Objective Little is known about the nature of the relationship between the alliance and client involvement in child psychotherapy. To address this gap, we examined the relationship between these therapy processes over the course of cognitive-behavioral therapy (CBT) for child anxiety disorders. Method The sample was 31 child participants (Mage = 9.58 years, SD = 2.17, range 6–13 years, 67.7% boys; 67.7% Caucasian, 6.5% Latino, 3.2% Asian/Pacific Islander, and 22.6% mixed/other) diagnosed with a primary anxiety disorder. The participants received a manual-based individual CBT program for child anxiety or a manual-based family CBT program for child anxiety. Ratings of alliance and client involvement were collected on early (session two) and late (session eight) treatment phases. Two independent coding teams rated alliance and client involvement. Results Change in alliance positively predicted late client involvement after controlling for initial levels of client involvement. In addition, change in client involvement positively predicted late alliance after controlling for initial levels of the alliance. The findings were robust after controlling for potentially confounding variables. Conclusions In CBT for child anxiety disorders, change in the alliance appears to predict client involvement; however, client involvement also appears to predict the quality of the alliance. Our findings suggest that the nature of the relationship between alliance and client involvement may be more complex than previously hypothesized. In clinical practice, tracking alliance and level of client involvement could help optimize the impact and delivery of CBT for child anxiety.

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The last decade has witnessed increased interest in the implementation and dissemination of evidence-based treatments (EBTs) for youth. Nakamura et al. (this issue) detail lessons learned over the past decade from the large-scale implementation of EBTS for children in Hawaii. This commentary discusses how lessons from Hawaii's initiative can help inform the next generation of implementation research. Specifically, we focus on how treatment integrity models and methods designed to characterize core aspects of treatment delivery can be used to study the implementation process. Using the new interactive online reporting systems developed by this research group to collect treatment integrity data offers researchers a way to determine how best to implement EBTs in community based service settings with integrity and skill.

The present study assessed the potential of a health behavior model used to explain adherence to treatment for chronic illnesses, the Integrative Behavioral Prediction Model (IBPM), to better understand therapy engagement (e.g., low participation) for child therapy in community-based service settings. Qualitative interview methods were used to assess the fit of the IBPM to therapy engagement. Caregivers of children (n = 17) who had successfully completed therapy, were at risk of dropping out, or terminated prematurely at a community mental health clinic were interviewed. Clinic therapists and administrative staff were also interviewed (n = 8). From the perspective of caregivers, therapists, and administrative staff, most IBPM elements-cognitions, intentions, and environmental/contextual factors-appear to be relevant to therapy engagement. Other factors, such as personal and psychological barriers (e.g., poor fit with therapist), not found in the IBPM also may influence therapy engagement. It appears that the core elements of the IBPM may translate to child therapy, though future research is needed to evaluate the generalizability of the study findings. Thus, health behavior models (e.g., IBPM) may improve our understanding of factors contributing to poor therapy engagement for children receiving psychosocial therapy in community-based service settings.