Psychometric properties of the Therapeutic Alliance Scale for Caregivers and Parents

'Turning up and tuning in'. Factors associated with parental non-attendance and non-adherence in intervention for young children with speech, language communication needs

BACKGROUND

When parents bring their child to appointments and then adhere to agreed speech and language therapy (SLT) recommendations, there is the potential to increase the intensity of the intervention, support generalization and improve outcomes. In SLT, however, little is known about factors that may promote attendance or adherence. Studies in other clinical areas such in medicine, psychology and physiotherapy have identified risk factors for non-attendance or non-adherence that are multifactorial and variable dependent on, for example, population and intervention.

AIMS

To identify rates of non-attendance and non-adherence, and to identify parent or child factors associated with parent involvement in intervention for children under 5 years of age receiving SLT.

METHODS

Parents completed questionnaires at two time points assessing the domains of parents' beliefs (problem perceptions, self-efficacy), personal circumstances (socio-demographics, family functioning), treatment experience and child factors. Predictors of parent attendance and adherence were identified through multiple regression analyses. Non-attendance rates were identified via local health records and non-adherence ascertained using a specific parent-reported measure within the treatment experience domain.

RESULTS

Participants (N = 199) were predominantly mothers, and were ethnically and socio-economically diverse, speaking a wide range of languages. Their children presented with a range of speech, language communication needs (SLCN). The rate of non-attendance was 25% and the main predictors of non-attendance were maternal age, education level and two factors within the parent beliefs domain. This model explained 40% of the variance in attendance. The rate of non-adherence in this cohort was 26% with parental rating of the importance of a recommendation and self-efficacy beliefs predicting adherence; this explained 56% of the variance in adherence to SLT recommendations at home.

CONCLUSIONS & IMPLICATIONS

Our research has provided preliminary evidence of the influence of parents' beliefs, personal circumstances and treatment experiences on their involvement in their child's therapy. Speech and language therapists should consider factors impacting attendance and adherence to treatment and explore parental perceptions of their child's SLCN before embarking on an intervention, a foundation for collaborative practice. A possible limitation of this study is that the levels of attrition in our sample led to generally high measured rates of participation, which should be considered in future studies. Future research should explore adherence in treatments with varying doses, with different types of SLCN or interventions and in different settings.

WHAT THIS PAPER ADDS

What is already known on the subject It is acknowledged that parent involvement in their child's therapy, such as attending and adhering to recommendations, is important but little is known about the rates of involvement and what factors may be associated with attendance and adherence in SLT. Qualitative research has explored parental involvement suggesting that beliefs about an intervention may be pertinent. Extensive research in other clinical areas suggest multiple and varied factors are influential and further exploration of particular populations and interventions is necessary. What this paper adds to the existing knowledge This study identified rates of parental non-attendance and non-adherence in a cohort of predominantly mothers of children under the age of 5 years. It is the first study to measure parent adherence in SLT and identify factors that are associated parental adherence to SLT recommendations. It adds to the small body of SLT specific research in understanding risk factors for non-attendance. What are the potential or actual clinical implications of this work? This study highlights the need for a speech and language therapist to consider and explore parents' perspectives of their child's SLCN as a part of achieving collaboration with a parent in order to achieve the best outcomes. It provides a foundation for further systematic research into parent involvement with the ultimate aim of enhancing outcomes for children with SLCN.

Collateral effects of Coping Power on caregiver symptoms of depression and long-term changes in child behavior

A large body of research demonstrates positive impacts of the Coping Power Program as a preventive intervention for youth behavioral outcomes, but potential collateral effects for caregivers is less known. The current study examined whether the youth-focused Coping Power Program can have a secondary impact on caregiver self-reported symptoms of depression and in turn result in longer-term impacts on child disruptive behavior problems including aggression, conduct problems and hyperactivity. Data from 360 youth/caregiver pairs across 8 waves of data (grades 4 through 10) were analyzed. We used two methodological approaches to (a) assess indirect effects in the presence of potential bidirectionality using timepoint-to-timepoint dynamic effects under Autoregressive Latent Trajectory modeling and (b) estimate scale scores in the presence of measurement non-invariance. Results showed that individually delivered Coping Power (ICP) produced greater direct effects on conduct problems and indirect effects on general externalizing and hyperactivity (through reductions in caregiver self-reported symptoms of depression), compared to group Coping Power (GCP). In comparison to GCP, ICP produced similar direct effects on reductions in caregiver depression. Child-focused prevention interventions can have an indirect impact on caregiver depression, which later shows improvements in longer-term reductions for child disruptive problems.

Intervention format and therapist-child agreement associated with therapeutic alliance and outcomes

OBJECTIVE

The study examined the effects of therapeutic alliance (TA; relational bond, task collaboration) on externalizing behavior outcomes, how TA can operate differently when children are seen in individual versus group sessions, and how therapist-child disagreement in perceptions of TA affects outcomes.

METHOD

Three hundred sixty children (Ages 9.2-11.8; 65% male; 78.1% Black) identified as having high rates of aggressive behavior by the fourth-grade teachers, and their 20 elementary schools were randomized to group versus individual delivery of the cognitive behavioral intervention, Coping Power. TA ratings were collected from children and therapists at mid and end of intervention using the Therapeutic Alliance Scale for Children. Teacher ratings of children's externalizing and internalizing behavior problems were collected prior to intervention and at 1-year follow-up after intervention using the Behavior Assessment System for Children.

RESULTS

Children receiving the intervention individually reported significantly higher trait-like levels of task collaboration than did children seen in groups. Independent of intervention format, higher trait-like levels of therapist-rated bond and task collaboration predicted reduced levels of externalizing problems, and higher trait-like levels of child- and therapist-rated task-collaboration and therapist-rated bond predicted reduced levels of internalizing problems. Differences between therapist and child reports of bond predicted weaker reductions in internalizing behavior for children seen in groups.

CONCLUSIONS

It is essential to train therapists to develop and assess for TA by midintervention with children with aggressive behavior problems, especially if they are seen in small groups, and to determine if therapists may misperceive the strength of TA. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Increasing the Efficacy of Treatment for Socially Anxious Youth Through Theoretically Derived Improvements: A Pilot Study

Cognitive behavioural therapy is the first line of treatment for social anxiety disorder; however, children with social anxiety disorder do not respond as well to generic cognitive behavioural therapy programs, compared to children with other anxiety disorders. The aim of the study was to provide a preliminary examination of the efficacy and applicability of a new disorder specific intervention for children with social anxiety disorder. Five children aged 7-13 years, with a primary or secondary DSM-5 diagnosis of social anxiety disorder were provided with an adapted version of the Cool Kids anxiety program. Three out of the five children were in remission from social anxiety disorder at the end of the intervention and at 3-month follow-up. Statistically significant improvements were also noted in overall anxiety symptoms and functioning. Preliminary evidence was found for the efficacy of a social anxiety version of the Cool Kids program.

