Bryce D. McLeod

The Therapy Process Observational Coding System Alliance scale: Measure characteristics and prediction of outcome in usual clinical practice

The authors describe psychometric characteristics of the new Therapy Process Observational Coding System-Alliance scale (TPOCS-A; B. D. McLeod, 2001) and illustrate its use in the study of treatment as usual. The TPOCS-A uses session observation to assess child-therapist and parent-therapist alliance. Both child and parent forms showed acceptable interrater reliability and internal consistency; when applied to cases treated for internalizing disorders, both forms were associated with youth outcomes. Child-therapist alliance during treatment predicted reduced anxiety symptoms at the end of treatment. Parent-therapist alliance during treatment predicted reduced internalizing, anxiety, and depression symptoms at the end of treatment. The findings held up well after confounding variables were controlled, which suggests that both child-therapist and parent-therapist alliance play key (and potentially different) roles in the outcome of treatment as usual.

Cognitive-Behavioral Therapy versus Usual Clinical Care for Youth Depression: An Initial Test of Transportability to Community Clinics and Clinicians

Community clinic therapists were randomized to (a) brief training and supervision in cognitive-behavioral therapy (CBT) for youth depression or (b) usual care (UC). The therapists treated 57 youths (56% girls), ages 8-15, of whom 33% were Caucasian, 26% were African American, and 26% were Latino/Latina. Most youths were from low-income families and all had Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) depressive disorders (plus multiple comorbidities). All youths were randomized to CBT or UC and treated until normal termination. Session coding showed more use of CBT by CBT therapists and more psychodynamic and family approaches by UC therapists. At posttreatment, depression symptom measures were at subclinical levels, and 75% of youths had no remaining depressive disorder, but CBT and UC groups did not differ on these outcomes. However, compared with UC, CBT was (a) briefer (24 vs. 39 weeks), (b) superior in parent-rated therapeutic alliance, (c) less likely to require additional services (including all psychotropics combined and depression medication in particular), and (d) less costly. The findings showed advantages for CBT in parent engagement, reduced use of medication and other services, overall cost, and possibly speed of improvement--a hypothesis that warrants testing in future research.

Does Cognitive Behavioral Therapy for Youth Anxiety Outperform Usual Care in Community Clinics? An Initial Effectiveness Test.

OBJECTIVE Most tests of cognitive behavioral therapy (CBT) for youth anxiety disorders have shown beneficial effects, but these have been efficacy trials with recruited youths treated by researcher-employed therapists. One previous (nonrandomized) trial in community clinics found that CBT did not outperform usual care (UC). The present study used a more stringent effectiveness design to test CBT versus UC in youths referred to community clinics, with all treatment provided by therapists employed in the clinics. METHOD A randomized controlled trial methodology was used. Therapists were randomized to training and supervision in the Coping Cat CBT program or UC. Forty-eight youths (56% girls, 8 to 15 years of age, 38% Caucasian, 33% Latino, 15% African-American) diagnosed with DSM-IV anxiety disorders were randomized to CBT or UC. RESULTS At the end of treatment more than half the youths no longer met criteria for their primary anxiety disorder, but the groups did not differ significantly on symptom (e.g., parent report, eta-square = 0.0001; child report, eta-square = 0.09; both differences favoring UC) or diagnostic (CBT, 66.7% without primary diagnosis; UC, 73.7%; odds ratio 0.71) outcomes. No differences were found with regard to outcomes of comorbid conditions, treatment duration, or costs. However, youths receiving CBT used fewer additional services than UC youths (χ(2)(1) = 8.82, p = .006). CONCLUSIONS CBT did not produce better clinical outcomes than usual community clinic care. This initial test involved a relatively modest sample size; more research is needed to clarify whether there are conditions under which CBT can produce better clinical outcomes than usual clinical care. CLINICAL TRIAL REGISTRY INFORMATION: Community Clinic Test of Youth Anxiety and Depression Study, URL: http://clinicaltrials.gov, unique identifier: NCT01005836.

