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In the youth treatment literature, the alliance has been defined and measured as a consensual or collaborative bond. In this article, we review varied definitions of the alliance, enumerate its frequent measures, and present clinical examples. We provide a meta-analytic review on the relation between the therapeutic alliance and treatment outcome in child and adolescent psychotherapy. In particular, this review only includes prospective studies of youth therapy that used an explicit measure of alliance. The meta-analysis of 28 studies revealed a weighted random effect size of r ϭ .19 (k ϭ 28, N ϭ 2419, p Ͻ .01, 95% confidence interval [.13, .25]), which is a small to medium effect (equivalent to d ϭ 0.39) consistent with the adult alliance literature and with prior youth meta-analyses. Given that a mediumlarge amount of heterogeneity was observed in effect sizes (I 2 ϭ 64.19%), theory-and method-based moderators were examined. Multiple moderators of the alliance-outcome association were found, including diagnosis class, type of therapy, study design (randomized controlled trials [RCT] vs. nonrandomized trials [non-RCT]), and treatment setting (inpatient vs. outpatient). Research limitations, patient contributions, and diversity considerations follow. The article concludes with research-informed practices for building and maintaining the therapeutic alliance with youth. Clinical Impact StatementAlthough many youth treatments have been found effective, less is known about treatment processes that may explain variability in treatment outcomes. Question: This study examined the strength of the correlation between the alliance and youth treatment outcome. Findings: This meta-analysis showed that the therapeutic alliance has a small to medium association to outcome that varies depending upon diagnosis, type of therapy, study design, and treatment setting. Meaning: Alliance formation and maintenance over the course of treatment has the potential to aid clinicians in achieving positive outcomes in youth psychotherapy across disorders. Next Steps: To investigate the effects on the alliance and treatment outcome of clinicians attending to youth and parent characteristics and their own behaviors when attempting to engage them in treatment.

Background Clinically elevated anxiety is a common, impairing feature of autism spectrum disorders (ASD). A modular CBT program designed for preteens with ASD, Behavioral Interventions for Anxiety in Children with Autism (BIACA; Wood et al., 2009), was enhanced and modified to address the developmental needs of early adolescents with ASD and clinical anxiety. Method Thirty-three adolescents (11–15 years old) were randomly assigned to 16 sessions of CBT or an equivalent waitlist period. The CBT model emphasized exposure, challenging irrational beliefs, and behavioral supports provided by caregivers, as well as numerous ASD-specific treatment elements. Independent evaluators, parents, and adolescents rated symptom severity at baseline and post-treatment/post-waitlist. Results In intent-to-treat analyses, the CBT group outperformed the waitlist group on independent evaluators’ ratings of anxiety severity on the Pediatric Anxiety Rating Scale (PARS) and 79% of the CBT group met Clinical Global Impressions-Improvement scale criteria for positive treatment response at posttreatment, as compared to only 28.6% of the waitlist group. Group differences were not found for diagnostic remission or questionnaire measures of anxiety. However, parent-report data indicated that there was a positive treatment effect of CBT on autism symptom severity. Conclusions The CBT manual under investigation, enhanced for early adolescents with ASD, yielded meaningful treatment effects on the primary outcome measure (PARS), although additional developmental modifications to the manual are likely warranted. Future studies examining this protocol relative to an active control are needed.

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