or EAN. However, there was a marginally
significant Time × Group × Predictor interaction for
CDN, F(2, 206.89) = 2.90, p = .057. Post hoc
Bonferroni-adjusted pairwise comparisons revealed
significant decreases for those with elevated symp-
toms in the UP-A group between the following time
points: T1 and T3 (p = .013, d = 0.96, MT1 = 17.33,
MT3 = 13.43, n = 9) and T2 and T3 (p = .026, d =
0.88, MT2 = 16.01, MT3 = 13.43, n = 9). However,
no significant results were found for those with
elevated symptoms in the WLCG for CDN (MT1 =
14.43, MT2 = 16.86, MT3 = 15.10, n = 7) or for
those with nonelevated symptoms regardless of the
group (UP-A or WLCG).
ACCEPTABILITY
The Satisfaction With the Program Questionnaire was
completed only at T2 by 80 adolescents (88.89% of
those in the UP-A group). Table 3 shows descriptive
statistics regarding satisfaction with the program.
Regarding “What did you like best about the
program?” the adolescents most often answered
“learned to control my emotions,” “learned things
about my emotions,” and “the activities that we did in

Table 3
Descriptive Statistics for Satisfaction With the Program Questionnaire (Acceptability)
Quantitative questions (range: 1-10) Mean SD
a
How much did you learn in this program? 5.72 2.69
How effective was this program in helping you cope with life in general? a 4.95 2.40
How much did you enjoy doing this program? a 5.29 2.79
What was your ability to cope with emotions before the program? a 4.58 2.35
What was your ability to cope with emotions after the program? a 6.13 2.45
Ability to cope with emotions after the program minus ability before 1.54 2.26
Qualitative questions (Options: Yes or No) n (%) [Yes]
Did this program help you to learn more about emotions and how they work? b 71 (89.9%)
Would you recommend the program to other adolescents your age? a 63 (79.7%)
Being honest with yourself, are you going to make efforts in the future to apply the strategies 59 (74.7%)
that you learnt in this program in your daily life? b
Note. a
Questions from Rapee et al.’s (2006) Satisfaction Questionnaire; b
Questions created for this study.

Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
 the up-a adapted as a prevention program
class.” Regarding the question “What did you like the
least?” most of the adolescents answered “having
homework,” “other classmates interrupting and being
loud when they should not have been,” and
“sometimes the information was repetitive.”
FEASIBILITY
Fig. 1 depicts the flow of recruitment and retention
during the trial at both the classroom and individual
adolescent levels. The parent consent forms were
returned for all the eligible students after 3 weeks.
One parent of an adolescent randomized to the
WLCG actively requested that the child not take part
in the questionnaire assessments. Baseline data (T1)
were collected from 148 of the participants
(98.01%). A total of 137 (90.73%) and 121
(80.13%) completed the T2 and T3 assessments,
respectively. These retention rates did not signifi-
cantly differ by study condition.
Additionally, nine (5.96%) of the participants were
missing two waves of data, 29 (19.21%) were missing
one wave of data, and 113 (74.83%) completed the
T1, T2, and T3 assessments. These retention rates did
not significantly differ by study condition. LMMs,
taking into account the clustered nature of the data,
were conducted to examine the potential baseline
differences in the primary outcome measures at T1
between the groups completing one, two, or three
waves of data. In the WLCG, there were no significant
differences between those groups. In the UP-A group,
those who missed two waves of data collection (n = 6)
trended toward showing higher levels of anxiety
according to the EAN questionnaire,F(2) = 6.91, p =
.002 and higher levels of OCD symptoms (according
to the RCADS OCD subscale) than those who missed
one or no waves, F(2) = 3.79, p = .027. However, as
stated above, only six of the participants in the UP-A
group missed two waves of data.
Below, we report the results regarding several
assessed aspects of the program implementation
(Bishop et al., 2014)—that is, dosage of intervention
(attendance to sessions and curriculum knowledge),
participant engagement (discipline during sessions and
practice of strategies outside sessions), and adherence
to the intervention. A total of 88.89% (n = 80) and
81.11% (n = 73) of the adolescents in the UP-A group
completed the questionnaires at T2 and T3 assess-
ments, respectively.
Dosage of Intervention
Regarding session attendance, the mean of sessions
missed for the 90 participants in the UP-A group
was 0.97 (SD = 1.36), and the average number of
sessions attended was 8.03 (SD = 1.36). Specifical-
ly, 46 (51.2%) participants attended all sessions, 23
(25.6%) missed one session, 10 (11.1%) missed
Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
9
two sessions, four (4.4%) missed three sessions,
four (4.4%) missed four sessions, two (2.2%)
missed five sessions, and one (1.1%) missed six
sessions. Additionally, in total, 79 (87.8%) partic-
ipants achieved completer status (attending at least
seven out of the nine sessions).
Regarding Question 1 of the Curriculum Knowl-
edge Questionnaire (“What are the three parts of an
emotion?”), 58.2% of the participants at T2 an-
swered the question correctly, while 34.2% answered
it incorrectly, and the rest (7.6%) answered it partially
right. Regarding Question 2 (“What can you do when
you are feeling sad or down to feel better?”), most of
the participants (75.9%) answered it correctly, while
20.3% answered it partially right, and only 3.8% had
an incorrect answer. Finally, regarding Question 3
(“What is a thinking trap?”), 68.4% answered it
right, while the rest answered it incorrectly. At T3,
Question 1 was answered correctly by 56.2%,
partially right by 9.6%, and incorrectly by 34.2%.
Question 2 was answered correctly by 67.1%,
partially right by 27.4%, and incorrectly by 5.5%.
Question 3 was answered correctly by 64.4% of the
participants and incorrectly by the rest.
Participant Engagement
The Discipline Problems During Sessions Question-
naire was completed only at T2. On the one hand,
the results (see Table 4) showed that most of the
students reported that they had paid attention to
the group leaders in many (46.8%) or almost all
(21.5%) of the sessions. Additionally, 78.5% and
63.3%, respectively, reported that they had en-
gaged in other schoolwork or received reprimands
in no or almost no sessions. On the other hand,
45.5% and 56.9% students, respectively, reported
that they had taken the program seriously or had
tried their best when doing the in-class activities in
only some of the sessions or in almost no sessions.
Finally, 48.1% of the students reported that only in
some sessions had they talked to their classmates
when they should not have.
In relation to the Strategies Practiced Outside of
Session Questionnaire, Table 5 shows the mean
frequencies of the home practice for each strategy
and the number of students who practiced each
strategy once a week or more both during the
course (assessed at T2) and after the course
(assessed at T3). On average, the adolescents
practiced the techniques more than once or twice,
but less than once a week, both during the course (n
= 79, M = 2.30, SD = 0.79) and after the course (n =
73, M = 2.32, SD = 0.85). The most practiced
strategies both at T2 and T3 were to plan
schoolwork and pleasant activities, to do pleasant
10 g a r c ı́ a - e s c a l e r a e t a l .