Better together? A randomized controlled microtrial comparing different levels of therapist and parental involvement in exposure-based treatment of childhood specific phobia

INTRODUCTION

Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE).

METHODS

Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up.

RESULTS

TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up.

CONCLUSIONS

These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.

Exploring the relationship between distress rumination, resilience, depression, and self-injurious behaviors among Chinese college athletes infected with COVID-19: a cross-sectional study

Objectives

Distress rumination is a cause of suicidality and self-injurious behavior (SSIB) among individuals. Although previous studies have shown that distress rumination, SSIB, resilience, and depression are significantly related, the interaction mechanism remains unclear. This study aimed to evaluate resilience and depression as mediators of the relationship between distress rumination and SSIB among Chinese college athletes infected with COVID-19.

Methods

Convenience sampling was used to recruit participants from the National College Football Championship in Guangxi City, China from January to February 2023. Participants completed the Ruminative Responses Scale (RRS), a subscale of the Health-Risk Behavior Inventory (HBI), the Mental Toughness Index (MTI) and the Patient Health Questionnaire (PHQ-9). We used the PROCESS macro for SPSS to determine the mediating effect of resilience and depression between distress rumination and SSIB.

Results

A total of 350 Chinese college athletes participated in this study and completed the questionnaire survey. 289 (81.7% boys; Mage = 20.31 years, SD = 1.60) of them have been infected with COVID-19. 59.9% (n = 173) participants were from urban areas and 15.6% (n = 45) of participants have engaged in self-injurious behaviors or suicidal ideation. College athletes' distress rumination was significantly negatively correlated with resilience (r = - 0.28, p < 0.01), and was significantly positively correlated with depression (r = 0.49, p < 0.01) and SSIB (r = - 0.18, p < 0.01). Resilience was significantly negatively correlated with depression (r = - 0.35, p < 0.01) and SSIB (r = - 0.30, p < 0.01). Finally, depression was significantly positively correlated with SSIB (r = - 0.38, p < 0.01). Resilience and depression played a mediating role of the total effects of distress rumination and SSIB, respectively. Meanwhile, the chain mediating effect of resilience and depression was also significant.

Conclusion

This study found that distress rumination can directly predict SSIB, and indirectly predict SSIB through the mediating effect of resilience and depression, and the chain mediating effect of resilience-depression. Therefore, reducing the degree of distress rumination of college athletes infected by COVID-19 and improving their resilience, as well as reducing their depression may help prevent SSIB.

Treating specific phobia in youth: A randomized controlled microtrial comparing gradual exposure in large steps to exposure in small steps

INTRODUCTION

Exposure may be especially effective when within exercises, there is a strong violation of threat expectancies and much opportunity for fear reduction. Outcomes of exposure may therefore improve when exposure is conducted in large steps (LargeSE) relative to small steps (SmallSE).

METHODS

Children and young people with a specific phobia (SP) (N = 50, age 8-17, 64 % girls) participated in a preregistered single-blind, randomized controlled microtrial comparing LargeSE and SmallSE in a four-week baseline-treatment design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up.

RESULTS

Within exercises, LargeSE resulted in higher initial fear levels and more within-session expectancy violation. Nevertheless, SmallSE resulted in a larger decline of SP severity from baseline to post-treatment and follow-up, and a larger decline of anxiety and avoidance towards one's individual goal from baseline to follow-up. There were no differences between LargeSE and SmallSE regarding changes in general self-efficacy or behavioral avoidance. Although session duration was standardized and similar for both conditions, participants in SmallSE received more (shorter) exercises.

DISCUSSION

SmallSE might be more effective in reducing SP severity because children in SmallSE were exposed to a larger number and variety of exercises than children in LargeSE.

A Meta-Analysis on Differences and Associations between Alliance Ratings in Child and Adolescent Psychotherapy

OBJECTIVE

The alliance in child and adolescent psychotherapy is widely recognized as an important factor in therapy. Studies on the alliance have increasingly focused on assessment of the alliance as a dyadic construct, measuring both client and therapist alliance ratings. However, cross-informant reports of the alliance in child psychotherapy have not yet been subjected to meta-analysis. Therefore, the present meta-analysis aims to increase knowledge on the degree of convergence and divergence between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy.

METHODS

A series of three-level meta-analyses of 78 studies was conducted to investigate differences and associations between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy.

RESULTS

Findings indicated that children and parents in general rated the alliance more positively than their therapists (d = 0.35, d = 0.72, respectively), and that child-therapist and parent-therapist alliance ratings were moderately correlated (r = .32, r = .23, respectively). Associations between child and therapist ratings and observer ratings were moderate to large (r = .43, r = .53, respectively).

CONCLUSIONS

It can be concluded that children and parents generally report more positively on the alliance compared to their therapists, which is consistent with research on the alliance in adult populations. The small to moderate associations between alliance ratings indicate that individuals to some extent have a shared perspective on their alliance, and that the various perspectives on alliance should be acknowledged when dealing with children and parents in therapy. Implications for future research are discussed.

The Association between Occupational Stress and Mental Health among Chinese Soccer Referees in the Early Stage of Reopening Soccer Matches during the COVID-19 Pandemic Outbreak: A Moderated Mediation Model

BACKGROUND

The sudden and unpredictable changes caused by the COVID-19 pandemic are a serious threat to the occupational stress and mental health of referees worldwide, which has not attracted widespread attention. The mental health of football referees has a certain influence on their job satisfaction or the accuracy of judgments.

METHODS

This study constructed a moderated mediation model to explore the buffer factors between occupational stress and mental health in Chinese soccer referees in the early stage of reopening soccer matches during the COVID-19 pandemic outbreak. Data from 317 Chinese soccer referees (aged 19-45) were collected through an online questionnaire in September-October 2022. Occupational stress, mental health, job burnout and perceived social support were measured, and moderated mediation model was analyzed.

RESULTS

The results of this study showed that occupational stress was negatively correlated with mental health through the mediating effect of job burnout and the moderated effect of perceived social support after controlling for demographic variables. Specifically, the association between occupational stress and mental health was weaker when perceived social support was higher and stronger.

CONCLUSIONS

The results demonstrate that job burnout and perceived social support played important roles in buffering the negative effects of occupational stress on the mental health of Chinese soccer referees in the early stage of reopening soccer matches during the COVID-19 pandemic outbreak. The findings provide implications for mental health interventions in soccer referees during the public health crises.

Involving Caregivers of Autistic Toddlers in Early Intervention: Common Practice or Exception to the Norm?

PURPOSE

Family-centered practice (FCP) is a core component of early intervention (EI) associated with improved child and family outcomes, but little is known about community-based speech-language pathologists' (SLPs') inclusion of families in EI. Many caregivers of autistic children experience caregiving-related stress, making these intervention principles especially critical to the provision of optimal services. This study aimed to characterize EI SLPs' use of FCP coaching strategies and the quality of caregiver-SLP relationships.

