Using Adherence and Competence Measures Based on Practice Elements to Evaluate Treatment Fidelity for Two CBT Programs for Youth Anxiety.

Measures designed to assess the quantity and quality of practices found across treatment programs for specific youth emotional or behavioral problems may be a good fit for evaluating treatment fidelity in effectiveness and implementation research. Treatment fidelity measures must demonstrate certain reliability and validity characteristics to realize this potential. This study examines the extent to which two observational measures, the Cognitive-Behavioral Treatment for Anxiety in Youth Adherence Scale (CBAY-A) and the CBAY Competence Scale (CBAY-C), can assess the quantity (the degree to which prescribed therapeutic techniques are delivered as intended) or quality (the competence with which prescribed techniques are delivered) of practices found in two distinct treatment programs for youth anxiety. Treatment sessions (N = 796) from 55 youth participants (M age = 9.89 years, SD = 1.71; 46% female; 55% White) with primary anxiety problems who participated in an effectiveness study were independently coded by raters who coded quantity, quality, and the youth-clinician alliance. Youth received one of three treatments: (a) standard (i.e., cognitive-behavioral therapy program), (b) modular (i.e., a cognitive-behavioral and parent-training program), and (c) usual clinical care. Interrater reliability for the CBAY-A items was good across the standard and modular conditions but mixed for the CBAY-C items. Across the standard and modular conditions, the CBAY-A Model subscale scores demonstrated evidence of construct validity, but the CBAY-C Model subscale scores showed mixed evidence. The results provide preliminary evidence that the CBAY-A can be used across different treatment programs but raise concerns about the generalizability of the CBAY-C.

The Content of Usual Clinical Care for Youth with Primary Anxiety Problems.

The current study was designed to describe usual clinical care for youth with primary anxiety problems in community mental health centers. The observer-rated Therapy Process Observational Coding System for Child Psychotherapy - Revised Strategies scale (TPOCS-RS), designed to assess therapeutic techniques from five theory-based domains, was used to code sessions (N = 403) from the usual clinical care group of two randomized effectiveness trials: (a) Youth Anxiety Study (YAS) with 21 youth (M age = 10.44 years, SD = 1.91; 49.2% Latinx; 46.6%, 53.4% male) and 16 clinicians (77.5% female; 43.8% White), and (b) Child STEPS Multisite Trial with 17 youth (M age = 10.00 years, SD = 1.87; 58.8% male; 41.2% White) and 13 clinicians (M age = 40.00 years; SD = 9.18; 76.9% female; 61.5% White). The average number of TPOCS-RS items observed per treatment session was more than 10, and multiple techniques were used together in each session. All TPOCS-RS items were observed at least once throughout a clinical case, and most items reoccurred (i.e., observed in two or more sessions). The dosage of TPOCS-RS in all items was below 5 on a 7-point scale. In conclusion, clinicians in both usual care samples used a wide range of techniques from several theory-based domains at a low to medium dose. However, the type and dosage of the techniques used did vary across the two samples.

Science for behavioral health systems change: evolving research-policy-public partnerships.

Potent partnerships among researchers, policymakers, and community members have potential to produce positive changes in communities on a range of topics, including behavioral health. The paper provides a brief illustrative review of such partnerships and then describes the development and evolution of one partnership in particular in Virginia. The origin of the partnership is traced, along with its founding vision, mission, and values. Some of its several projects are described, including (a) needs assessment for implementation of evidence-based programs (EBPs) pursuant to the Family First Prevention Services Act; (b) statewide fidelity monitoring of key EBPs; and (c) projects to synergize state investments in specific EBPs, like multisystemic therapy, functional family therapy, and high fidelity wraparound. The paper concludes with some themes around which the center has evolved to serve the state and its citizens more effectively.

Core Elements of Family Therapy for Adolescent Behavioral Health Problems: Validity Generalization in Community Settings.

