849985

research-article2019
AUT0010.1177/1362361319849985AutismAlbaum et al.

Original Article

Autism

Predictors and outcomes associated 2020, Vol. 24(1) 211­–220

© The Author(s) 2019
Article reuse guidelines:
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DOI: 10.1177/1362361319849985
https://doi.org/10.1177/1362361319849985

behaviour therapy for children journals.sagepub.com/home/aut

with autism

Carly Albaum , Paula Tablon, Flora Roudbarani

and Jonathan A Weiss

Abstract
Therapeutic alliance is often an important aspect of psychotherapy, though it is rarely examined in clients with autism.
This study aims to determine the child pre-treatment variables and treatment outcomes associated with early and late
alliance in cognitive behaviour therapy targeting emotion regulation for children with autism. Data were collected from 48
children with autism who participated in a larger randomized-controlled trial. Pre-treatment child characteristics included
child, parent, and clinician report of child emotional and behavioural functioning. Primary outcome measures included
child and parent-reported emotion regulation. Therapeutic alliance (bond and task-collaboration) was measured using
observational coding of early and late therapy sessions. Pre-treatment levels of child-reported emotion inhibition were
associated with subsequent early and late bond. Pre-treatment levels of parent and child-reported emotion regulation
were related to early and late task-collaboration. Late task-collaboration was also associated with pre-treatment levels
of behavioural and emotional symptom severity. Task-collaboration in later sessions predicted improvements in parent-
reported emotion regulation from pre- to post-therapy. Future research is needed to further examine the role of task-
collaboration as a mechanism of treatment change in therapies for children with autism.