METHOD

Participants included 25 families with an autistic toddler and their EI SLP. One intervention session for each SLP-family dyad was recorded and coded for the SLP's use of FCP coaching strategies. Caregivers and SLPs completed surveys about their working alliance, caregiver perceptions of family-centered care, and SLPs' approach to FCP.

RESULTS

SLPs primarily use child-directed strategies without caregiver involvement. When involving caregivers, SLPs infrequently use coaching strategies that are important for caregiver learning and collaboration (e.g., joint planning and guided practice with feedback). However, caregivers perceived their child's services to be highly family-centered, and caregivers and SLPs rated their working alliance to be of high quality.

CONCLUSIONS

The presence of strong caregiver-SLP working alliances alongside infrequent usage of effective coaching strategies indicates that SLPs may engage caregivers in ways that are perceived to be highly collaborative but are not optimal for caregiver involvement in all aspects of their child's services (goal setting and implementation of intervention). Consideration of family preferences and SLP beliefs about FCP will inform ways to disseminate FCPs needed to optimize families' capacities to support their child's development.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20113550.

In-Person Versus Telehealth for Concussion Clinical Care in Adolescents: A Pilot Study of Therapeutic Alliance and Patient Satisfaction

OBJECTIVE

To conduct a pilot study of caregiver ratings of therapeutic alliance and patient satisfaction outcomes between telehealth and in-person concussion clinical care in male and female adolescent athletes.

SETTING

Outpatient neuropsychology concussion clinic.

PARTICIPANTS

Fifteen patients (aged 15.40 ± 1.35 years; 33% female) with a concussion and their accompanying caregivers ( n = 15; 87% female) were randomly assigned to an in-person clinic visit and 15 patients (aged 15.13 ± 1.25 years; 40% female) with a concussion and their accompanying caregivers ( n = 15; 73% female) were randomly assigned to a telehealth clinic visit.

DESIGN

A prospective, randomized design.

MAIN MEASURES

Therapeutic alliance and patient satisfaction scores.

RESULTS

Therapeutic alliance scores were not significantly different for patients in the in-person or telehealth setting, and caregiver therapeutic alliance scores were significantly higher for the in-person condition than for the telehealth condition. There were no significant differences between in-person and telehealth session satisfaction scores for patients on depth, smoothness, positivity, arousal, and bad-good outcomes. Patient and caregiver satisfaction with the clinical setting was high (ie, General Endorsement).

CONCLUSION

Telehealth is feasible for assessing and interpreting clinical concussion examination, interview, and neurocognitive findings, which are perceived by patients and their caregivers to be comparable with in-person care. Positive satisfaction scores also serve to reinforce the need for healthcare providers to seek ways to actively engage with patients and their caregivers through elements of communicative skills such as active listening, building patient rapport, encouraging patient autonomy, and providing an adequate amount of time for interaction and questions. Telehealth for concussion care is increasing in implementation across health systems, and demand is likely to grow in light of the current COVID-19 pandemic and advances in telehealth delivery.

Four perspectives on traumatized youths' therapeutic alliance: Correspondence and outcome predictions

OBJECTIVE

Does the rater-perspective of youths' therapeutic alliance matter? To answer this, we evaluated the relationships between four perspectives of youths' alliance, then, we examined whether each perspective and potential discordance between the perspectives predicted outcomes.

METHOD

Participants were 65 youth (M age = 15.11, SD = 2.14; 76.9% girls) undergoing trauma-focused cognitive behavioral therapy (TF-CBT) and their therapists (n = 24). Youths' alliance was rated by youth, therapists and parents using the Therapeutic Alliance Scale for Children-revised and by observers using the Therapy Process Observational Coding System-Alliance scale. Posttraumatic stress symptoms (PTSS) were assessed with the Child PTSD Symptom Scale (CPSS) and the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA).

RESULTS

The alliance ratings by youth-parent, parent-therapist, and therapist-observer significantly correlated. Only a higher youth-rated alliance significantly predicted fewer PTSS. Furthermore, a higher therapist-rated than youth-rated alliance significantly predicted higher scores on CPSS and CAPS-CA, and a higher parent-rated than youth-rated alliance predicted significantly higher CPSS score.

CONCLUSION

Therapists should explicitly check in with youth clients about the alliance; because only youths' evaluation of their alliance predicted the outcome and an overestimation of their alliance by therapists and parents predicted more PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Designing Dynamic Interventions to Improve Adherence in Pediatric Long-Term Treatment - The Role of Perceived Value of the Physician by Primary Caregivers

Primary Caregivers are the fulcrum in the physician-caregiver-child triad. Existing literature discusses static multi-component interventions in detail. In long-term treatments, dynamic intervention design is needed as the environment and situations of the families are dynamic. The objectives of this study are (a) to identify the components of the primary caregiver's perception of the physician's value with reference to the effectiveness of consultation and relationships with the former and with the child; (b) to establish the role of this perception in designing dynamic interventions, and (c) to describe the perception's potential influence on adherence. A PRISMA, chronological, and morphological analysis of the literature is carried out about caregivers' adherence in the pediatric long-term treatment context. We define communication and consultation as the functional, whereas relationship as the emotional component of the caregiver's perception of the physician. We propose a theoretical model that incorporates intervention as an integral component of care. Adherence happens as a response to changing situations and hence fluctuates. Hence, a dynamic intervention design to benefit the child should be incorporated into care through the caregiver-physician bridge. Future research should explore how intervention needs change and the driving reasons for understanding the static and dynamic components of interventions.

Longitudinal trajectory and predictors of change in family accommodation during exposure therapy for pediatric OCD

Family accommodation (FA) is key in the maintenance of OCD. However, most studies are cross-sectional, and have not identified long-term trajectories and correlates of FA changes over treatment. This study investigated changes in clinician-rated FA over 10 sessions of cognitive behavioral therapy (CBT) for 142 children with OCD, as well as several key predictors/correlates: (a) clinician-rated OCD symptom severity, (b) child- and parent-rated functional impairment, (c) parent-rated treatment expectancies, and (d) child- and parent-rated therapeutic alliance. Multi-level models indicated that FA changed significantly during treatment, with gains maintained over 6-months. Baseline clinician-rated OCD severity did not predict changes in FA. Significant interactions indicated that children with higher child- and parent-rated impairment exhibited greater FA improvements over treatment (versus children with lower impairment). Child- and parent-rated therapeutic alliance and parent-rated expectancies did not predict FA changes. Finally, FA mediated the relationship between OCD severity and parent- (but not child-) rated impairment. Reverse mediation models were also significant. Findings indicate that CBT can successfully reduce FA (a) even if children experience high OCD severity and interference in school, relationships, and family life, and (b) regardless of non-specific factors like treatment expectancies and alliance. FA reductions are an important mechanism mediating treatment response.

