Therapist alliance building behavior and treatment adherence for dutch children with mild intellectual disability or borderline intellectual functioning and externalizing problem behavior.
Therapist warmth and manual fidelity each add unique value in group CBT for school-age kids with mild ID and externalizing behavior.
01Research in Context
What this study did
van Herwaarden et al. (2022) ran a group program in the Netherlands. Nine- to eighteen-year-olds with mild or borderline intellectual disability and behavior problems attended child CBT groups. Their parents attended behavioral parent-training groups at the same time.
The team watched recordings of every session. They scored how well therapists followed the manual. They also counted warm alliance-building moves such as praising, using the child’s name, and smiling. Kids and parents were tested before and after the ten-week program.
What they found
When therapists stuck close to the manual, parents later said their bond with their child had improved. When therapists used more alliance-building moves, parents reported fewer rule-breaking and angry outbursts at home.
Both therapist skills mattered, but each helped a different outcome. Fidelity helped the relationship. Warm style helped the behavior.
How this fits with other research
Dudley et al. (2019) saw the same link in autistic children. Stronger therapist-child and therapist-parent alliances predicted bigger anxiety drops after CBT. The pattern repeats: alliance boosts CBT results across diagnoses.
Sappok et al. (2024) took parent training online. Four brief Zoom sessions cut disruptive behavior in Vietnamese preschoolers. Their telehealth format extends the Dutch idea—parent training works, and it can travel across cultures and screens.
Glazemakers et al. (2013) tried the flip side. They tweaked Triple P for parents who themselves have intellectual disability. Those parents also saw fewer child conduct problems. Together the studies show: adapt the program to the learner, whether the learner is the parent or the child.
Why it matters
You can measure two simple things tomorrow: are you doing the steps in the manual, and are you showing warmth each minute? Track one for fidelity and one for alliance. Raising either score can lift parent or child outcomes in your next group CBT cycle.
Want CEUs on This Topic?
The ABA Clubhouse has 60+ free CEUs — live every Wednesday. Ethics, supervision & clinical topics.
Join Free →Pick one session today, tally every praise and smile you give, then set a goal to raise that count in the next session.
02At a glance
03Original abstract
BACKGROUND: Psychological interventions targeting children with mild intellectual disability or borderline intellectual functioning (MID-BIF) are suggested to be effective in reducing their externalizing problem behavior, but less is known about the specific treatment processes that may be associated with these effects. AIMS: The current study investigated whether the treatment processes of observed treatment adherence (i.e., the degree to which a therapist sticks to the protocol of a treatment and provides the treatment as intended) and observed therapist alliance-building behavior (TA-BB; i.e., behavior contributing to the affective bond between the therapist and the client) predicted treatment outcomes in a group behavioral parent training combined with group child cognitive behavior therapy targeting externalizing problem behavior in children with MID-BIF. METHODS AND PROCEDURES: Seventy-two children (aged 9-18; Mage = 12.1) and their parents in The Netherlands received the intervention program. They reported on children's externalizing behavior, parenting practices and the parent-child relationship by questionnaires at pre-test and post-test, and the observed treatment processes were coded by audio tapes of therapeutic sessions. OUTCOMES AND RESULTS: The results showed high levels of both treatment adherence (M = 2.49; SD = 0.20; range 1 - 3) and TA-BB (M = 4.11; SD = 0.32; range 1 - 5). Additionally, repeated measures analyses revealed that levels of treatment adherence significantly predicted the improvement of the parent-child relationship (F(1, 66) = 5.37; p = .024) and that levels of TA-BB significantly predicted the decrease of parent reported externalizing problem behavior (F(1, 66) = 9.89; p = .002). CONCLUSIONS AND IMPLICATIONS: The current study suggested that optimal treatment processes are important for treatment outcomes in an intervention targeting children with MID-BIF.
Research in developmental disabilities, 2022 · doi:10.1016/j.ridd.2022.104296