Keywords
autism, children, cognitive behavioural therapy, therapeutic alliance

Children with autism often exhibit mental health and
behavioural challenges, including high rates of anxiety,
depression or aggressive behaviour. Cognitive behaviour
therapy (CBT), if adapted, has been shown to be effica-
cious in reducing mental health problems and improving
emotion regulation in verbally able children with autism,
with small to moderate treatment effects (Weston,
Hodgekins, & Langdon, 2016). Only a portion of individu-
als with autism who take part in therapeutic interventions
demonstrate significant gains, with approximately 30%
showing no improvement following CBT (Vasa et al.,
2014). To refine and maximize treatment effects, focus
needs to be directed towards examining the therapeutic
factors that function as mechanisms of change (Lerner,
White, & McPartland, 2012).
Therapeutic alliance is a recognized contributor to
treatment outcome. Therapeutic alliance is conceptualized
as the working relationship between therapist and client
based on treatment goals central to both the client and
therapist, collaboration on therapeutic tasks and a positive
bond (Bordin, 1979). This relationship is dynamic and
transactional in nature, influenced by both therapist and
client attributes and varying in quality over the course of
treatment (Bordin, 1994). In treatment for children without
autism, alliance is thought to account for a significant por-
tion of therapeutic outcomes (Karver, Handelsman, Fields,
& Bickman, 2005). Recent meta-analyses suggest that alli-
ance is associated with small to moderate effects (McLeod,
2011; Murphy & Hutton, 2018) and is related to improve-
ments in both internalizing (Chiu, McLeod, Har, & Wood,
2009) and externalizing symptoms (Kazdin, Marciano, &
Whitley, 2005) following CBT.
York University, Canada
Corresponding author:
Jonathan A Weiss, 230 Behavioural Science Building, 4700 Keele Street,
Toronto, Ontario, Canada M3J 1P3.
Email: jonweiss@yorku.ca
212 Autism 24(1)
The quality of therapeutic alliance appears to be influ-
enced in part by child pre-treatment factors. For example,
children who are more motivated and prepared to change
(Christensen & Skogstad, 2009), and who have better
social competence and securer social relationships (Levin,
Henderson, & Ehrenreich-May, 2012) tend to have a
stronger alliance with their therapist based on ratings from
multiple informants. Results from the adult literature indi-
cate a relation between emotion regulation, client-reported
alliance and treatment outcome (Owens, Haddock, &
Berry, 2013), with at least one study reporting a link for
children with anxiety (Chu, Skriner, & Zandberg, 2014).
Results are more mixed around how pre-treatment inter-
nalizing and externalizing symptom severity is associated
with the formation of bond and task-collaboration (Shirk
& Karver, 2011).
Beyond child and treatment-specific factors, researchers
have examined differences in the alliance-outcome associa-
tion as a function of reporting source. Although the therapeu-
tic alliance is undoubtedly a subjective experience for both
client and therapist, objective techniques for assessing this
relationship, such as through independent observer reports,
may serve to be a more equitable methodological approach.
In their meta-analysis, Shirk and Karver (2003) note that
children may not be equipped with the social and cognitive
skills needed to assess their own therapeutic alliance. Ceiling
effects may also be observed in child reports of alliance
because ratings are only provided by a subgroup of children
who remain in treatment (Accurso & Garland, 2015). It has
been argued that reports on process and outcome variables
from the same source may potentially bias results by inflat-
ing effect sizes (Horvath & Symonds, 1991; McLeod, 2011).
In addition, parent report of the therapist–child alliance may
be biased (either positively or negatively) by the parent’s
own perceptions and attitudes towards the therapist and the
context of the assessment (e.g. providing ratings while the
therapist is present; McLeod & Weisz, 2005). Few studies
have looked at alliance in children with autism receiving
psychotherapy. Kerns, Collier, Lewin, and Storch (2018)
examined the relation between child- and therapist-reported
alliance and treatment response in CBT designed to address
anxiety in children and adolescents. Treatment responsive
children were found to have greater post-treatment, retro-
spective therapist-rated (but not child-rated) levels of alli-
ance than non-responsive children, with no link to child age
or the severity of autism or internalizing and externalizing
symptoms. Results from the grey literature support the link
between therapist reports of alliance in therapy and anxiety
symptom reduction (Klebanoff, 2015), and according to par-
ent interviews, specific therapist qualities (i.e. collaborating,
being fun, giving praise, being patient) are important for a
strong therapist-child alliance (Houlding, 2014).
Although therapeutic alliance is a subjective experi-
ence, independent observation has emerged as a useful
way to gauge quality, addressing concerns around validity
of child reports (McLeod, Southam-Gerow, & Kendall,
2017). Only one intervention study has used independent
observer ratings of alliance with participants with autism.
As part of a pilot randomized-controlled trial (RCT) com-
paring CBT to non-directive, supportive counselling for
adolescents with autism, Murphy and colleagues (2017)
used the Therapy Process Observational Coding Scheme–
Alliance Scale (TPOCS-A; McLeod & Weisz, 2005) as an
index of treatment fidelity. Results indicated good inter-
rater agreement among coders, and independent observer
ratings of alliance were comparable to those given in pre-
vious therapy studies involving youth without autism
(Brown et al., 2015). It is yet to be determined whether
pre-treatment child characteristics are associated with
observer ratings of alliance or whether such ratings are
predictive of treatment change.
Current study
This study stems from a larger RCT evaluating an emotion
regulation focused CBT intervention for children with
autism (Weiss et al., 2018). Using independent observer
ratings of early and late therapeutic alliance (operational-
ized as task-collaboration and therapeutic bond), the fol-
lowing research questions and hypotheses were addressed:
1. Do pre-treatment child characteristics, including
emotional and behavioural symptoms, emotion
regulation and readiness for therapy, predict the
quality of therapeutic alliance? Based on previous
research, it was expected that emotional and behav-
ioural symptoms and emotion regulation chal-
lenges would negatively predict therapeutic
alliance in early and in late sessions, whereas read-
iness for treatment would be a positive predictor.
2. Is therapeutic alliance in early and in late sessions
a significant predictor of change in the CBT inter-
vention’s primary outcome variable: emotion regu-
lation? It was hypothesized that therapeutic alliance
would account for a moderate portion of the vari-
ance in changes of emotion regulation, as reported
by children and parents.
Methods
Participants
Participants included 48 children (91.7% male) between
the ages of 8 and 12 years (M = 9.60, SD = 1.25), who took
part in a RCT of an emotion regulation focused CBT
intervention (Weiss et al., 2018). All children (1) demon-
strated at least average intellectual functioning (IQ ⩾ 79)
based on the Wechsler Abbreviated Scale of Intelligence–
Second Edition (WASI-II; Wechsler, 2011); (2) exhibited
some degree of willingness to participate in therapy; (3)
Albaum et al. 213
had a documented autism diagnosis from a qualified
healthcare professional; and (4) met cut-offs on either the
parent-report versions of the Social Communication
Questionnaire (SCQ cut-off > 14; Rutter & Bailey, 2003)
or the Social Responsiveness Scale–Second Edition (SRS-
2 Total T score cut-off > 59, Constantino, 2012). For
children whose parent could not provide documentation
and did not meet cut-off scores for either screening tool
(n = 2), the Autism Diagnostic Observation Schedule–
Second Edition (ADOS-2; Lord et al., 2012) Module 3
was administered. Children were not eligible to partici-
