Treatment adherence, therapeutic alliance, and clinical outcomes during an exposure-based cognitive-behavioral therapy for pediatric irritability

Background: This study explores changes in treatment adherence and alliance during a novel parent- and child-psychotherapy for pediatric irritability. Associations between in-session therapeutic processes and symptom change were examined. Methods: Forty participants (Mean age = 11.23, SD = 1.85; 37.5% female, 77.5% white) with severe irritability, and their parents, received 12 sessions of exposure-based cognitive behavioral therapy (CBT) with parent management training (PMT). Measures included clinician-rated adherence to the manual, alliance scales (Alliance Scale for Children-revised; TASC-r, and Working Alliance Inventory; WAI, respectively), and clinician-, parent- and child-reported irritability scales (Affective Reactivity Index; ARI). Linear mixed models examined session-by-session changes and associations between adherence/alliance and subsequent irritability, and vice versa. Results: First, adherence to standard treatment elements decreased over time (Bs ≥ − 0.03, ps ≤ 0.010), while the focus on specific treatment components increased (i.e., exposure: B = 0.15, p = 0.001; PMT: B = 0.07, p = 0.002). Second, adherence to standard treatment elements were associated with decreased clinician-reported irritability (Bs ≥ − 2.23, p ≤ 0.042). For the alliance measures, parent-reported alliance increased over time (Bs ≥ 0.10, p ≤ 0.01); child-reported alliance did not change. Bidirectional associations were found between alliance and symptoms; specifically, child-reported alliance predicted clinician-rated irritability at next session (Bs ≥ − 0.66, p ≤ 0.053), and decreases in clinician- (Bs ≥ − 0.02, ps ≤ 0.043) and parent- (B = − 0.15, p = 0.024) reported irritability predicted increased alliance at next session. Conclusions: Findings underscore the predictive role of treatment adherence and therapeutic alliance on outcomes, in exposure-based CBT for pediatric irritability. Trial registration : ClinicalTrials.gov identifier: NCT02531893; date of registration: 25/08/2015.