UC San Diego

Therapeutic alliance may be an important predictor of mental health outcomes for children and their families, but the research literature in this area is limited. This study examined the extent to which child and caregiver alliance are associated with therapeutic outcomes in a sample of 209 children (ages 4-13) with disruptive behavior problems and their caregivers who received usual care services in community mental health clinics. Children, therapists, and observers rated child-therapist alliance, while caregivers, therapists, and observers rated caregiver-therapist alliance at four, eight, and twelve months, provided the family was active in treatment within the given time point. All families were active in treatment at four months, but only 67% (n=141) were in treatment within eight months and 48% (n=100) within twelve months due to naturalistic attrition. Autoregressive cross-lagged models were used to examine alliance-outcome associations within and across time points with child symptom severity, positive parenting practices, and family functioning (positive versus negative family interactions) as outcomes. Results indicated that child self-report of alliance and therapist -reported child alliance were simultaneously associated with less severe child symptomatology (at least one time point), but neither predicted decreased symptomatology with cross-lagged associations. No associations were found between child symptoms and caregiver alliance across reporters. For family functioning, observer-coded child alliance and caregiver self-reported alliance were simultaneously associated with family functioning at each time point, but only caregiver ratings of their alliance with the therapist were predictive of improved family functioning at eight months. No other reports of child- therapist or caregiver-therapist alliance were associated with improved family functioning. Similarly, observer- reported child alliance and caregiver self-reported alliance were simultaneously associated with positive parenting practices, but only caregiver-reported alliance was predictive of later improvements in these practices at twelve months. Again, no other reports of child or caregiver alliance were associated with positive parenting practices. This study helps to disentangle the differential impact of child-therapist and caregiver- therapist alliance, from multiple perspectives, on therapeutic outcomes in child psychotherapy. Given the predictive validity of the caregiver alliance for improved family functioning and parenting practices, future research might examine psychotherapy processes that impact this therapeutic alliance