OBJECTIVE: The core elements of family therapy for adolescent mental health and substance use problems, originally distilled from high-fidelity sessions conducted by expert clinicians, were tested for validity generalization when delivered by community therapists in routine settings. METHOD: The study sampled recorded sessions from 161 cases participating in one of three treatment pools: implementation trial of Functional Family Therapy (98 sessions/50 cases/22 therapists), adaptation trial of Multisystemic Therapy (115 sessions/59 cases/2 therapists), and naturalistic trial of non-manualized family therapy in usual care (107 sessions/52 cases/21 therapists). Adolescents were identified as 60% male and 40% female with an average age of 15.4 years; 49% were Latinx, 27% White Non-Latinx, 15% African American, 3% another race/ethnicity, 6% race/ethnicity unknown. Session recordings (n = 320) were randomly selected for each case and coded for 21 discrete family therapy techniques. Archived data of one-year clinical outcomes were gathered. RESULTS: Confirmatory factor analyses replicated the factor structure from the original distillation study, retaining all four clinically coherent treatment modules comprised of all 21 techniques: Interactional Change (ICC = .77, Cronbach's α = .81); Relational Reframe (ICC = .75, α = .81); Adolescent Engagement (ICC = .72, α = .78); Relational Emphasis (ICC = .76, α = .80). Exploratory analyses found that greater use of core techniques predicted symptom improvements in one treatment pool. CONCLUSIONS: Core techniques of family therapy distilled from manualized treatments for adolescent behavioral health problems showed strong evidence of validity generalization, and initial evidence of links to client outcomes, in community settings.

Can a Single Measure Estimate Protocol Adherence for Two Psychosocial Treatments for Youth Anxiety Delivered in Community Mental Health Settings?

Treatment adherence measurement can be time and resource-intensive in clinical trials, so the ability to measure protocol adherence for two distinct treatment programs with a single measure may benefit the field. The present study sought to determine if the Therapy Process Observational Coding System - Revised Strategies Scale (TPOCS-RS) could assess protocol adherence to two youth treatment programs. Treatment sessions (N = 796) from 55 youth (M age = 9.89 years, SD = 1.71; range 7-15 years; 55.0% White; 46.0% female) with primary anxiety problems treatment by 39 clinicians (M age = 40.54 years, SD = 9.56; 50.0% White; 80.0% female) were independently scored by coders using observational treatment adherence and alliance measures. The youth received one of three treatments: (a) Standard (i.e., cognitive-behavioral treatment program), (b) Modular (i.e., a program with cognitive-behavioral and parent training components), or (c) Usual Care. Consultants filled out a self-report measure of protocol adherence within the Standard and Modular conditions. Interrater reliability, ICC(2,2) for the various items for the full sample ranged from .17 to .92 (M ICC = .67; SD = .17). Scores from a TPOCS-RS subscale that mapped onto the specific content of the treatment protocols used in the Standard and Modular conditions evidenced convergent validity with the consultant-report adherence measure and discriminant validity with the alliance measure. The model-specific TPOCS-RS subscales also discriminated between the Standard and Modular treatments and Usual Care. This study provides initial evidence that (a) the TPOCS-RS has utility in estimating protocol adherence in different treatment programs and (b) support the score validity of the self-report consultation records.

Development and Initial Psychometrics of a Generic Treatment Integrity Measure Designed to Assess Practice Elements Targeting Social, Emotional, and Behavioral Outcomes in Early Childhood Settings.