Implementation of a Scalable Family-Based Behavioral Treatment for Childhood Obesity Delivered through Primary Care Clinics: Description of the Missouri Childhood Obesity Research Demonstration Study Protocol

Background: Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families who are disproportionately affected by obesity. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project (CORD 3.0), the Missouri team (MO-CORD) aims to increase access to and dissemination of an efficacious pediatric obesity treatment, specifically family-based behavioral treatment (FBT), for low-income families. Methods/Design: The implementation pilot study is a multisite matched-comparison group pilot of packaged FBT in pediatric clinics for low-income children with obesity, of ages 5 to 12 years old. The study is implemented in two Missouri pediatric primary care clinical sites, Freeman Health System Pediatric Clinics (rural Joplin) and Children's Mercy Hospital Pediatric Clinics (urban Kansas City). The design focuses on pragmatism through utilization of PRECIS (Pragmatic Explanatory Continuum Indicator Summary) domains, such as open eligibility criteria, limited follow-up intensity, reliance on medical records for creating a usual care comparison group data, and unobtrusive measurement of participant and provider adherence. The evaluation focuses on effectiveness as well as implementation outcomes and barriers to inform implementation scale up. Conclusions: Findings from this study will advance both science and practice by providing novel and immediately useful information to families, health care providers, health care organizations, payers, and other state Medicaid plans by developing and optimizing evidence-based pediatric weight management treatment for implementation and dissemination in health systems to address health disparities among low-income populations most affected by overweight and obesity.

Knowledge and competency standards for specialized cognitive behavior therapy for pediatric obsessive-compulsive disorder

Although exposure-based cognitive behavior therapy (CBT) and pharmacotherapy have demonstrated efficacy for obsessive-compulsive disorder (OCD), the lack of clinicians effectively trained in these treatments significantly limit effective intervention options for affected youth. This is very unfortunate since child onset is reported by 50% of adults with OCD. To ameliorate this serious global issue the 14 nation International Obsessive-Compulsive Disorders Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) has developed knowledge and competency standards recommended for specialized treatments for OCD through the lifespan. Currently available guidelines are considered by experts to be essential but insufficient because there are not enough clinicians with requisite knowledge and competencies to effectively treat OCD. This manuscript presents knowledge and competency standards recommended for specialized cognitive behavior therapy (CBT) for pediatric OCD, derived from comprehensive literature review and expert synthesis. In addition to standards covering the elements of individual CBT-based assessment and treatment, family and school interventions are addressed given the critical role these domains play in the psychosocial development of youths. The ATF standards presented in these phase two papers will be foundational to the upcoming development of certification (individuals) and accreditation (sites) for specialized treatments in OCD through the lifespan.

The factor structure of the Working Alliance Inventory short-form in youth psychotherapy: an empirical investigation

Objective: The Working Alliance Inventory short form (WAI-S) is one of the most commonly used alliance measures with adolescents. Yet, its factor structure has received minimal attention in the youth alliance literature. This study investigated the factor structure of the WAI-S in psychotherapy for adolescent depression and explored its measurement invariance across time, therapeutic approaches and patients' and therapists' perspectives. The existence of method effects associated with the negatively worded items of the scale was also assessed.Method: The setting of this study is the IMPACT trial, a randomized controlled trial assessing the effects of three therapeutic interventions in the treatment of adolescent depression. The WAI-S was completed at 6, 12 and 36 weeks after randomization by 338 adolescents and 159 therapists. Data were analysed using confirmatory factor analysis.Results: The hypothesized Bond-Task-Goal alliance structure was not supported and a general, one-factor model was found to be more psychometrically valid. The existence of a method effect and measurement invariance across time and treatment arms were also found.Conclusions: While the distinction between the specific alliance dimensions is conceptually and clinically interesting, at an empirical level the alliance features of the WAI-S in youth psychotherapy remain strongly intercorrelated.

Therapist Alliance-Building Behaviors, Alliance, and Outcomes in Cognitive Behavioral Treatment for Youth Anxiety Disorders

OBJECTIVE

The alliance influences outcomes in CBT for youth anxiety disorders. Thus, knowledge about how therapists can enhance the alliance is needed.

METHOD

Seventy-three youth with anxiety diagnoses (M age = 11.5 years, SD = 2.2; range 8 to 15 years; 47.9% boys; 90.4% white-European) participated in 10-session cognitive behavioral therapy in community clinics. Therapist alliance-building behaviors in session 2 was reliably coded with the observer-rated Adolescent Alliance-Building Behavior Scale (Revised) (AABS(R)). Alliance was measured as youth- and therapist-rated alliance, and youth-therapist alliance discrepancy in session 3. Outcomes were diagnostic recovery and anxiety symptom reduction at post-treatment and one-year follow-up, and treatment dropout. We examined the direct effects of alliance-building on alliance, alliance on outcomes, and alliance-building on outcomes in multilevel mediation models, and between- versus within-therapist variance across these effects.

RESULTS

The alliance-building behaviors collaborate, present treatment model, and explore motivation positively predicted alliance, whereas actively structuring the session (i.e., dominating) negatively predicted alliance. The alliance-building behaviors attend to experience, collaborate, explore motivation, praise, and support positively predicted outcomes. The alliance-building behaviors present treatment model, express positive expectations, explore cognitions, and support negatively predicted outcomes. The effect of collaborate on symptom reduction was mediated by youth-therapist alliance discrepancy. There was almost zero between-therapist variance in alliance-building, and considerable within-therapist variance.

CONCLUSION

Therapist alliance-building behaviors were directly (positively and negatively) associated with alliance and/or outcomes, with only one effect mediated by alliance. Alliance-building behaviors varied far more within therapists (i.e., across clients) than between therapists.

The therapeutic alliance between the child, parents, and health professionals

Therapeutic alliance (TA), a term first used by Zetzel (1956), refers to the collaborative relationship between a patient and a therapist, leading to the development of an affective bond during the process of treatment/therapy and an agreement on treatment/therapy-related tasks and goals. Over time, it became clear that therapeutic alliance has a bidirectional nature, not unique to any one form of therapy but universal in all forms of helping relationships. Engagement of both patient and therapist is essential to its development. Trust, empathy, acceptance, and honesty are among the many constituents of a TA. Alongside this, characteristics of healthcare professionals influence TA, with a warm, empathic, gentle, and accepting therapist enhancing positive TA and a rigid, critical, and less involved therapist posing a hindrance to the development of TA. Literature is sparse for TA in children, and it also essentially involves multiple relationships, namely child alliance, caregiver alliance, and child-parent relationship, which need to be taken into account. Developmental aspects should also be kept in mind while dealing with children and adolescents. It is seen that a strong and positive caregiver alliance influences the development of child alliance. There are ways to foster TA with the child and parent/caregiver to maximize benefits from therapy.