Table 4
Answers to Discipline Problems During Sessions Questionnaire (n = 79)
In no or almost no Only in some In quite a lot of the In all or almost all
sessions of the sessions of the sessions of the sessions of the
program program program program
1. I have talked to my classmates when I 18 (22.8%) 38 (48.1%) 12 (15.2%) 11 (13.9%)
should not have.
2. I have payed attention to what the girls 6 (7.6%) 19 (24.1%) 37 (46.8%) 17 (21.5%)
delivering the program were saying.
3. I have done things from other subjects 62 (78.5%) 14 (17.7%) 1 (1.3%) 2 (2.5%)
during program sessions.
4. I have been reprimanded for my 50 (63.3%) 18 (22.8%) 8 (10.1%) 3 (3.8%)
behavior.
5. I have taken the program seriously. 14 (17.7%) 22 (27.8%) 27 (34.2%) 16 (20.3%)
6. I have tried to do my best when doing 20 (25.3%) 25 (31.6%) 25 (31.6%) 9 (11.4%)
the in-class activities of the program.

activities when being sad, and to try to focus on the Discussion

present moment.
Adherence to the Intervention
The objectives and specific activities for each
session were detailed in a file accessible to the
group leaders. Additionally, in all group sessions, a
PowerPoint presentation was used to deliver
content and increase the fidelity of the implemen-
tation. The group leaders also completed a
checklist at the end of each session indicating
whether they had covered each session objective
“completely,” “partially,” or “not at all.” The
objectives included presenting the main contents of
the UP-A program, assigning homework, and
engaging in planned activities with the adolescents
(such as filling out forms, conducting group
exercises, etc.). Combining all the sessions con-
ducted with the adolescents in the UP-A group, the
group leaders rated 78.3% of the session objectives
as covered “completely,” 10.7% as “partially,”
and 11% as “not at all.”
This paper describes the main results of an initial-
cluster RCT testing the first adaptation of the UP-A
as a school-based anxiety and depression preventive
intervention. The first aim of this study was to
examine whether the adapted UP-A was more
effective than a WLCG in reducing the symptoms
of anxiety and depression at posttreatment and at
the 3-month follow-up.
Contrary to expectations, the results failed to find
significant effects of the program on the symptoms of
anxiety and depression regarding the entire sample.
The lack of significant effects may be due to several
factors. First, there was a higher than expected
dropout rate (19.74% when ~ 10% dropout rate at
follow-up was expected) and higher than expected
ICCs (range between 0.04 and 0.14 when ICCs of
0.02 were expected) that considerably reduced the
study’s power. At T2, the attrition rate (~ 10%) was in
line with other similar studies (e.g., Ahlen et al.,
2018), whereas at the 3-month follow-up, the