The Therapy Process Observational Coding System for Child Psychotherapy Strategies Scale

Most everyday child and adolescent psychotherapy does not follow manuals that document the procedures. Consequently, usual clinical care has remained poorly understood and rarely studied. The Therapy Process Observational Coding System for Child Psychotherapy–Strategies scale (TPOCS–S) is an observational measure of youth psychotherapy procedures designed to support the study of usual clinical care by providing a means of characterizing it. Coders independently rated usual care therapy sessions conducted with 43 children (aged 8–15 years) diagnosed with anxiety and depressive disorders. The TPOCS–S showed good interrater reliability, its 5 subscales (e.g., Behavioral, Cognitive, Psychodynamic, Client-Centered, Family) showed good internal consistency, and analyses supported TPOCS–S validity.

Examining the relation between the therapeutic alliance, treatment adherence, and outcome of cognitive behavioral therapy for children with anxiety disorders.

Little is known about the contribution of technical and relational factors to child outcomes in cognitive behavioral therapy (CBT) for children with anxiety disorders. This study investigated the association between treatment adherence, the child-therapist alliance, and child clinical outcomes in manual-guided individual- and group-based CBT for youths diagnosed with anxiety disorders. Trained observers rated tapes of therapy sessions for treatment adherence and child-therapist alliance in a sample of 52 children (aged 8 to 12) with anxiety disorders. Self-reported child anxiety was assessed at pre-, mid-, and posttreatment; parent-reported child internalizing symptoms was assessed at pre- and posttreatment. The results showed high levels of treatment adherence and child-therapist alliance in both CBT programs. Neither treatment adherence nor child-therapist alliance predicted traditional measurements of child outcomes in the present study, but a relation between alliance and outcome was found using a more precise estimation of the true pre-post differences. Implications of these findings for expanding our understanding of how treatment processes relate to child outcome in CBT for children with anxiety disorders are discussed.

Child–therapist alliance and clinical outcomes in cognitive behavioral therapy for child anxiety disorders

BACKGROUND Few studies have examined the link between child-therapist alliance and outcome in manual-guided cognitive behavioral therapy (CBT) for children diagnosed with anxiety disorders. This study sought to clarify the nature and strength of this relation. METHODS The Therapy Process Observational Coding System for Child Psychotherapy - Alliance scale (TPOCS-A; McLeod, 2005) was used to assess the quality of the child-therapist alliance. Coders independently rated 123 CBT therapy sessions conducted with 34 children (aged 6-13 years) diagnosed with anxiety disorders. Parents reported on childrens symptomatology at pre- mid-, and post-treatment. RESULTS A stronger child-therapist alliance early in treatment predicted greater improvement in parent-reported outcomes at mid-treatment but not post-treatment. However, improvement in the child-therapist alliance over the course of treatment predicted better post-treatment outcomes. CONCLUSIONS The quality of the child-therapist alliance assessed early in treatment may be differentially associated with symptom reduction at mid- and post-treatment. Results underscore the importance of assessing the relation between alliance and outcome over the course of therapy to clarify the role the child-therapist alliance plays in child psychotherapy.

Do Treatment Manuals Undermine Youth-Therapist Alliance in Community Clinical Practice?

OBJECTIVE Some critics of treatment manuals have argued that their use may undermine the quality of the client-therapist alliance. This notion was tested in the context of youth psychotherapy delivered by therapists in community clinics. METHOD Seventy-six clinically referred youths (57% female, age 8-15 years, 34% Caucasian) were randomly assigned to receive nonmanualized usual care or manual-guided treatment to address anxiety or depressive disorders. Treatment was provided in community clinics by clinic therapists randomly assigned to treatment condition. Youth-therapist alliance was measured with the Therapy Process Observational Coding System--Alliance (TPOCS-A) scale at 4 points throughout treatment and with the youth report Therapeutic Alliance Scale for Children (TASC) at the end of treatment. RESULTS Youths who received manual-guided treatment had significantly higher observer-rated alliance than usual care youths early in treatment; the 2 groups converged over time, and mean observer-rated alliance did not differ by condition. Similarly, the manual-guided and usual care groups did not differ on youth report of alliance. CONCLUSIONS Our findings did not support the contention that using manuals to guide treatment harms the youth-therapist alliance. In fact, use of manuals was related to a stronger alliance in the early phase of treatment.