Though treatment integrity measurement is important for research intended to promote social and behavioral outcomes of children at risk for emotional and behavioral disorders (EBDs) in early childhood settings, measurement gaps exist in the field. This paper reports on the development and preliminary psychometric assessment of the treatment integrity measure for early childhood settings (TIMECS), an observational measure designed to address existing measurement gaps related to treatment integrity with tier 2 interventions in the early childhood field. To assess the preliminary score reliability (interrater) and validity (construct, discriminant) of the TIMECS, live observations (N = 650) in early childhood classrooms from 54 teachers (92.6% female, 7.4% male; 61.1% White) and 91 children (M age = 4.53 years, SD = .44; 45.1% female, 54.9% male; 45.1% Black) at risk for EBDs were scored by 12 coders using the TIMECS and an observational measure designed to assess teacher-child interactions. Teachers also self-reported on the quality of the teacher-child relationship. Interrater reliability (intraclass correlation coefficients, ICC [2,2]) for the quantity (i.e., adherence) item scores had a mean of .81 (SD = .07; range from .68 to .95), and the quality (i.e., competence) item scores had a mean of .69 (SD = .08; range from .52 to .80). Scores on the TIMECS Quantity and Quality items and scales showed evidence of construct validity, with the magnitude of the correlations suggesting that the quantity and quality items assess distinct components of treatment integrity. A TIMECS quantity scale also showed promise for intervention evaluation research by discriminating between teachers who had and had not been trained in a specific evidence-based intervention targeting social and behavioral skills in early childhood. The findings support the potential of the TIMECS to assess treatment integrity of teacher-delivered practices designed to address child social and behavioral outcomes of children at risk for EBDs in early childhood settings.

Examining the Relation Between Technical and Global Competence in Two Treatments for Youth Anxiety.

Although technical (quality of delivering techniques from a specific treatment) and global (general clinical expertise) competence are believed to be important ingredients of successful psychosocial treatment with youth, there have been few empirical efforts to measure both dimensions. Efforts to understand the role that each competence dimension plays in the process and outcome of youth treatment starts with determining whether the dimensions can be measured separately. This study examined whether scores from measures designed to assess technical and global competence were distinct. Treatment sessions (N = 603) from 38 youths (M age = 9.84 years, SD = 1.65; 60.5% White; 52.6% male) treated for primary anxiety problems within a randomized effectiveness trial were coded. Four coders used observational measures designed to assess technical competence, global competence, protocol adherence, and the alliance. Mean item interrater reliability was .70 (SD = .09) for technical competence and .66 (SD = .05) for global competence. While most components of global competence were distinct from technical competence scores, two components showed redundancy (r > .70). Scores on both competence measures were empirically distinct (r < .70) from scores on measures of protocol adherence and the alliance. Although the measures did not fully distinguish between technical and global competence, our findings do indicate that some components of technical and global competence may provide unique information about competence.

Reliability, factor structure, and validity of an observer-rated alliance scale with youth.

Measurement limitations lessen the conclusions about the role of the alliance in youth psychosocial treatment. This article examined the score reliability, factor structure, and validity of the 9-item Therapy Process Observational Coding System for Child Psychotherapy-Alliance scale (TPOCS-A). The sample, 51 youth aged 7-15 years (Mage = 10.36 years, SD = 1.90; 86.3% White; 60.8% male, 39.2% female), met diagnostic criteria for a principal anxiety disorder and received cognitive-behavioral therapy. Treatment sessions (N = 463) were coded by independent coders using the TPOCS-A along with observational measures of treatment adherence and therapist competence. Youth and therapists also completed self-report alliance measures at the end of each session. Reliability estimates, ICC(2,2), at the item level indicated a mean interrater reliability of .68 (SD = .10) and a mean coder stability of .64 (SD = .11). An exploratory factor analysis identified a one-factor solution with five items. TPOCS-A scores evidenced convergent validity with the therapist and adolescent reports of alliance but did not converge with the child-report alliance measure. TPOCS-A scores evidenced discriminant validity when compared with scores on adherence and competence measures. The reliability and validity profile of the 9- and 5-item versions of the TPOCS-A were similar. Overall, findings support the reliability and validity of the TPOCS-A scores, but questions remain about how best to assess the alliance with children. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Are therapist adherence and competence related to clinical outcomes in cognitive-behavioral treatment for youth anxiety?