pate in the study if they had a recent history of aggressive
behaviour towards others or self-injurious behaviours
that could potentially be a serious safety concern, or if
they were currently receiving CBT or another therapy
targeting emotion regulation.
For the current sample, child Full-Scale IQ–2 (FSIQ-2)
scores ranged from 79 to 140 (M = 105.00, SD = 14.64).
Children varied in autism symptom severity both on the
SRS-2 total T scores (M = 74.40, SD = 9.33) and SCQ total
scores (M = 21.62, SD = 4.45). The majority of parents
identified their children as White/Caucasian (78.6%) and
reported themselves as being married (91.5%), having
post-secondary education (90.7%), and having an annual
family income of at least CAD$100,000 before taxes
(65.1%; 18.6% preferred not to disclose).
Measures
Therapeutic alliance.  Child and parent reports of therapeu-
tic alliance were not included in the initial protocol for the
larger RCT in which this study is embedded. Therapists
did provide ratings of their perceived quality of the thera-
peutic alliance following each session. However, this was
only measured using a single-item (‘How would you
describe the quality of the therapeutic relationship during
the session with the child?’ 1 = very poor; 7 = very good)
and was collected for the purposes of assessing treatment
fidelity. For these reasons, this study opted to focus on the
use of retrospective independent observational ratings.
Therapeutic alliance was measured using the TPOCS-A
(McLeod & Weisz, 2005). The TPOCS-A is a nine-item
observational measure evaluating two facets of the alli-
ance: the therapeutic bond between therapist and client
(bond; six items) and compliance and collaboration on
therapeutic tasks (task-collaboration; three items). Items
are rated by an independent observer on a 6-point Likert-
type scale (0 = not at all; 5 = great deal), indicating the
extent to which the client or therapist demonstrate given
behaviours in session. Initial psychometric properties of
the measure in children 8–14 years of age suggest accept-
able interrater reliability (intraclass correlation coefficient
(ICC) ⩾ 0.40) for all nine items and excellent internal
consistency (α = 0.95). The measure also has convergent
validity with therapist reports of alliance (McLeod et al.,
2017). The TPOCS-A has been used in other studies of
alliance in both individual and group CBT for children
with acceptable reliability (Chiu et al., 2009; Liber et al.,
2010). For this study, ratings ranged from 1.75 to 3.75 for
early bond (M = 2.80, SD = 0.46), 1.17 to 5.00 for early
task-collaboration (M = 4.04, SD = 0.76), 2.00 to 3.92 for
late bond (M = 2.98, SD = 0.48) and 1.83 to 5.00 for late
task-collaboration (M = 3.99, SD = 0.69). Interrater relia-
bility is described below.
Primary treatment outcome. The primary treatment out-
come of the intervention trial was emotion regulation, as
reported by parent and child.
Children’s Emotion Management Scales (CEMS). 
Child self-reported emotion regulation was measured using
the CEMS (Zeman, Cassano, Suveg, & Shipman, 2010).
The CEMS include three separate scales assessing self-
regulation during feelings of Sadness (12 items), Anger (11
items) and Worry (10 items), each yielding three subscales:
Inhibition (e.g. ‘I hide my sadness’), Dysregulation (e.g. ‘I
do things like slam doors when I am mad’) and Coping (e.g.
‘I talk to someone until I feel better when I’m worried’).
A research assistant read each statement aloud and con-
firmed the child understood each item. Children then rated
how frequently they engage in each behaviour on a 3-point
scale (1 = hardly ever; 3 = often). Items were averaged across
emotion scales to provide overall scores for each subscale.
Average pre-treatment scores in this study ranged from 1.00
to 3.00 for Inhibition (M = 1.74, SD = 0.47), 1.00 to 2.78 for
Dysregulation (M = 1.73, SD = 0.41) and 1.17 to 2.75 for
Coping (M = 1.96, SD = 0.42). The CEMS has demonstrated
convergent and divergent validity (Zeman et al., 2010) and
acceptable to good internal consistency for this sample
(α = 0.71–0.85).
Emotion Regulation Checklist (ERC).  The ERC (Shields &
Cicchetti, 1997) is a 24-item parent-report measure assess-
ing emotion regulation processes. Each item is rated on
a 4-point scale (1 = never; 4 = almost always). The ERC
includes two subscales: Lability/Negativity (15 items),
measuring mood swings, reactivity, emotional intensity, and
dysregulated emotions (e.g. ‘Is prone to disruptive outbursts
of energy and exuberance’), with higher scores indicating
greater dysregulation, and Emotion Regulation (eight items;
one item was not included), measuring adaptive regulation
processes (e.g. ‘Responds positively to neutral or friendly
overtures by adults’), with higher scores indicating bet-
ter emotion regulation (Shields & Cicchetti, 1998). Pre-
treatment scores in this study ranged from 1.67 to 3.53 for
Lability/Negativity (M = 2.43, SD = 0.41) and 1.88 to 4.00
for Emotion Regulation (M = 2.87, SD = 0.49). The ERC has
good to excellent internal consistency (Shields & Cicchetti,
1997, 1998) and acceptable to good internal consistency for
this study (α = 0.75–0.80).
214 Autism 24(1)
Predictors of therapeutic alliance. In addition to pre-treat-
ment levels of emotion regulation, as assessed using the
CEMS and ERC measures described above, the following
pre-treatment child characteristics were included as pre-
dictors of therapeutic alliance.
Readiness to participate.  Child readiness to participate
in therapy was assessed at initial screening using three
questions: (1) ‘How much do you want to be part of the
program?’ (2) ‘How much do you want to change?’ and
(3) ‘How hard you are willing to work?’ Children rated
each question on 8-point Likert-type scale, ranging from
0 = not at all to 8 = very, very much, and an overall readi-
ness score was calculated by averaging the three ratings.
Pre-treatment mean readiness was 4.89 (SD = 2.00), rang-
ing from 0.33 to 8.00.
Behavioural Assessment System for Children–Second Edition,
Parent Rating Scale (BASC-2 PRS).  The BASC-2 PRS (Reyn-
olds & Kamphaus, 2004) assesses behavioural and emotional
problems and adaptive functioning. For children between 8
and 11 years of age, parents completed the PRS-Child form
(160 items), while parents of children who were 12 years of
age completed the PRS-Adolescent form (150 items). Three
composites were included in this study: Externalizing Prob-
lems (M = 58.06, SD = 10.47, Range = 41–86), Internaliz-
ing Problems (M = 61.33, SD = 12.70, Range = 40–95) and
Behavioural Symptoms Index (BSI; M = 69.25, SD = 10.05,
Range = 53–95). The BASC-2 has strong internal consist-
ency and concurrent validity with other child behaviour
rating scales (Reynolds & Kamphaus, 2004) and has been
used as an assessment tool in a number of studies that have
included children with autism (Grondhuis & Aman, 2012;
Volker et al., 2010).
Anxiety Disorder Interview Schedule–Parent Version (ADIS-
P). The ADIS-P (Silverman & Albano, 2004) is a semi-
structured interview of both internalizing and externalizing
disorders based on Diagnostic and Statistical Manual of
Mental Disorders (4th ed.; DSM-IV; American Psychiatric
Association 1994). Parents provide information regarding
symptomology, age of onset and degree of interference in
daily life for each disorder. Based on the information pro-
vided, the interviewer then gives an overall clinical severity
rating ranging from 0 to 8, with higher ratings indicating
greater severity. The overall severity rating for the current
sample ranged from 0 to 7 (M = 4.04, SD = 1.66). The ADIS-
P is recognized as the most commonly used outcome meas-
ure in CBT trials for children with autism (Sung et al., 2011;
Walters, Loades, & Russell, 2016).
Procedures
The larger RCT from which this study was derived began
in September 2013. This research has received ethics
review and approval by the York University’s Ethics
Review Board (#e2013-229). Thirty-two children were
excluded for not meeting study inclusion criteria, and 11
declined to participate despite being eligible. Sixty-eight
children were eligible to participate in the larger RCT.
Once eligibility was determined, parents provided written
informed consent and children provided either written or
verbal informed assent. For the purposes of this study, all