Do caregivers' perspectives matter? Working alliances and treatment outcomes in trauma-focused cognitive behavioural therapy with children and adolescents

Background: Caregivers play a key role in the success of trauma-focused cognitive behavioural therapy (TF-CBT). Yet, the effect of their alliance on treatment outcomes besides the other parties in treatment has hardly been studied. Objective: This study examined the working alliance (WA) of therapists, patients and caregivers in TF-CBT and its contribution on treatment outcome over time. Methods: N = 76 children and adolescents (mean age = 12.66 years, range 7-17, M/F ratio: .43) participated in the TF-CBT arm of a randomized controlled trial. The WA was assessed with the Working Alliance Inventory Short Version (WAI-S) at two measurement points, while symptom level of posttraumatic stress symptoms (PTSS) was assessed with the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA). Paired sample t-tests, intraclass correlations (ICC), and mixed-effects regression models for longitudinal data were performed. Results: The alliance rating was high across all informants, with caregivers achieving the highest rating. The average level of cross-informant agreement on the alliance was low between therapists and caregivers (ICC = .26) and moderate between therapists and patients (ICC =.65). A significant contribution of an alliance improvement to the reduction of PTSS over time was found in each of the two tested models: therapists with patients model (b = .682) and therapists with caregivers model (b = .807). However, these effects were not detected with all four perspectives in one comprehensive model. Conclusion: In summary, the potential of caregivers' views should receive more attention in the therapeutic process of trauma-focused therapy.

The therapeutic alliance in cognitive-behavioral therapy for school-aged children with autism and clinical anxiety

Little is known about the alliance between therapists and children with autism spectrum disorder who are receiving psychological therapies in outpatient treatment settings. This study examined the therapeutic alliance in children with autism spectrum disorder and clinical anxiety, who were receiving cognitive behavioral therapy in a randomized, controlled trial. The Therapeutic Alliance Scale for Children was administered to a sample of children and youth with autism spectrum disorder and anxiety ( N = 64; aged 7–14) as well as to their parents and therapists. A comparison sample of typically developing youth with clinical anxiety ( N = 36; aged 5–12) was included. The child-therapist alliance was more positive among typically developing children than among children with autism spectrum disorder; correspondingly, the parent-therapist alliance was also more positive among parents of typically developing children. Therapist reports of positive child-therapist alliance predicted post-treatment reductions in anxiety among children with autism spectrum disorder, although child reports of this alliance did not. Parent reports of positive parent-therapist alliance also predicted post-treatment reductions in the child’s anxiety in the group with autism spectrum disorder. A strong therapeutic alliance appears to be associated with better treatment outcomes in children with autism spectrum disorder receiving cognitive behavioral therapy, although a thoughtful and diagnostically sensitive approach is advisable to promote a positive alliance with children with autism spectrum disorder.

Parent perspectives on the clinician-client relationship in speech-language treatment for children

Few studies have explored clinician-client relationships in speech-language treatment for children, although evidence indicates that these relationships may be important. Parents play a unique role in clinician-client relationships and their views have yet to be considered in the speech-language pathology literature. This study explored parents' perspectives on the clinician-client relationship in speech-language treatment for children using both quantitative and qualitative information. An online survey collected responses from 159 parents with children enrolled in speech-language services. Respondents were asked to complete a rating of the clinician-client relationship, provide information on length of treatment and treatment setting, and respond to open-ended questions about what enhances the clinician-client relationship. Length of treatment was unrelated to the parent rating of the clinician-client relationship. However, ratings did vary by treatment setting; parents of children enrolled in treatment services in schools provided lower ratings than parents with children enrolled in other settings. Thematic analysis of parent views on what enhances the clinician-client relationship yielded four main themes: qualities of the speech-language pathologist (SLP), session characteristics, the child-SLP bond, and communication. The most frequent subthemes in the analysis related to characteristics of the sessions: the integration of play and fun, and a child-oriented approach to sessions. These results provide insight into the development of clinician-client relationships in children's speech-language treatment, with implications for both clinicians and researchers.

The global therapist competence scale for youth psychosocial treatment: Development and initial validation

OBJECTIVE

We describe the development and initial psychometric properties of the observer-rated Global Therapist Competence Scale for Youth Psychosocial Treatment (G-COMP) in the context of cognitive-behavioral treatment (CBT) for youth anxiety disorders.

METHOD

Independent coders rated 744 sessions from a sample of 68 youth (mean age = 10.56 years) using the G-COMP and the instruments of alliance, involvement, CBT adherence, CBT competence.

RESULTS

Inter-rater reliability coefficients, ICC(2,2), were greater than .60 for the 5 G-COMP domain scores. G-COMP scores yielded small to medium correlations with instruments of alliance (rs = .17-.44) and youth involvement in treatment (rs = .08-.53), and medium to large correlations with instruments of CBT competence and adherence (rs = .26-.63). Therapists in the research setting were rated higher compared to newly trained therapists in community clinics.

CONCLUSION

Preliminary reliability and validity of the G-COMP are promising, but future research is needed with non-CBT samples.

Adaptation and implementation of family-based treatment enhanced with dialectical behavior therapy skills for anorexia nervosa in community-based specialist clinics

Although family-based therapy (FBT) is a well-established treatment for anorexia nervosa, its implementation and effectiveness in clinical settings has been neglected. A group of seven therapists at a community-based eating disorders clinic were trained in skills-enhanced FBT and provided treatment to 11 youth with anorexia nervosa. Family-based skills training, which borrowed heavily from dialectical behavior therapy, was introduced in four additional sessions and then integrated throughout the remainder of FBT. FBT was perceived as appropriate and acceptable by all participants. Therapists reported high treatment fidelity. There was a large improvement in weight and moderate improvement in caregiver-reported eating disorder psychopathology but no clinically significant change by youth report. This study provides preliminary data on the implementation and effectiveness of FBT in the community.

Measures of Parent Engagement for Children Receiving Developmental or Rehabilitation Interventions: A Systematic Review

AIM

To examine the conceptual and clinometric properties of measures for parent engagement in developmental or rehabilitation interventions for children and youth (<18 years of age).

METHODS

Four electronic databases were searched. Studies were included if they reported measures of at least one domain of parent engagement (i.e. affective, cognitive or behavioral). Reviewers independently identified measures and evaluated studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and the CanChild Outcome Measures Rating Form.

RESULTS

A total of 9,500 unique papers were retrieved, and 36 reported parent engagement measurement. Four measures met inclusion criteria: the Parent Involvement Index (PII), the Parent Participation Measure (PPM), the General Adherence subscale of the Medical Outcomes Study (GAMOS) and the Triadic Intervention and Evaluation Rating Scale (TIERS). No measure captured all domains of in-session parent engagement. Two addressed out-of-session parent engagement. There were limitations in validity and reliability.