INTRODUCTION: Studies have found that psychological treatments produce positive clinical outcomes for many problems experienced by youth. However, there is limited research on whether therapist adherence and competence in delivering these treatments are related to differential clinical outcomes. METHOD: We examined the relationship of therapist adherence and competence to clinical outcomes in a sample of 51 youth aged 7-14 years (M age = 10.36, SD = 1.90; 86.3% white; 60.8% male) treated for anxiety disorders with a manualized individual cognitive-behavioral therapy. Adherence and competence were measured via coding of recorded treatment session content and outcomes were measured by caregiver and youth report across multiple timepoints. We used two-level mixed-effects regression models to test the degree to which adherence and competence predicted differential youth clinical outcomes. RESULTS: Across multiple caregiver- and child-reported symptom and diagnostic outcomes, we found no statistically significant relationship between adherence or competence and clinical outcomes. DISCUSSION: Although there was variability in both treatment integrity and clinical outcome, neither adherence to nor competence in youth anxiety treatment was related to clinical outcomes for youth with anxiety disorders treated with individual cognitive-behavioral treatment (CBT) in a research clinic-based efficacy trial. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessing Stakeholder Perceptions of the Utility of Genetic Information for the Clinical Care of Mental Health Disorders: We Have a Will but Need to See the Way.

Academic stakeholders' (primarily mental health researchers and clinicians) practices and attitudes related to the translation of genetic information into mental health care were assessed. A three-part survey was administered at two large, urban universities. Response frequencies were calculated. Participants (N = 64) reported moderate levels of translational practice, adequate levels of genetic knowledge, and variable levels of genetic competence. They held positive attitudes toward translating genetic information about mental health broadly but negative attitudes about the impact that such information would have on specific aspects of care. The current study lays the groundwork for further inquiry into translating genetic information to mental health care.

Examining How CBT Interventions for Anxious Youth Are Delivered Across Settings.

Most efforts to assess treatment integrity-the degree to which a treatment is delivered as intended-have conflated content (i.e., therapeutic interventions) and delivery (i.e., strategies for conveying the content, such as modeling). However, there may be value in measuring content and delivery separately. This study examined whether the quantity (how much) and quality (how well) of delivery strategies for individual cognitive behavioral therapy (ICBT) for youth anxiety varied when the same evidence-based treatment was implemented in research and community settings. Therapists (N = 29; 69.0% White; 13.8% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.4% white; 52.9% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols for therapists were comparable across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess the quantity and quality of delivery of interventions found in ICBT approaches. Overall, both the quantity and quality of delivery of interventions found in ICBT approaches were significantly lower in the community settings. The extent to which didactic teaching, collaborative teaching, and rehearsal were used systematically varied over the course of treatment. In general, differences in the quantity and quality of delivery observed between settings held when differences in youth characteristics between settings were included in the model. Our findings suggest the potential relevance of measuring how therapists deliver treatment separate from the content.

Generalizability and Decision Studies of a Treatment Adherence Instrument.

Observational measurement of treatment adherence has long been considered the gold standard. However, little is known about either the generalizability of the scores from extant observational instruments or the sampling needed. We conducted generalizability (G) and decision (D) studies on two samples of recordings from two randomized controlled trials testing cognitive-behavioral therapy for youth anxiety in two different contexts: research versus community. Two doctoral students independently coded 543 session recordings from 52 patients treated by 13 therapists. The initial G-study demonstrated that context accounted for a disproportionately large share of variance, so we conducted G- and D-studies for the two contexts separately. Results suggested that reliable cognitive-behavioral therapy adherence studies require at least 10 sessions per patient, assuming 12 patients per therapists and two coders-a challenging threshold even in well-funded research. Implications, including the importance of evaluating alternatives to observational measurement, are discussed.

Testing Robustness of Child STEPs Effects with Children and Adolescents: A Randomized Controlled Effectiveness Trial.

