Positive Association of Child Involvement and Treatment Outcome Within a Manual-Based Cognitive–Behavioral Treatment for Children With Anxiety Brian C. Chu University of California, Los Angeles Philip C. Kendall Temple University Ratings of child involvement in manual-based cognitive– behavioral treatment for anxiety were associ- ated with the absence of primary anxiety diagnosis and reductions in impairment ratings at posttreatment for 59 children with anxiety (ages 8 –14 years). Good-to-excellent interrater reliability was established for the independent ratings of 237 therapy sessions, and strong psychometrics were established for the involvement measure. Child involvement at midtreatment, just prior to in vivo exposures, was positively associated with treatment gains but earlier involvement was not. Increased involvement during therapy (positive involvement shifts) may provide a useful index of change and may also predict outcomes. Involvement was not associated with client demographics or diagnostic category. Implications for treatment and measurement of psychotherapy process within manual-based treatments are discussed. Individual cognitive– behavioral treatment (CBT) for children with anxiety has received empirical support (e.g., Barrett, Dadds, & Rapee, 1996; Cobham, Dadds, & Spence, 1998; Kendall et al., 1997; Manassis et al., 2002), but its within-session processes have received little empirical attention (Kendall & Chu, 2000). Re- search dedicated to understanding the process of child therapy is rare (Kazdin & Kendall, 1998; Russell & Shirk, 1998), yet under- standing therapist, child, and interaction factors that have an im- pact on outcomes is essential to improving outcomes and under- standing the mechanisms of empirically supported treatments (Kazdin & Weisz, 1998; Kendall & Flannery-Schroeder, 1998). The processes of child therapy deserve special attention given that children rarely refer themselves for treatment, often do not recog- nize or acknowledge the existence of problems, and frequently are at odds with their parents about the goals of therapy (DiGiuseppe, Linscott, & Jilton, 1996; Shirk & Saiz, 1992). In a manual-based treatment for anxiety that relies on the child learning specific cognitive skills, learning emotion management, and participating in exposure-based tasks, the child’s level of involvement in these activities may be critical to treatment success. Involvement includes the child’s willingness to behaviorally par- ticipate in therapy activities as well as the child’s willingness to self-disclose, ask questions, and mentally engage the therapeutic material (e.g., Braswell, Kendall, Braith, Carey, & Vye, 1985). The issue of child involvement is timely and important given criticism that the structure of manual-based treatments may poten- tially limit client engagement because it prescribes certain topics and activities (Eifert, Evans, & McKendrick, 1990) that may, under some circumstances, foster restrictive therapist behaviors (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996). Previous research with both adult and child clients suggests that positive engagement is important for beneficial outcomes. In adults, involvement, typically defined as verbal self-disclosure and initiation of difficult topics, has been found to be significantly related to client-rated, therapist-rated, and independent-evaluator- rated outcomes across theoretical orientations and professional experience (Eugster & Wampold, 1996; Gomes-Schwartz, 1978; O’Malley, Suh, & Strupp, 1983; Windholz & Silberschatz, 1988). Client involvement has also been associated with other important within-session processes such as the therapeutic alliance (Rean- deau & Wampold, 1991; Tryon & Kane, 1995). Typically, signif- icant relationships between client involvement and outcome can be identified early in treatment and may become stronger over the course of therapy (O’Malley et al., 1983). In research with children, preliminary findings suggest a role for child involvement. In an uncontrolled study of community practice that examined diverse clients and eclectic treatment modalities, child involvement accounted for 20% of outcome variance (Gorin, 1993). In a randomized controlled trial that compared cognitive– behavioral, contingency-management, and attention-control condi- tions for children with impulsive behavior problems, child involve- ment accounted for roughly 16% of the variance of improvement in teacher-reported self-control and child hyperactivity (Braswell et al., 1985). Analyses of similar constructs (e.g., therapeutic relationship) also indicate that process measured later as compared Brian C. Chu, Department of Psychology, University of California, Los Angeles; Philip C. Kendall, Department of Psychology, Temple University. This research was supported in part by National Institute of Mental Health Grants MH44042 and MH64484. We thank the participating chil- dren and their families and the dedicated independent coders: Celanie Chenet-Norfleet, Stephanie Dobbins, Tori Lodge, Bernadette Emore, Mel- issa Marco, and Anne Schmolze. We also thank the following individuals for their consultation and support for this project: Alan Sockoloff, Jerome Resnick, Brian Marx, Denise Sloan, Jennifer Hudson, and John Weisz. Correspondence concerning this article should be addressed to Brian C. Chu, who is now at the Graduate School of Applied and Professional Psychology, 152 Frelinghuysen Road, Rutgers, The State University of New Jersey, Piscataway, NJ 08854. E-mail: brianchu@rci.rutgers.edu Journal of Consulting and Clinical Psychology Copyright 2004 by the American Psychological Association 2004, Vol. 72, No. 5, 821– 829 0022-006X/04/$12.00 DOI: 10.1037/0022-006X.72.5.821 821