children who received the intervention in its entirety were
combined to form one treatment group regardless of
whether they were initially randomized to treatment imme-
diate or waitlist. Measures were administered within the
2 weeks prior to treatment receipt (pre-treatment) and
within 1 week of completing therapy (post-treatment).
Of the 68 eligible families, 13 withdrew from the study
after confirming enrolment (nine children dropped out
before beginning the intervention and four dropped out
part way through the programme). Data were not available
for an additional six children because parents did not con-
sent to having session videos used for research purposes
(n = 4) or technical issues caused session videos to be
unusable (n = 2). Finally, data for one participant was
excluded due to a change in therapist midway through
treatment, leaving a final sample of n = 48.
Intervention. The Secret Agent Society: Operation Regula-
tion (SAS:OR; Beaumont, 2013) is a manualized CBT pro-
gramme targeting emotion regulation adapted for children
with autism. The programme includes 10 individual ther-
apy sessions that the therapist, child and primary caregiver
attend. Over the course of the study trial, sessions were
facilitated by three post-doctoral fellows and 19 trained
graduate students (90.9% female; Mage = 26.95, SD = 3.05)
enrolled in clinical or clinical-developmental psychology
programmes, under the supervision of a registered clinical
psychologist. Treatment integrity across sessions was
acceptable (85% ± 11%, Range = 50%–100%). Additional
details of the SAS:OR programme and therapist training
procedures are provided elsewhere (Weiss et al., 2018).
Coding. TPOCS-A coding followed procedures outlined
by McLeod and Weisz (2005). Training included in-depth
review of the test development and scoring manual, cod-
ing practice sessions and weekly check-ins between cod-
ers to discuss any discrepancies or issues that arose during
practice coding. The coders (C.A., P.T., and F.R.) worked
in close proximity, allowing for regular meetings and
brief check-ins. During the first week of training, coders
met to code two therapy sessions together (for a pilot par-
ticipant who was not included as part of the final study).
This provided an opportunity to discuss coding as the ses-
sion was being reviewed and make detailed notes on the
coding system. Coders met in person for at least 2 h for the
5 weeks following (3 weeks of practice coding, followed
by 2 weeks of study coding). During these meetings, dis-
crepancies in ratings were thoroughly discussed and video
content was reviewed to ensure all coders established a
Albaum et al. 215
similar repertoire of examples that corresponded with par-
ticular ratings. Coders were trained over a 1-month period
and reached excellent reliability (ICC = 0.92, p < 0.001).
Once reliability was established, sessions were randomly
assigned to coders. To avoid rater drift, coders continued
to meet in person throughout the data collection phase (bi-
weekly early on and then monthly once reliability was
evidently stable) and regularly corresponded between
meetings if any questions arose. Coders were not involved
in therapy provision for sessions they were coding and
were unaware of treatment outcome.
Sampling of therapy sessions for study coding mim-
icked methods employed by previous research examining
early and late phases of therapy for children (Chiu et al.,
2009; McLeod & Weisz, 2005). Sessions 2 and 3 (early)
and sessions 8 and 9 (late) were coded, and ratings were
averaged to produce early and late bond and task-collab-
oration scores. If video recordings were not available
(e.g. technical issues with recording equipment), subse-
quent sessions for early alliance (i.e. session 4) and pre-
vious sessions for late alliance (i.e. session 7) were coded.
This was the case for nine early sessions (session 2, n = 5;
session 3, n = 4), and eight late sessions (session 8, n = 5;
session 9, n = 3). Kruskal–Wallis analyses confirmed that
ratings on TPOCS-A items did not significantly differ
between cases where sessions 4 and 7 were coded as
alternates.
Interrater reliability for the TPOCS-A was then calcu-
lated using ICCs for approximately 30% of available ses-
sions (n = 60). Reliability coefficients were based on the
one-way random effects ICC (1, 1) model. The overall inter-
rater reliability for TPOCS-A was excellent (ICC = 0.95,
p < 0.001). Interrater reliability for individual items was all
within acceptable range (ICC ranging from 0.76 to 0.96).
Analysis plan
All analyses were conducted using IBM SPSS Statistics
version 24. Spearman-rho correlations were calculated to
test the hypothesis that pre-treatment characteristics
would be associated with subsequent measures of early
and late bond and task-collaboration at the bivariate
level. Multiple regressions were then calculated to deter-
mine if pre-treatment child characteristics that were sig-
nificant at the bivariate level predicted therapeutic
alliance. If predictor variables were largely correlated
with each other (i.e. r > 0.50), only the variable with the
strongest association with bond and task-collaboration
was included in the model to maintain power to detect
moderate to large effects.
A series of hierarchical regression analyses were con-
ducted to test the hypothesis that early and late alliance
would predict treatment outcomes. The first step con-
trolled for time in treatment, child IQ and baseline levels
of an outcome measure (McLeod & Weisz, 2005). The
second block consisted of either early or late bond and
task-collaboration scores. Separate analyses were run for
each outcome variable.
We recognize that conducting these analyses raises
questions about issues related to multiplicity, including
inflated Type I error rates. Scientific and clinical risk
associated with Type I error within the context of this
study include identifying and placing undue emphasis on
pre-treatment factors that are not true predictors of the
quality of alliance, and falsely predicting the extent to
which therapeutic alliance predicts treatment change.
While failing to correct for multiple comparisons may
increase the likelihood of identifying false positive find-
ings, the small sample size, limited research in the area
and an interest in balancing the examination of signifi-
cance in terms of the probability of identifying a true
effect serve as rationale for no adjustments being made
(Feise, 2002). All variables included in the analyses
were selected on the basis of clinical relevance and pre-
viously derived empirical evidence. Power analyses
using G*Power 3.1 (Faul, Erdfelder, Buchner, & Lang,
2009) indicated that moderate to large effects could be
detected using multiple linear regression analyses with a
sample of 48 children, depending on the number of pre-
dictors included.
Results
Pre-treatment child characteristics and
therapeutic alliance
As shown in Table 1, several pre-treatment child character-
istics were associated with TPOCS-A ratings, both early and
late in treatment. Child age and autism symptom severity
(SCQ and SRS) were not related to any early or late alliance
measure. Child IQ was associated with late task-collabora-
tion, but no other indicator of alliance. Early and late bond
were both positively associated with child report of emo-
tional inhibition (CEMS-Inhibition). Early task-collabora-
tion was positively related to child-reported coping
(CEMS-Coping) and negatively associated with child report
of emotional dysregulation (CEMS-Dysregulation). Late
task-collaboration was positively associated with child
report of inhibition (CEMS-Inhibition) and negatively
related to child report of emotional dysregulation (CEMS-
Dysregulation), parent report of child emotional lability
(ERC Lability/Negativity), child externalizing symptoms
(BASC-2 Externalizing), child behavioural symptoms
(BASC-2 BSI) and clinician rated overall severity of psy-
chopathology (ADIS-P Overall Severity).
Multiple regression analyses were not calculated for
early or late bond, as only a single bivariate correlate
emerged as significant. Results of multiple regressions
revealed that child pre-treatment characteristics did not
account for a significant portion of the variance in early
216 Autism 24(1)