A critical task in psychotherapy research is identifying the conditions within which treatment benefits can be replicated and outside of which those benefits are reduced. We tested the robustness of beneficial effects found in two previous trials of the modular Child STEPs treatment program for youth anxiety, depression, trauma, and conduct problems. We conducted a randomized trial, with two significant methodological changes from previous trials: (a) shifting from cluster- to person-level randomization, and (b) shifting from individual to more clinically feasible group-based consultation with STEPs therapists. Fifty community clinicians from multiple outpatient clinics were randomly assigned to receive training and consultation in STEPs (n= 25) or to provide usual care (UC; n= 25). There were 156 referred youths-ages 6-16 (M= 10.52, SD = 2.53); 48.1% male; 79.5% Caucasian, 12.8% multiracial, 4.5% Black, 1.9% Latino, 1.3% Other-who were randomized to STEPs (n= 77) or UC (n= 79). Following previous STEPs trials, outcome measures included parent- and youth-reported internalizing, externalizing, total, and idiographic top problems, with repeated measures collected weekly during treatment and longer term over 2 years. Participants in both groups showed statistically significant improvement on all measures, leading to clinically meaningful problem reductions. However, in contrast to previous trials, STEPs was not superior to UC on any measure. As with virtually all treatments, the benefits of STEPs may depend on the conditions-for example, of study design and implementation support-in which it is tested. Identifying those conditions may help guide appropriate use of STEPs, and other treatments, in the future.

Core Elements of Family Therapy for Adolescent Behavior Problems: Empirical Distillation of Three Manualized Treatments.

Family therapy has the strongest evidence base for treating adolescent conduct and substance use problems, yet there remain substantial barriers to widespread delivery of this approach in community settings. This study aimed to promote the feasibility of implementing family-based interventions in usual care by empirically distilling the core practice elements of three manualized treatments. The study sampled 302 high-fidelity treatment sessions from 196 cases enrolled in 1 of 3 manualized family therapy models: multidimensional family therapy (102 sessions/56 cases), brief strategic family therapy (100 sessions/94 cases), or functional family therapy (100 sessions/46 cases). Adolescents were 57% male; 41% were African American, 31% White non-Hispanic, 9% Hispanic American, 6% another race/ethnicity, and 13% unknown. The observational fidelity measures of all three models were used to code all 302 sessions. Fidelity ratings were analyzed to derive model-shared treatment techniques via exploratory factor analyses on half the sample; the derived factors were then validated via confirmatory factor analyses supplemented by Bayesian structural equation modeling on the remaining half. Factor analyses distilled 4 clinically coherent practice elements with strong internal consistency: Interactional Change (6 treatment techniques; Cronbach's α = .93), Relational Reframe (7 techniques; α = .79), Adolescent Engagement (4 techniques; α = .68), and Relational Emphasis (4 techniques; α = .67). The 4 empirically derived factors represent the core elements of 3 manualized family therapy models for adolescent behavior problems, setting the foundation of a more sustainable option for delivering evidence-based family interventions in routine practice settings. Public Health Significance: Increasing implementation of high-fidelity family-based interventions would improve the quality of treatment services for adolescent conduct and substance use problems.

Treatment integrity in psychotherapy research and implications for the delivery of quality mental health services.

OBJECTIVE: Treatment integrity, or the degree to which an intervention is delivered as intended, serves a crucial function as an independent variable check in treatment outcome research. Implementation science focuses on understanding and improving the processes (e.g., training, supervision, monitoring) that establish and support treatment integrity in community settings. This review assessed the adequacy of treatment integrity procedures (i.e., establishing, assessing, evaluating, and reporting integrity) implemented in treatment outcome research with the goals of updating the review by Perepletchikova, Treat, and Kazdin (2007) and connecting findings to implementation science goals. METHOD: Using the Implementation of Treatment Integrity Procedures Scale (Perepletchikova et al., 2007), 2 trained raters coded the treatment integrity procedures described by randomized controlled trials of psychosocial interventions published in 6 high-impact-factor journals from 2011 to 2015 (N = 188 studies describing 270 treatments). RESULTS: Compared with Perepletchikova et al., current findings indicate significant improvement, but the frequency of adequate treatment integrity implementation remains low (10.7%). CONCLUSIONS: Recommendations for future work include focus on conceptualization of treatment integrity, establishment of treatment integrity standards, and use of findings from implementation science to improve treatment integrity procedures. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Benchmarking Treatment Adherence and Therapist Competence in Individual Cognitive-Behavioral Treatment for Youth Anxiety Disorders.