Anxiety in youth with and without autism spectrum disorder: Examination of factorial equivalence

Although anxiety is frequently reported among children and adolescents with autism spectrum disorder (ASD), it has not been established that the manifest symptoms of anxiety in the context of ASD are the same as those seen in youth without ASD. This study sought to examine the metric and latent factor equivalence of anxiety as measured by the Multidimensional Anxiety Scale for Children, parent-report (MASC-P) and child-report (MASC-C), in youth with anxiety disorders and ASD with intact verbal ability (n=109, M(age)=11.67 years, 99 male) and a gender-matched comparison group of typically developing (TD) children and adolescents with anxiety disorders but without ASD (n=342, M(age)=11.25 years, 246 male). Multigroup factorial invariance (MFI) using structural equation modeling indicated equivalent latent factors in youth with and without ASD on the MASC-C (metric invariance). However, the item means and covariances along with the relations among the factor scores were different for the youth with ASD (i.e., lack of evidence for scalar or structural invariance). The MASC-P data did not fit the measures established structure for either the ASD or TD group, and post-hoc exploratory factor analysis revealed a different factor structure in the ASD group. Findings suggest that the MASC-C may not measure identical constructs in anxious youth with and without ASD. Further research on the structure of the MASC in clinical samples is warranted.

Effectiveness of Modular CBT for Child Anxiety in Elementary Schools.

Most randomized controlled trials of cognitive-behavioral therapy (CBT) for children with anxiety disorders have evaluated treatment efficacy using recruited samples treated in research settings. Clinical trials in school settings are needed to determine if CBT can be effective when delivered in real world settings. This study evaluated a modular CBT program for childhood anxiety disorders in two elementary schools. Forty children (5-12 years old) with anxiety disorders, referred by teachers and school staff, were randomly assigned to modular CBT or a 3-month waitlist. Clinicians worked with individual families as well as teachers and school staff. Evaluators blind to treatment condition conducted structured diagnostic interviews and caregivers and children completed symptom checklists at pre- and posttreatment. The primary study outcome, the Clinical Global Impressions-Improvement scale, yielded a positive treatment response at posttreatment for 95.0% of CBT participants, as compared with only 16.7% of the waitlist participants. CBT also outperformed the waitlist on diagnostic outcomes and caregiver-report measures of anxiety. Treatment effects did not extend beyond anxiety diagnoses and symptoms. Results suggest that modular CBT delivered within the elementary school setting may be effective for the treatment of child anxiety disorders. A replication of the study results with a larger sample is indicated.

Parenting and Child Anxiety Disorders

What role does parenting play in the development, maintenance, and amelioration of child anxiety? In this chapter, we address this question by reviewing the current state of knowledge regarding the nature and direction of the relationship between parenting and child anxiety. Numerous theoretical models outline the role that various parenting practices may play in the development, maintenance, and amelioration of childhood anxiety. These models vary in terms of their precision and specificity. Traditional models of childhood anxiety focused primarily on broad parenting dimensions of acceptance and psychological control (see Gerlsma, Emmelkamp, & Arrindell, 1990; Masia & Morris, 1998; Rapee, 1997). However, these broad parenting dimensions have fallen out of favor in recent years as meta-analyses have demonstrated that these dimensions explain little of the variance in child anxiety (McLeod, Wood, & Weisz, 2007; van der Bruggen, Stams, & Bogels, 2008). Consequently, experts have issued calls for a move toward a more precise study of the parenting–child anxiety linkage (McLeod et al., 2007; Wood, McLeod, Sigman, Hwang, & Chu, 2003). In response, the field has adopted a more microscopic approach with greater theoretical specificity that focuses upon particular salient parenting practices that may influence children’s acquisition of fear.