Table 1.  Spearman-rho correlations between pre-treatment child characteristics and TPOCS-A ratings (N = 48).

Characteristic Early TPOCS-A Late TPOCS-A

Bond Task-collaboration Bond Task-collaboration

Age −0.15 0.16 −0.04 0.04
FSIQ-2a 0.20 0.07 0.29† 0.34*
SRS-2 0.03 0.03 0.05 −0.25†
SCQ 0.22 0.14 0.13 0.19
Readiness to participatea 0.17 0.25† 0.02 −0.05
CEMSb
 Inhibition 0.30* 0.27† 0.36* 0.30*
 Dysregulation −0.24 −0.38* −0.27† −0.32*
 Coping 0.09 0.36* 0.24 0.28†
ERC
 Lability/negativity −0.16 −0.27† −0.07 −0.39**
  Emotion regulation 0.11 0.17 −0.02 0.14
BASC-2
  Externalizing problems −0.12 −0.22 −0.14 −0.37**
  Internalizing problems 0.04 −0.09 0.05 −0.26†
 BSI −0.06 −0.11 −0.02 −0.36*
ADIS-P overall severity −0.17 −0.14 −0.04 −0.30*

TPOCS-A = Therapist Process Observational Coding System–Alliance Scale; FSIQ-2 = Full-Scale IQ–2 Subscales; SRS-2 = Social Responsiveness
Scale–Second Edition, Total T Score; SCQ = Social Communication Questionnaire; CEMS = Children’s Emotion Management Scale; ERC =
Emotion Regulation Checklist; BASC-2 = Behavioural Assessment System for Children–Second Edition; BSI = Behavioural Symptoms Index; ADIS-P
= Anxiety Disorder Interview Schedule–Parent Version.
an = 47.
bn = 45.
†p < 0.10; *p < 0.05; **p < 0.01.

task-collaboration and no unique predictors emerged. Discussion

Child pre-treatment characteristics accounted for a moder-
ate portion of the variance in late task-collaboration,
R2 = 0.40, F(7, 34) = 3.20, p = 0.01; however, there were no
significant unique predictors.
Therapeutic alliance and primary treatment
outcome
A series of hierarchical linear regressions were conducted
to determine if alliance variables predicted treatment out-
comes. Early bond and task-collaboration were not predic-
tive of treatment change for any outcome variables
(Supplemental Table 1). In contrast, significant patterns
emerged when measures of late alliance were included as
predictors, as shown in Table 2. Specifically, late ratings of
alliance accounted for a significant portion of variance in
treatment change in parent reports of child emotional labil-
ity (ERC Lability/Negativity), ΔR2 = 0.07, p = 0.02, with
late task-collaboration emerging as a unique predictor
(β = –0.36, p = 0.02). Late task-collaboration emerged as a
unique predictor of improvements in child report of emo-
tional dysregulation (CEMS-Dysregulation), β = –0.45,
p = 0.04, even though late alliance as a whole was not a
significant predictor (ΔR2 = 0.12, p = 0.07). Late alliance
ratings were not predictive of change in CEMS-Inhibition
or Coping and ERC Emotion Regulation (all ps > 0.05).
This study examined the role of therapeutic alliance in
CBT for children with autism by evaluating the contribu-
tion of pre-treatment child characteristics to the quality of
alliance and the contribution of alliance to change in emo-
tion regulation following treatment. This was among the
first study to explore predictors of alliance and consider
how it relates to treatment outcome in therapy for children
with autism. It is also the first to use a behavioural obser-
vation method that assesses alliance at multiple points in
treatment.
Pre-treatment child characteristics and
therapeutic alliance
Consistent with the initial hypothesis, emotion regulation
was significantly related to the quality of therapeutic alli-
ance at different points of treatment. In particular, child
self-reported tendencies to inhibit emotional responses
were associated with a stronger therapeutic bond and bet-
ter task-collaboration both early and late in treatment. In
the context of therapy with children with autism, emo-
tional inhibition may benefit the therapeutic process, in
contrast to the negative effects that suppressing one’s
emotions may have in day-to-day life (Aldao, Nolen-
Hoeksema, & Schweizer, 2010). In comparison
Albaum et al. 217