Evidence-based treatments (EBTs) for youth are typically developed and established through studies in research settings designed to ensure treatment integrity, that is, protocol adherence and competence by therapists. An important question for implementation science is how well integrity is maintained when these EBTs are delivered in community settings. The present study investigated whether the integrity achieved by therapists in community settings achieved a benchmark set by therapists in a research setting when they delivered the same EBT-an individual cognitive-behavioral treatment (ICBT) for youth anxiety. Therapists (N = 29; 68.97% White; 13.79% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.35% White; 52.94% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols were the same across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess ICBT adherence and competence. Both adherence and competence were higher in the research setting. Group differences in competence were consistent across treatment, but differences in adherence were most pronounced when treatment shifted to exposure, widely viewed as the most critical component of ICBT. When using the benchmarks from the research setting, therapists from the community settings fell short for indices of adherence and competence. However, given differences between therapists and clients, as well as the fact that treatment outcomes were similar across settings, our findings raise questions about whether it is appropriate to use treatment integrity benchmarks from research settings for community.

Development and Initial Psychometrics for a Therapist Competence Instrument for CBT for Youth Anxiety.

Therapist competence is an important component of treatment integrity. This article reports on the development and initial psychometric assessment of the Cognitive-Behavioral Treatment for Anxiety in Youth Competence Scale (CBAY-C), an observational instrument designed to capture therapist limited-domain competence (i.e., competence in the delivery of core interventions and delivery methods found in a specific psychosocial treatment program) in the delivery of the core practice elements in individual cognitive-behavioral treatment (ICBT) for youth anxiety. Treatment sessions (N = 744) from 68 youth participants (M age = 10.60 years, SD = 2.03; 82.3% Caucasian; 52.9% male) of the same ICBT program for youth anxiety from (a) an efficacy study and (b) an effectiveness study were independently scored by 4 coders using observational instruments designed to assess therapist competence, treatment adherence, treatment differentiation, alliance, and client involvement. Interrater reliability-intraclass correlation coefficients (2,2)-for the item scores averaged 0.69 (SD = 0.11). The CBAY-C item, scale, and subscale (Skills, Exposure) scores showed evidence of validity via associations with observational instruments of treatment adherence to ICBT for youth anxiety, theory-based domains (cognitive-behavioral treatment, psychodynamic, family, client centered), alliance, and client involvement. Important to note, although the CBAY-C scale, subscale, and item scores did overlap with a corresponding observational treatment adherence instrument independently rated by coders, the degree of overlap was moderate, indicating that the CBAY-C assesses a distinct component of treatment integrity. Applications of the instrument and future research directions discussed include the measurement of treatment integrity and testing integrity-outcome relations.

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.

Does the Delivery of CBT for Youth Anxiety Differ Across Research and Practice Settings?

Does delivery of the same manual-based individual cognitive-behavioral treatment (ICBT) program for youth anxiety differ across research and practice settings? We examined this question in a sample of 89 youths (M age = 10.56, SD = 1.99; 63.70% Caucasian; 52.80% male) diagnosed with a primary anxiety disorder. The youths received (a) ICBT in a research setting, (b) ICBT in practice settings, or (c) non-manual-based usual care (UC) in practice settings. Treatment delivery was assessed using four theory-based subscales (Cognitive-behavioral, Psychodynamic, Client-Centered, Family) from the Therapy Process Observational Coding System for Child Psychotherapy-Revised Strategies scale (TPOCS-RS). Reliable independent coders, using the TPOCS-RS, rated 954 treatment sessions from two randomized controlled trials (1 efficacy and 1 effectiveness trial). In both settings, therapists trained and supervised in ICBT delivered comparable levels of cognitive-behavioral interventions at the beginning of treatment. However, therapists trained in ICBT in the research setting increased their use of cognitive-behavioral interventions as treatment progressed whereas their practice setting counterparts waned over time. Relative to the two ICBT groups, the UC therapists delivered a significantly higher dose of psychodynamic and family interventions and a significantly lower dose of cognitive-behavioral interventions. Overall, results indicate that there were more similarities than differences in manual-based ICBT delivery across research and practice settings. Future research should explore why the delivery of cognitive-behavioral interventions in the ICBT program changed over time and across settings, and whether the answers to these questions could inform implementation of ICBT programs.

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