CONCLUSIONS

Few measures of parent engagement are available. Existing measures mostly captured the behavioral domain of in-session engagement, and none assessed cognitive or affective aspects of engagement. Out-of-session engagement was infrequently captured. There is currently no comprehensive measure of parent engagement in pediatric developmental and rehabilitation services that demonstrates good clinical utility or is conceptually and psychometrically sound.

Motivation and treatment credibility predict alliance in cognitive behavioral treatment for youth with anxiety disorders in community clinics

OBJECTIVE

We examined whether motivation and treatment credibility predicted alliance in a 10-session cognitive behavioral treatment delivered in community clinics for youth anxiety disorders.

METHOD

Ninety-one clinic-referred youths (mean_age  = 11.4 years, standard deviation = 2.1, range 8-15 years, 49.5% boys) with anxiety disorders-rated treatment motivation at pretreatment and perceived treatment credibility after session 1. Youths and therapists (YT) rated alliance after session 3 (early) and session 7 (late). Hierarchical linear models were applied to examine whether motivation and treatment credibility predicted YT early alliance, YT alliance change, and YT alliance agreement.

RESULTS

Motivation predicted high early YT alliance, but not YT alliance change or alliance agreement. Youth-rated treatment credibility predicted high early youth alliance and high YT positive alliance change, but not early therapist alliance or alliance agreement.

CONCLUSION

Conclusion Efforts to enhance youth motivation and treatment credibility early in treatment could facilitate the formation of a strong YT alliance.

Patterns of Change in Collaboration Are Associated with Baseline Characteristics and Predict Outcome and Dropout Rates in Treatment of Multi-Problem Families. A Validation Study

Objective: The present study validates the Multi-Problem Family (MPF)-Collaboration Scale), which measures the progress of goal directed collaboration of patients in the treatment of families with MPF and its relation to drop-out rates and treatment outcome.

Method: Naturalistic study of symptom and competence-related changes in children of ages 4–18 and their caregivers.

Setting: Integrative, structural outreach family therapy.

Measures: The data of five different groups of goal directed collaboration (deteriorating collaboration, stable low collaboration, stable medium collaboration, stable high collaboration, improving collaboration) were analyzed in their relation to treatment expectation, individual therapeutic goals (ITG), family adversity index, severity of problems and global assessment of a caregiver’s functioning, child, and relational aspects.

Results: From N = 810 families, 20% displayed stable high collaboration (n = 162) and 21% had a pattern of improving collaboration. The families with stable high or improving collaboration rates achieved significantly more progress throughout therapy in terms of treatment outcome expectancy (d = 0.96; r = 0.43), reaching ITG (d = 1.17; r = 0.50), family adversities (d = 0.55; r = 0.26), and severity of psychiatric symptoms (d = 0.31; r = 0.15). Furthermore, families with stable high or improving collaboration maintained longer treatments and had a bigger chance of finishing the therapy as planned. The odds of having a stable low or deteriorating collaboration throughout treatment were significantly higher for subjects who started treatment with low treatment expectation or high family-related adversities.

Conclusion: The positive outcomes of homebased interventions for multi-problem families are closely related to “stable high” and an “improving” collaboration as measured with the MPF-Collaboration Scale. Patients who fall into these groups have a high treatment outcome expectancy and reduce psychological stress. For therapeutic interventions with multi-problem families it seems beneficial to maintain a stable high collaboration or help the collaboration, e.g., by fostering treatment expectation.

Clinicians' perspectives of therapeutic alliance in face-to-face and telepractice speech-language pathology sessions

PURPOSE

To investigate the face validity of a measure of therapeutic alliance for paediatric speech-language pathology and to determine whether a difference exists in therapeutic alliance reported by speech-language pathologists (SLPs) conducting face-to-face sessions, compared with telepractice SLPs or in their ratings of confidence with technology.

METHOD

SLPs conducting telepractice (n = 14) or face-to-face therapy (n = 18) completed an online survey which included the Therapeutic Alliance Scales for Children - Revised (TASC-r) (Therapist Form) to rate clinicians' perceptions of rapport with up to three clients. Participants also reported their overall perception of rapport with each client and their comfort with technology.

RESULT

There was a strong correlation between TASC-r total scores and overall ratings of rapport, providing preliminary evidence of TASC-r face validity. There was no significant difference between TASC-r scores for telepractice and face-to-face therapy (p = 0.961), nor face-to-face and telepractice SLPs' confidence with familiar (p = 0.414) or unfamiliar technology (p = 0.780).

CONCLUSION

The TASC-r may be a promising tool for measuring therapeutic alliance in speech-language pathology. Telepractice does not appear to have a negative effect on rapport between SLPs and paediatric clients. Future research is required to identify how SLPs develop rapport in telepractice.

Observer, youth, and therapist perspectives on the alliance in cognitive behavioral treatment for youth anxiety

This study examined the score reliability and validity of observer- (Therapy Process Observational Coding System for Child Psychotherapy-Alliance scale [TPOCS-A]; Vanderbilt Therapeutic Alliance Scale Revised, Short Form [VTAS-R-SF]), therapist- (Therapeutic Alliance Scale for Children Therapist Version [TASC-T]), and youth-rated (Therapeutic Alliance Scale for Children Child Version [TASC-C]) alliance instruments. Youths (N = 50) aged 7-15 (Mage = 10.28 years, SD = 1.84; 88.0% Caucasian; 60.0% male) diagnosed with a principal anxiety disorder received manual-based cognitive-behavioral treatment. Four independent coders, 2 using the TPOCS-A and 2 using the VTAS-R-SF, rated 2 sessions per case from early (Session 3) and late (Sessions 12) treatment. Youth and therapists completed the TASC-C and TASC-T at the end Session 3 and 12. Internal consistency of the alliance instruments was α > .80 and interrater reliability of the observer-rated instruments was ICC(2,2) > .75. The TPOCS-A, VTAS-R-SF, and TASC-T scores showed evidence of convergent validity. Conversely, the TASC-C scores failed to converge with the other instruments in a sample of children (age <11), but did converge in a sample of adolescents (age ≥11). Findings supported the predictive validity of the TASC-T and TASC-C scores. However, whereas the direction of the alliance-outcome association for both observer-rated instruments was in the expected direction for children (negative), the correlations were in the opposite direction for adolescents (positive). Overall, findings support the score reliability of observer- and therapist-report alliance instruments, but questions are raised about the score validity for the observer- and youth-report alliance instruments. (PsycINFO Database Record

Measuring Clinician-Client Relationships in Speech-Language Treatment for School-Age Children

PURPOSE

Clinician-client relationships may influence treatment success in speech-language pathology, but there are no established tools for measuring these relationships. This study describes the development and application of a set of scales for assessing clinician-client relationships in children's speech-language treatment.