Table 2.  Linear regression results for late therapeutic alliance ability and the presentation of emotional dysregulation
predicting treatment outcome. are pertinent to consider when working to establish thera-
Variable B SE B β peutic rapport with children in treatment, especially since
emotion regulation is a common challenge for children
CEMS-inhibitiona with autism (Mazefsky & White, 2014).
  Baseline score 0.78 0.17 0.66** Parent reports of child externalizing problems, and cli-
  Days in treatment <0.01 <0.01 0.06 nician judgements of overall psychopathology, were asso-
 FSIQ-2 <–0.01 0.01 −0.07 ciated with poorer task-collaboration in later sessions, but
  TPOCS-A bond 0.03 0.19 0.02 not to early therapeutic alliance or to late-session ratings of
  TPOCS-A task −0.15 0.13 −0.20
therapeutic bond. In the only other study of pre-treatment
CEMS-dysregulationa
characteristics and alliance for children with autism,
  Baseline score 0.15 0.12 0.19
demographic factors and pre-treatment clinical levels of
  Days in treatment <–0.01 <0.01 −0.05
internalizing and externalizing symptoms were not related
 FSIQ-2 0.01 <0.01 0.27†
  TPOCS-A bond 0.05 0.13 −0.08
to post-treatment retrospective ratings of alliance, as
  TPOCS-A task −0.19 0.09 −0.45* reported by child, parent or therapist (Kerns et al., 2018).
CEMS-copinga Beyond autism, associations of child factors and alliance
  Baseline score 0.42 0.12 0.48** are known to occur as a result of differences in source of
  Days in treatment <0.01 <0.01 0.17 reporting (e.g. child report vs therapist report vs independ-
 FSIQ-2 <–0.01 <0.01 <0.01 ent observer) and the timing of reporting (e.g. at early or
  TPOCS-A bond −0.07 0.13 −0.09 late sessions, or retrospectively following treatment com-
  TPOCS-A task 0.17 0.09 0.34† pletion; McLeod, 2011; McLeod et al., 2017), and thus
ERC lability/negativitya may contribute to why our findings differed.
  Baseline score 0.72 0.11 0.68** Contrary to expectations, child readiness to participate
  Days in treatment <0.01 <0.01 −0.01 in therapy was not significantly related to the quality of
 FSIQ-2 0.01 <0.01 0.16 therapeutic alliance, though there was a trending associa-
  TPOCS-A bond 0.10 0.12 0.11 tion with early task-collaboration. Although children var-
  TPOCS-A task −0.22 0.09 −0.36* ied in their degree of readiness to participate, treatment
ERC emotion regulationa was sought by the child’s primary caregiver, and in this
  Baseline score 0.57 0.08 0.75** context, children may fail to recognize personal emotional
  Days in treatment <0.01 <0.01 0.03 and behavioural challenges (Shirk & Russell, 1998, as
 FSIQ-2 <0.01 <0.01 0.02 cited in Shirk & Karver, 2003). From a process and devel-
  TPOCS-A bond −0.05 0.10 −0.07 opmental perspective, this lack of insight may serve as a
  TPOCS-A task 0.10 0.07 0.20
unique challenge when trying to establish alliance with
CEM = Children’s Emotion Management Scale; FSIQ-2 = Full-Scale younger clients (Shirk & Karver, 2003). An additional
IQ–2 Subscales; TPOCS-A = Therapist Process Observational Coding unexpected finding was that in this sample of children
System–Alliance Scale; ERC = Emotion Regulation Checklist. with at least average estimated intellectual functioning,
aOutcome variable.
†p < 0.10; *p < 0.05; **p < 0.01. IQ was related to late task-collaboration and had a trend-
ing association with bond. Given the heterogeneity in
intellectual functioning for children with autism, future
to common overt emotional dysregulation that require research should continue to examine the role of cognitive
significant management of behaviours from parents and functioning and variable profiles within the context of
individuals working with children with autism (Mazefsky, CBT, as this treatment orientation is so focused on active
2011), children who are better able to inhibit highly emo- task-collaboration.
tional displays may allow for therapists to more easily Although not a focus of this study, exploratory analy-
establish rapport. It is also likely that those children who ses indicated no significant association between autism
are more emotionally inhibited are less likely to demon- symptom severity and observer-rated therapeutic bond or
strate negative behaviours and affect that would impede task-collaboration. To our knowledge, only one study to
on the quality of the bond as operationalized on the date has compared therapeutic alliance in children with
TPOCS-A bond subscale. Several other pre-treatment and without autism. Klebanoff (2015) found that in CBT
indicators of emotion regulation were associated with targeting anxiety in children, therapist ratings of alliance
better task-collaboration at early and late sessions. This were significantly lower for children with autism aged
included child report of greater coping skills and less 10–11  years, compared with those without autism.
emotional dysregulation and parent report of greater However, there was no significant difference between rat-
child emotion regulation. These findings suggest that ings for children below 10 years of age. This age by group
both parent and child reports of emotional regulation finding certainly warrants further study of potentially
218 Autism 24(1)
autism-specific dynamics, and the TPOCS may be a use-
ful tool given its application in both clients with and with-
out autism.
Child pre-treatment characteristics did not predict
either aspect of the therapeutic alliance early in treatment,
or the therapeutic bond later in treatment, when entered
into regressions. Furthermore, only a moderate portion of
variance of late task-collaboration was accounted for by
the pre-treatment characteristic regression model, with no
significant unique predictors. This lack of significant
regression results may be a result of the low power to
account for small to moderate effects in models where the
predictor variables, though not at the level of multicollin-
earity, continue to show correlations with each other.
Therapeutic alliance and primary treatment
outcome
The initial hypothesis around therapeutic alliance and
treatment outcome was partially supported, in that only a
particular aspect of late alliance was associated with
child change in therapy. More specifically, late task-col-
laboration was predictive of improvements in child emo-
tion dysregulation. Although this study was the first to
examine alliance as it relates to emotion regulation as a
treatment outcome, these findings align with those from
studies involving children without autism, where alli-
ance-outcome effect sizes tend to be greater when con-
sidering changes in externalized symptom presentation,
compared with internalized presentations (McLeod,
2011). Whereas emotion regulation involves internalized
processes (Mazefsky et al., 2013), the current results
reflect changes in emotion dysregulation; the child’s neg-
ative externalized behavioural response. The measures of
emotion regulation that were not significantly predicted
by alliance (e.g. ERC Emotion Regulation subscale)
focused more on the internalized aspects of emotion reg-
ulation. Considerable literature also favours late meas-
ures of alliance versus early ones in being related to
treatment outcome in therapy for children (Karver,
Handelsman, Fields, & Bickman, 2006; McLeod, 2011;
Shirk & Karver, 2011). Although ratings of later alliance
may be biased by symptom improvement when the
reporter has been actively involved or invested in the
treatment process (McLeod & Weisz, 2005; Shirk &
Karver, 2011), this study used independent observational
coding, which may have helped to reduce the perception