Table 5
Frequency of Strategies Practiced Outside of the Sessions Assessed at Time 2 and Time 3
During course (n = 79) Since course (n = 73)
Meana (SD) n (%) b
Meana (SD) n (%) b

1. Identifying the three parts of an emotion. 2.2 (1.1) 11 (13.9) 2.1 (1.1) 24 (32.9)
2. Plan school work and pleasant activities. 2.8 (1.4) 26 (32.9) 2.8 (1.4) 21 (28.7)
3. Do pleasant activities when being sad. 2.6 (1.2) 19 (24.1) 2.7 (1.3) 22 (30.1)
4. Practice detective thinking. 2.1 (1.7) 12 (15.2) 2.1 (1.1) 10 (13.7)
5. Practice problem solving strategies. 2.1 (1.1) 8 (10.2) 2.2 (1.2) 11 (15.0)
6. Try to focus in the present moment. 2.4 (1.2) 16 (20.3) 2.7 (1.4) 23 (31.5)
7. Meditate. 2.0 (1.2) 10 (12.7) 1.7 (1.2) 9 (12.3)
8. Practice exposure. 2.3 (1.2) 14 (17.8) 2.2 (1.2) 10 (13.7)
Note. a Range: 1 (never practiced), 2 (once or twice in total), 3 (greater than twice in total but less than once a week), 4 (once or twice each
week) and 5 (practiced three times or more weekly). b Practiced the strategy once a week or more.

Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
 the up-a adapted as a prevention program
attrition rate was 20%, a higher rate than that of
other prevention studies with longer follow-up
assessments (e.g., Gillham et al., 2012, had a 14%
dropout rate at the 6-month follow-up). This
discrepancy might have to do with our study
including a high proportion of ethnic-minority
students (especially Latino youth) since research has
shown that these students are less likely to complete
the follow-up assessments than other students
(Duong et al., 2016; Gillham et al., 2012). Other
reasons for the lack of significant effects might be
related to the program itself, such as the intervention
being significantly shorter than the standard UP-A or
a greater focus on psychoeducation and less focus on
experiential behavioral practice.
Furthermore, it might have been challenging for this
adaptation of the UP-A protocol to be true to the
original framework of the protocol—for instance, in
the UP-A, the strategies are built on a framework of
emotional education, cognitive flexibility, and oppo-
site action during intense emotions that may have been
experienced less frequently within a universal preven-
tion sample, especially since the size of the groups
(classes of 30–32 students) made it difficult to provide
individual attention to the students. Additionally, the
UP-A includes a parental component that is not
present in this adaptation and that could have
contributed to the lack of significant effects since
previous research has identified family factors as being
strongly associated with mental health outcomes,
especially depressive symptoms (Bond, Toumbourou,
Thomas, Catalano, & Patton, 2005).
Apart from the results failing to find significant
effects of the program on the symptoms of anxiety
and depression regarding the entire sample, an
unexpected decline in anxiety and depression levels
was found in both groups. This could be partially
attributed to the so-called test–retest effect, when
the mean change in the scores tended toward less
psychopathology between the two measurements
without any formal intervention having taken
place, which might have contributed to the
unexpected decline in the WLCG—however, ad-
ministering the same tests three times rather than
two usually nullifies this effect (Arrindell, 2001).
Additionally, contamination of program contents
could have taken place between the UP-A group
and the WLCG, especially because paper handouts
were supplied to the students in the UP-A group.
Regarding the second aim of the study, adoles-
cents in the UP-A group with elevated emotional
symptoms at baseline trended toward significantly
greater decreases in depression symptoms com-
pared to the elevated symptoms’ adolescents in the
WLCG. Although these results should be inter-
preted with caution due to the small sample of
Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
11
symptomatic adolescents at baseline (a total of 16),
we believe that schools could especially benefit
from a stepped-care approach in which the UP-A is
delivered as a selective or indicated intervention to
those symptomatic adolescents who do not improve
with a universal program different from the UP-A.
Overall, the findings are similar to those of other
prevention studies that showed only significant
reductions in anxiety and/or depression symptoms
at posttreatment and/or short-term follow-up for the
high-risk, most symptomatic subjects, whereas for the
whole sample, the symptoms decreased for both the
intervention and control groups (Ahlen et al., 2018;
Gillham et al., 2012). In other words, our preventive
intervention has only found treatment effects (i.e., a
decline in the level of psychological symptoms relative
to controls) with the most symptomatic participants,
which could be explained by the potential floor effects
affecting universal studies (Horowitz & Garber,
2006) and by the other reasons discussed above.
However, to assess true preventive effects of the UP-A
program—that is, a reduction of the expected
increase in symptoms in the intervention group
relative to controls, longer follow-ups (e.g., 12
months) are needed (Horowitz & Garber, 2006).
As a matter of fact, some similar studies have found
prevention effects at the 12-month follow-up and not
at posttreatment or short-term follow-up (Barrett,
Lock, & Farrell, 2005; Gillham et al., 2012).
In relation to the third aim of this study, some of
the results regarding the feasibility of the program
implementation suggest that a desired exposure to
the UP-A contents might not have been achieved.
For instance, concerning dosage of intervention,
although the mean number of sessions attended
(8.03 out of 9.00) was similar to other studies
(Johnson et al., 2016), the low percentages of
correct answers (67.50% at T2 and 62.57% at T3)
in the Curriculum Knowledge Questionnaire sug-
gest that it is possible that the program’s core
content was not fully assimilated by all participants.
This result might be related to the apparently low
engagement shown by some adolescents during the
program. First, the behavior of some of the students
during the sessions was not ideal. It seems especially
worrisome that, for instance, only ~ 20% of the
participants reported that in all or almost all
sessions they had paid attention to the group
leaders, or had taken the program seriously. A
much higher proportion of students reported
engaging in these desirable behaviors in the
uncontrolled trial with the WLCG participants,
probably because the groups were half the size and
the group leader was able to personalize the
intervention content more and incorporate more
active teaching methodologies (García-Escalera et
12 g a r c ı́ a - e s c a l e r a e t a l .
al., 2019). Second, the adolescents practiced the
strategies less than once a week, which is similar to
the results obtained by Johnson et al. (2016) and by
the uncontrolled trial with the WLCG participants
(García-Escalera et al., 2019). Interestingly, in both
the latter study and the present study, the most
practiced strategies were to plan schoolwork and
pleasant activities, to try to focus on the present
moment, and to do pleasant activities when de-
pressed. Future studies might benefit from using
focus groups with the students to explore their views
about the usefulness of the different strategies.
Finally, concerning the acceptability of the adapted
UP-A, the adolescent rating revealed moderate
satisfaction with the program, with the mean ratings
ranging between 4.95 and 5.72 in relation to the
questions assessing the amount learned in the
program, the program’s effectiveness in helping cope
with life in general, and the enjoyment of participating
in the program. These results are slightly better than
the ones in Rapee et al.’s (2006) study, which obtained
mean ratings ranging between 4.00 and 4.58, and
slightly worse than the results of the participants in the
WLCG that later on received the intervention (mean
satisfaction ratings obtained range between 6.22 and
6.48), probably because of advantages related to
smaller group sizes when conducting the mental
health programs discussed above.
This study has certain limitations due to its
preliminary nature. First, and probably most
important, it had a small sample size (151
adolescents across five classes) that together with
an imbalanced number of students between condi-
tions and higher than expected attrition rates and
ICCs resulted in the study possibly being under-
powered to estimate the effects with adequate
precision. Additionally, a WLCG was used when
an active control group would have been prefera-
ble, and the adolescents were recruited from only
one school, which may limit the generalizability of
the findings. Also, the study incorporated only
adolescent self-reported measures, and these can be
affected by situational factors, high attrition, and
social desirability bias. Furthermore, intervention
adherence was evaluated by group leader self-
reporting that might have led to biases, and the
program itself was not manualized, and, therefore,
there could have been variations during delivery
that inadvertently had an impact on the effect.
Finally, the short follow-up of 3 months made it
difficult to assess prevention effects.
CONCLUSIONS
The findings of this study do not support the
hypothesis that the UP-A adapted as a universal
Please cite this article as: J. García-Escalera, R. M. Valiente, B. Sandín, et al., The Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders in Adolescents (UP-A) Adapted as a S..., , https://doi.org/10.1016/j.beth.2019.08.003
program is more effective than a WLCG in reducing
the symptoms of anxiety and depression at posttreat-
ment and 3-month follow-up. Nevertheless, explor-
atory analyses revealed that those adolescents with
greater baseline emotional symptoms in the UP-A
group trended toward a significantly greater decrease
in symptoms of depression compared to the WLCG.
Given these results, future studies should address
whether the adapted UP-A would be more efficacious
and feasible as a selective rather than a universal
prevention program. Additionally, when further
developed and evaluated, efforts should be made to
include larger samples, improve some aspects of the
implementation of the program, and increase the
dose of behavioral components.
Conflict of Interest Statement
Dr. Ehrenreich-May receives royalties from the publication of the
Unified Protocols for Transdiagnostic Treatment of Emotional
Disorders in Children and Adolescents, as well as compensation
for providing training and consultation on these treatments.
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R E C E I V E D : May 22, 2018
A C C E P T E D : August 6, 2019
A V A I L A B L E O N L I N E : xxxx