METHOD

Twenty-two triads of participants completed a longitudinal study. Each triad had 1 school-age child enrolled in speech-language treatment, 1 caregiver, and 1 speech-language pathologist (SLP). The clinician-client relationship scales were administered to all 3 types of participants at study onset and again 2 weeks later. Treatment progress measures were collected 4 months later. Analyses established the reliability and validity of the clinician-client relationship scales.

RESULTS

Adequate internal consistency reliability and test-retest reliability were established for all 3 versions of the scale (child, caregiver, and SLP). Convergent validity was moderate between SLPs and children but lower when caregivers were included. Predictive validity analyses established significant relationships between caregiver and SLP ratings of the clinician-client relationship and future treatment progress.

CONCLUSIONS

This exploratory study established the viability of the clinician-client relationship scales for further development and application. The importance of establishing and utilizing measures of the clinician-client relationship in speech-language pathology is discussed.

Investigating treatment characteristics and first-session relationship variables as predictors of dropout in the treatment of traumatized youth

OBJECTIVE

Attrition is a common problem in youth trauma treatment, but there is currently little knowledge of why so many youths drop out. In this study, treatment variables (caregiver attendance in the first session and exposure vs. non-exposure-based treatment) and first-session process variables (the therapeutic alliance and youths' perceptions of parental treatment approval) were investigated as predictors of dropout.

METHOD

Participants (N = 156, mean age = 15.1) were randomly assigned to trauma-focused cognitive behavioral therapy or therapy as usual in a community trial.

RESULTS

Dropout (n = 39, 25.0%) was predicted by a lack of caregiver attendance, lower rates of youth-perceived parental treatment approval, and weaker therapist-rated youth alliance. Neither type of treatment, youth-rated alliance or caregiver alliance, predicted dropout.

CONCLUSIONS

The findings indicate that in addition to caregivers' actual participation in the first session, youths' perception of their parents' approval of treatment seems to influence treatment attendance. This finding implies that therapists should engage caregivers in therapy and address possible discordance in treatment goals and tasks. Furthermore, consistent with adult studies, exposure-based treatments do not appear to increase dropout rates.

Therapist-youth agreement on alliance change predicts long-term outcome in CBT for anxiety disorders

BACKGROUND

In individual cognitive behavioral therapy (ICBT) for youth anxiety disorders, it is unclear whether, and from whose perspective, the alliance predicts outcome. We examined whether youth- and therapist-rated alliance, including level of youth-therapist alliance agreement, predicted outcome in a randomized controlled trial.

METHODS

Youth (N = 91, M age = 11.4 years (SD = 2.1), 49.5% boys, 86.8% Caucasian) diagnosed with separation anxiety disorder, social phobia, or generalized anxiety disorder drawn from the ICBT condition of an effectiveness trial were treated with an ICBT program. Youth- and therapist-rated alliance ratings, assessed with the Therapeutic Alliance Scale for Children (TASC-C/T), were collected following session 3 (early) and 7 (late). Early alliance, change in alliance from early to late, and level of youth-therapist agreement on early alliance and alliance change were examined, in relation to outcomes collected at posttreatment and 1-year follow-up. Outcome was defined as primary diagnosis loss and reduction in clinicians' severity ratings (CSR; Anxiety Disorders Interview Schedule; ADIS-C/P) based on youth- and parent-report at posttreatment and follow-up, and youth treatment satisfaction collected at posttreatment (Client Satisfaction Scale; CSS).

RESULTS

Early TASC-C scores positively predicted treatment satisfaction at posttreatment. Higher levels of agreement on change in TASC-C and TASC-T scores early to late in treatment predicted diagnosis loss and CSR reduction at follow-up.

CONCLUSIONS

Only the level of agreement in alliance change predicted follow-up outcomes in ICBT for youth anxiety disorders. The findings support further examination of the role that youth-therapist alliance discrepancies may play in promoting positive outcomes in ICBT for youth anxiety disorders. Clinical trial number NCT00586586, clinicaltrials.gov.

The role of setting versus treatment type in alliance within youth therapy

OBJECTIVE

Does the strength of the youth-therapist alliance differ across treatment settings or treatment type? We examined these questions in the context of youth therapy.

METHOD

Eighty-nine youths (M age = 10.56, SD = 1.99; 63.70% Caucasian; 52.80% male) diagnosed with an anxiety disorder received (a) manual-based individual cognitive-behavioral therapy (ICBT) in a research setting, (b) manual-based ICBT in practice settings, or (c) nonmanualized usual care (UC) in practice settings. Coders, using the Therapy Process Observational Coding System-Alliance scale, rated 865 sessions. Youth completed the Therapeutic Alliance Scale for Children at posttreatment.

RESULTS

Youth who received ICBT in a research setting had significantly higher observer-rated alliance than youth who received either therapy delivered in practice settings. In practice settings, youth who received ICBT had significantly stronger observer-rated alliance early in treatment than youth in UC, but this difference was not observed at the end of treatment. Similarly, youth-report alliance at posttreatment was significantly higher in ICBT in the research setting, and there was no difference between ICBT and UC delivered in practice settings. Alliance differences largely held when controlling for youth characteristics; however, differences early in treatment between the ICBT groups were no longer statistically significant when controlling for anxiety severity or primary anxiety diagnosis.

CONCLUSIONS

Our findings suggest that (a) the alliance may be stronger in research settings, and (b) treatment manuals do not undermine alliance. Future research is required to help pinpoint whether other youth, therapist, or setting factors contribute to the lower alliance seen in practice settings.

Assessment of the therapeutic alliance of youth and parents with team members in youth residential psychiatry

Although therapeutic alliance is widely acknowledged as a key component for therapeutic change, its role is almost unknown in youth residential psychiatry. A likely reason for the lack of research is the absence of assessment tools and procedures for youth residential settings. This study assesses the psychometric properties of the Dutch version of the Family Engagement Questionnaire (FEQ), an alliance measure completed by team members. In addition, agreement among team members is explored. Eleven youth psychiatric day and inpatient units participated. Parent counsellors and case managers of 86 patients from 6 to 17 years old reported on the therapeutic alliance. Exploratory factor analysis of team members' reports resulted in meaningful structures, with child and parent alliance scales primarily corresponding to the conceptualization of the developers and earlier factor analysis. Internal reliability and validity were good for most of the subscales. The hypothesis that team members would show low levels of agreement in their reports of the therapeutic alliance was confirmed, demonstrating the need to include multiple team members in assessment procedures. Overall, this study underscores the psychometric properties of the Dutch version of the FEQ. Team members in residential youth psychiatric settings are encouraged to reflect regularly with their colleagues on the youth and parent therapeutic alliance.