of treatment progress as a confound.
Limitations
There are several limitations with this study that should be
considered. First, results should be interpreted with the
consideration that no alpha-level adjustments were made
to correct for multiple comparisons. The sample only
included participants who completed treatment, and for
whom post-treatment data were available. Premature ter-
mination is recognized as an important methodological
issue for intervention research because it limits generaliz-
ability of results, introduces sampling bias and, depending
on sample size available, reduces statistical power (Nock
& Ferriter, 2005). In addition, the sample included was
predominately male, limiting how results generalize to
females with autism. Although previous research has not
demonstrated a gender-effect in the association between
alliance-outcome (Kerns et al., 2018; McLeod, 2011),
future studies should aim to include a larger proportion of
females to determine if this finding holds within the autism
population. Coders could also not be completely blind to
session number. Although session order was randomized
to reduce coding bias, the session content is manualized
for each session and the client or therapist may also have
mentioned the session number in video recordings, making
it difficult for coders to be blind to the session. Notably,
this study only assessed therapeutic alliance using inde-
pendent observer ratings. Given that alliance-outcome
associations tend to vary as a result of informant source,
future research should consider assessing the convergence
and predictive validity of multi-informant ratings in ther-
apy for children with autism. Finally, this study was part of
a larger efficacy trial that in part looked to evaluate thera-
pist fidelity to a manualized protocol, potentially affecting
the generalizability of findings to the real-world context.
Conclusion
Therapeutic alliance is an important process factor to con-
sider when providing therapy to children with autism.
Although this study could not determine whether the qual-
ity of alliance differs from children without autism, it
appears that this relationship can still develop and is rel-
evant to the benefit some children with autism experience
from participating in CBT. Child pre-treatment character-
istics, particularly intellectual functioning, emotion dys-
regulation and overall symptom severity, may influence
aspects of alliance, most notably, the in-session task-col-
laboration between therapist and child. Task-collaboration
was found to be a stronger predictor of treatment outcome
and appears to be more heavily influenced by child char-
acteristics prior to treatment than was the therapeutic
bond. Since task-collaboration in later sessions was iden-
tified as an important predictor of treatment change,
addressing challenges related to engagement throughout
the treatment process and applying therapeutic skills that
foster a collaborative relationship may be important
aspects of therapy provision when working with children
with autism. This active collaboration between therapist
and child during session activities fits into the broader
process-related factor of treatment adherence or engage-
ment, which is known to be crucial for making treatment
Albaum et al. 219
gains (Meichenbaum & Turk, 1987). Clinicians working
with children with autism would benefit from skills train-
ing that specifically focuses on promoting and supporting
child engagement and collaboration in therapy.
Acknowledgements
The authors wish to thank the many families, graduate students
and research assistants who participated in this research.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This study was supported by the Chair in Autism Spectrum
Disorders Treatment and Care Research, the Canadian Institutes
of Health Research in partnership with Autism Speaks Canada,
the Canadian Autism Spectrum Disorders Alliance, Health
Canada, Kids Brain Health Network (formerly NeuroDevNet)
and the Sinneave Family Foundation.
Supplemental material
Supplemental material for this article is available online.
ORCID iDs
Carly Albaum https://orcid.org/0000-0002-0011-8813
Jonathan A Weiss https://orcid.org/0000-0002-5849-7334
References
Accurso, E. C., & Garland, A. F. (2015). Child, caregiver, and ther-
apist perspectives on therapeutic alliance in usual care child
psychotherapy. Psychological Assessment, 27, 347–352.
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-
regulation strategies across psychopathology: A meta-ana-
lytic review. Clinical Psychology Review, 30, 217–237.
American Psychiatric Association. (1994). Diagnostic and statis-
tic manual of mental disorders (4th ed.). Washington, DC:
American Psychiatric Publishing.
Beaumont, R. (2013). Secret Agent Society – Operation
Regulation (SAS-OR) manual. Brisbane, Queensland,
Australia: Social Skills Training.
Bordin, E. S. (1979). The generalizability of the psychoanalytic
concept of the working alliance. Psychotherapy: Theory,
Research and Practice, 16, 252–260.
Bordin, E. S. (1994). Theory and research on the therapeutic
working alliance: New directions. In A. O. Horvath & L. S.
Greenberg (Eds.), The working alliance: Theory, research,
and practice (pp. 13–37). New York, NY: John Wiley & Sons.
Brown, R., Iqbal, Z., Reynolds, L., Press, D. A., Shaker-Naeeni,
H., Scrivener, L., . . . Murphy, S. (2015). Inter-rater reli-
ability of treatment fidelity and therapeutic alliance meas-
ures for psychological therapies for anxiety in young people
with autism spectrum disorders. International Journal of
Developmental Disabilities, 61, 190–199.
Chiu, A. W., McLeod, B. D., Har, K., & Wood, J. J. (2009).
Child-therapist alliance and clinical outcomes in cognitive
behavioral therapy for child anxiety disorders. Journal of
Child Psychology and Psychiatry, 50, 751–758.
Christensen, M., & Skogstad, R. S. (2009). What predicts qual-
ity of the therapeutic alliance in a cognitive behavioural
treatment for children with anxiety disorders? Therapeutic
alliance measured from the patient, therapist and observer
perspective (Master’s thesis). The University of Bergen,
Bergen, Norway.
Chu, B. C., Skriner, L. C., & Zandberg, L. J. (2014). Trajectory
and predictors of alliance in cognitive behavioral therapy
for youth anxiety. Journal of Clinical Child & Adolescent
Psychology, 43, 721–734.
Constantino, J. N. (2012). Social Responsiveness Scale™ (SRS™-
2) (2nd ed.). Los Angeles, CA: Western Psychological
Services.
Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009).
Statistical power analyses using G*Power 3.1: Tests for
correlation and regression analyses. Behaviour Research
Methods, 41, 1149–1160.
Feise, R. J. (2002). Do multiple outcome measures require
p-value adjustment? BMC Medical Research Methodology,
2, 8.
Grondhuis, S. N., & Aman, M. G. (2012). Assessment of anxiety
in children and adolescents with autism spectrum disorders.
Research in Autism Spectrum Disorders, 6, 1345–1365.
Horvath, A. O., & Symonds, B. D. (1991). Relation between
working alliance and outcome in psychotherapy: A meta-
analysis. Journal of Counseling Psychology, 38, 139–149.
Houlding, K. (2014). Exploring the therapeutic alliance in cog-
nitive-behavior therapy with children with autism spectrum
disorder: An interpretative phenomenological approach
(Master’s thesis). Retrieved from https://dr.library.brocku
.ca/handle/10464/5384
Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L.
(2005). A theoretical model of common process factors in
youth and family therapy. Mental Health Services Research,
7, 35–51.
Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L.
(2006). Meta-analysis of therapeutic relationship variables
in youth and family therapy: The evidence for different
relationship variables in the child and adolescent treatment
outcome literature. Clinical Psychology Review, 26, 50–65.
Kazdin, A. E., Marciano, P. L., & Whitley, M. K. (2005). The
therapeutic alliance in cognitive-behavioral treatment of
children referred for oppositional, aggressive, and antisocial
behavior. Journal of Consulting and Clinical Psychology,
73, 726–730.
Kerns, C. M., Collier, A., Lewin, A. B., & Storch, E. A. (2018).
Therapeutic alliance in youth with autism spectrum disor-
der receiving cognitive-behavioral treatment for anxiety.
Autism, 22, 636–640.
Klebanoff, S. (2015). The therapeutic alliance in cognitive-
behavioral therapy for children with autism and anxi-
ety (Unpublished Master’s thesis). Retrieved from https://
escholarship.org/uc/item/9v57p5jn
Lerner, M. D., White, S. W., & McPartland, J. C. (2012).
Mechanisms of change in psychosocial interventions
for autism spectrum disorders. Dialogues in Clinical
Neuroscience, 14, 307.
Levin, L., Henderson, H. A., & Ehrenreich-May, J. (2012).
Interpersonal predictors of early therapeutic alliance in a
220 Autism 24(1)
transdiagnostic cognitive-behavioral treatment for adoles-
cents with anxiety and depression. Psychotherapy, 49, 218.
Liber, J. M., McLeod, B. D., Van Widenfelt, B. M., Goedhart, A.
W., van der Leeden, A. J., Utens, E. M., & Treffers, P. D.
(2010). Examining the relation between the therapeutic alli-
ance, treatment adherence, and outcome of cognitive behav-
ioral therapy for children with anxiety disorders. Behavior
Therapy, 41, 172–186.
Lord, C., Rutter, M., Dilavore, P. C., Risi, S., Gotham, K., &
Bishop, S. L. (2012). Autism Diagnostic Observation
Schedule® (ADOS®-2) (2nd ed.). Los Angeles, CA: Western
Psychological Services.
Mazefsky, C. A. (2011). Managing problem emotions and
behaviors in children with ASD: An assessment-driven
three-step approach. Perspectives Language Learning
Education, 19, 38–47.
Mazefsky, C. A., Herrington, J., Siegel, M., Scarpa, A., Maddox,
B. B., Scahill, L., & White, S. W. (2013). The role of emo-
tion regulation in autism spectrum disorder. Journal of the
American Academy of Child & Adolescent Psychiatry, 52,
679–688.
Mazefsky, C. A., & White, S. W. (2014). Emotion regulation:
Concepts & practice in autism spectrum disorder. Child and
Adolescent Psychiatric Clinics of North America, 23, 15–24.
McLeod, B. D. (2011). Relation of the alliance with outcomes in
youth psychotherapy: A meta-analysis. Clinical Psychology
Review, 31, 603–616.
McLeod, B. D., Southam-Gerow, M. A., & Kendall, P. C. (2017).
Observer, youth, and therapist perspectives on the alli-
ance in cognitive behavioral treatment for youth anxiety.
Psychological Assessment, 29, 1550–1555.
McLeod, B. D., & Weisz, J. R. (2005). The Therapy Process
Observational Coding System – Alliance Scale: Measuring
characteristics and prediction of outcome in usual clinical
practice. Journal of Consulting and Clinical Psychology,
73, 323–333.
Meichenbaum, D., & Turk, D. C. (1987). Facilitating treatment
adherence: A practitioner’s guidebook. Berlin, Germany:
Plenum Press.
Murphy, R., & Hutton, P. (2018). Practitioner review: Therapist
variability, patient-reported therapeutic alliance, and clinical
outcomes in adolescents undergoing mental health treatment
– A systematic review and meta-analysis. Journal of Child
Psychology and Psychiatry, 59, 5–19.
Murphy, S. M., Chowdhury, U., White, S. W., Reynolds, L.,
Donald, L., Gahan, H., & Press, D. A. (2017). Cognitive
behaviour therapy versus a counselling intervention for anx-
iety in young people with high-functioning autism spectrum
disorders: A pilot randomised controlled trial. Journal of
Autism and Developmental Disorders, 47, 3446–3457.
Nock, M. K., & Ferriter, C. (2005). Parent management of
attendance and adherence in child and adolescent therapy: A
conceptual and empirical review. Clinical Child and Family
Psychology Review, 8, 149–166.
Owens, K. A., Haddock, G., & Berry, K. (2013). The role of the
therapeutic alliance in the regulation of emotion in psy-
chosis: An attachment perspective. Clinical Psychology &
Psychotherapy, 20, 523–530.
Reynolds, C. R., & Kamphaus, R. W. (2004). Behavioral
Assessment System for Children (BASC-2) (2nd ed.). San
Antonio, TX: NCS Pearson.
Rutter, M., & Bailey, A. (2003). Social Communication
Questionnaire (SCQ). Los Angeles, CA: Western
Psychological Services.
Shields, A., & Cicchetti, D. (1997). Emotion regulation among
school-age children: The development and validation of a
new criterion Q-sort scale. Developmental Psychology, 33,
906–916.
Shields, A., & Cicchetti, D. (1998). Reactive aggression among
maltreated children: The contributions of attention and emo-
tion dysregulation. Journal of Clinical Child Psychology,
27, 381–395.
Shirk, S. E., & Karver, M. (2011). Alliance in child and adolescent
psychotherapy. In J. C. Norcross (Ed.), Psychotherapy rela-
tionships that work: Evidenced-based responsiveness, 2nd
Edition (pp. 70–91). Oxford, UK: Oxford University Press.
Shirk, S. R., & Karver, M. (2003). Prediction of treatment out-
come from relationship variables in child and adolescent
therapy: A meta-analytic review. Journal of Consulting and
Clinical Psychology, 71(3), 452–464.
Shirk, S. R., & Russell, R. L. (1998). Process issues in child
psychotherapy. In A. Bellack & M. Hersen (Eds.),
Comprehensive clinical psychology (Vol. 5, pp. 57–82). (T.
Ollendick Children and adolescents Clinical formulation
and treatment). Oxford, UK: Pergamon.
Silverman, W. K., & Albano, A. M. (2004). Anxiety Disorders
Interview Schedule for DSM-IV – Parent interview sched-
ule. Oxford, UK: Oxford University Press.
Sung, M., Ooi, Y. P., Goh, T. J., Pathy, P., Fung, D. S., Ang, R.
P., . . .Lam, C. M. (2011). Effects of cognitive-behavioral
therapy on anxiety in children with autism spectrum dis-
orders: A randomized controlled trial. Child Psychiatry &
Human Development, 42, 634–649.
Vasa, R. A., Carroll, L. M., Nozzolillo, A. A., Mahajan, R.,
Mazurek, M. O., Bennett, A. E., . . . Bernal, M. P. (2014).
A systematic review of treatments for anxiety in youth
with autism spectrum disorders. Journal of Autism and
Developmental Disorders, 44, 3215–3229.
Volker, M. A., Lopata, C., Smerbeck, A. M., Knoll, V. A.,
Thomeer, M. L., Toomey, J. A., & Rodgers, J. D. (2010).
BASC-2 PRS profiles for students with high-function-
ing autism spectrum disorders. Journal of Autism and
Developmental Disorders, 40, 188–199.
Walters, S., Loades, M., & Russell, A. (2016). A systematic
review of effective modifications to cognitive behavioural
therapy for young people with autism spectrum disorders.
Review Journal of Autism and Developmental Disorders, 3,
137–153.
Wechsler, D. (2011). Wechsler Abbreviated Scale of Intelligence
(WASI-II) (2nd ed.). San Antonio, TX: NCS Pearson.
Weiss, J. A., Thomson, K., Burnham Riosa, P., Albaum, C., Chan,
V., Maughan, A., . . . Black, K. (2018). A randomized wait-
list-controlled trial of cognitive behavior therapy to improve
emotion regulation in children with autism. Journal of Child
Psychology and Psychiatry, 59, 1180–1191.
Weston, L., Hodgekins, J., & Langdon, P. E. (2016). Effectiveness
of cognitive behavioural therapy with people who have
autistic spectrum disorders: A systematic review and meta-
analysis. Clinical Psychology Review, 49, 41–54.
Zeman, J. L., Cassano, M., Suveg, C., & Shipman, K. (2010).
Initial Validation of the Children’s Worry Management
Scale. Journal of Child and Family Studies, 19, 381–392.