The feasibility of improving CBT for childhood anxiety disorders through a dismantling study

This preliminary randomized controlled trial (RCT) examines the feasibility of dismantling cognitive behavioral therapy (CBT) for childhood anxiety disorders. Fourteen children (10 girls) ages 7 to 14 (m = 10.2) with social phobia, generalized anxiety disorder, separation anxiety disorder, or panic disorder were randomized to receive 6 sessions of either a) the pre-exposure anxiety management strategies presented in traditional CBT, or b) parent-coached exposure therapy. The sample was selected from a treatment seeking population and is representative of children in clinical settings. Examination of fidelity ratings, dropouts, and satisfaction ratings indicated that the interventions were distinguishable, safe, and tolerable. The overall sample improved significantly with pre-post effect sizes generally in the large range for both conditions. Between-group effect sizes indicating greater improvement with parent-coached exposure therapy were moderate or large for ten of 12 variables (i.e., 0.53 to 1.52). Re-evaluation after three months of open treatment suggested that the intervention emphasizing exposure early maintained its superiority while requiring fewer appointments.

A Measure of the Parent-Team Alliance in Youth Residential Psychiatry: The Revised Short Working Alliance Inventory

BACKGROUND

The therapeutic alliance between multidisciplinary teams and parents within youth (semi) residential psychiatry is essential for the treatment process and forms a promising process variable for Routine Outcome Monitoring (ROM). No short evaluative instrument, however, is currently available to assess parent-team alliance.

OBJECTIVE

In this study, the Working Alliance Inventory-Short Version (WAV-12), a widely used alliance questionnaire, was adjusted to assess parent-team alliance from both a parent and team perspective within a youth residential setting. Psychometric properties, including factor structure and validity of the subscales, were explored.

METHODS

A sample of youth with mainly complex developmental disorders admitted to 11 inpatient and day patient units of a child and adolescent psychiatric institute participated in this study. The case manager involved with the youth and the primary caregiver of 87 youth completed the revised WAV-12 (WAV-12R).

RESULTS

The team version of the WAV-12R showed a good fit to the original conceptualized model, and distinguished Bond, Task and Goal scales. For the parents' version an adjusted model with Insight, Bond and combined Task/Goal scales had the best fit. The reliability and validity of the scales were shown to be good.

CONCLUSIONS

This paper presents preliminary evidence that the parent and treatment team versions of the WAV-12R are psychometrically sound for assessing parent-team alliance within youth (semi) residential psychiatry in the Netherlands. The team and parents' versions of the WAV-12R are recommended instruments to complement outcome measures in ROM.

Therapist and client perspectives on the alliance in the treatment of traumatized adolescents

OBJECTIVE

Client ratings of the therapeutic alliance are an important predictor of outcome in the treatment of traumatized adolescents and adults, but less is known about the therapists' perspective. The aim of this study was to investigate how therapists' ratings relate to the adolescents' perspective, how individual therapist and adolescent ratings relate to change in symptoms and treatment satisfaction, and whether discrepant alliance perspectives impact treatment outcome.

METHOD

The sample consisted of 156 youth (mean age 15.1, range 10-18), randomized to trauma-focused cognitive behavioral therapy or treatment as usual, and alliance ratings from 62 therapists. Alliance was measured midtreatment with the Therapeutic Alliance Scale for Children, and the factor structure of the two scales was analyzed with exploratory factor analyses. A change in posttraumatic symptoms was assessed with the Child PTSD Symptom Scale (CPSS) and the Clinicial-Administered PTSD Scale for Children and Adolescents (CAPS-CA).

RESULTS

Therapist and client perspectives on the alliance were significantly, but moderately, associated (intraclass correlations [ICC]=0.54, p<0.001). Both scales predicted adolescent treatment satisfaction but only the client scale was significantly related to change in symptoms. Factor analyses revealed differences in factor structure with therapist ratings organized around bond and task dimensions and adolescent ratings organized by item valence. Higher therapist ratings compared to adolescent ratings predicted higher residual PTS symptoms.

DISCUSSION

Although adolescent and therapist alliance ratings are moderately associated, results suggest that the ratings are differentially associated with outcomes. These findings, along with results indicating important differences in factor structure, imply that adolescent and therapist ratings are not interchangeable. Future studies should investigate how therapists can improve their judgments of adolescents' perceptions of the alliance as an overestimation of the quality of the relationship seems to be negatively related to outcome.

Child, caregiver, and therapist perspectives on therapeutic alliance in usual care child psychotherapy

This study examined the temporal stability and cross-informant agreement on multiple perspectives of child and caregiver alliance with therapists in usual care psychotherapy. Baseline predictors of alliance were also examined. Children with disruptive behavior problems (n = 209) and their caregivers were followed for up to 16 months after initiating psychotherapy at a community-based clinic. Alliance was rated by children, caregivers, and therapists every 4 months for as long as families participated in treatment. Repeated-measures analyses using linear mixed models with random intercepts were conducted to determine whether child and caregiver alliance differed across time, as well to examine factors associated with each perspective on alliance. Intraclass correlations between child, caregiver, and therapist reports of alliance were also examined. Alliance was rated relatively high overall across perspectives. Clients (children and caregivers) tended to report the strongest and most stable alliance, while therapists reported the weakest alliance and perceived deteriorations in child alliance over time. Inter-informant agreement was variable for child and caregiver alliance; agreement was moderate between clients and therapists. Several predictors of alliance emerged, including child gender, anxiety diagnosis, caregiver race/ethnicity, and therapist experience. This study provides methodological information about reports of therapeutic alliance across time and informants that can inform current efforts to understand the alliance-outcome association.

Searching for elements of evidence-based practices in children's usual care and examining their impact

Most of the knowledge generated to bridge the research-practice gap has been derived from experimental studies implementing specific treatment models. Alternatively, this study uses observational methods to generate knowledge about community-based treatment processes and outcomes. Aims are to (a) describe outcome trajectories for children with disruptive behavior problems (DBPs), and (b) test how observed delivery of a benchmark set of practice elements common in evidence-based treatments may be associated with outcome change while accounting for potential confounding variables. Participants included 190 children ages 4 to 13 with DBPs and their caregivers, plus 85 psychotherapists, recruited from six clinics. All treatment sessions were videotaped and a random sample of 4 sessions in the first 4 months of treatment was reliably coded for intensity on 27 practice elements (benchmark set and others). Three outcomes (child symptom severity, parent discipline, and family functioning) were assessed by parent report at intake, 4, and 8 months. Data were collected on several potential covariates including child, parent, therapist, and service use characteristics. Multilevel modeling was used to assess relationships between observed practice and outcome slopes while accounting for covariates. Children and families demonstrated improvements in all 3 outcomes, but few significant associations between treatment processes and outcome change were identified. Families receiving greater intensity on the benchmark practice elements did demonstrate greater improvement in the parental discipline outcome. Observed changes in outcomes for families in community care were generally not strongly associated with the type or amount of treatment received.