Discussion

Our first aim of this study was to examine change in idiographic Top Problem severity ratings across the entirety of the UP-C/A. As hypothesized, the TPA is able to capture change in problem severity across the course of treatment, as demonstrated by significant reductions in parent- and child-report TPA severity ratings between the first and last sessions. Our second aim was to examine if this reduction is meaningful beyond statistical significance. Indeed, the majority of the sample demonstrated reliable change in symptom severity as measured by the reliable change index. This significant and reliable reduction in ideographically identified problem severity is consistent with past work indicating the success of the UP-C/A in reducing symptom severity in research clinic and community samples (Milgram et al., 2021; Kennedy et al., 2019; Garcia-Escalera et al., 2020). More generally, these results are consistent with findings indicating that transdiagnostic, modular therapies can improve treatment outcomes in youth (Weisz et al., 2012). These findings contribute to the growing literature advocating for the use of ideographic measurement tools in the psychotherapeutic interventions for youth.

For the third aim of the study, we investigated which pre-treatment demographic and clinical variables impact the change in TPA severity rating. We found that pre-treatment depression significantly predicted change in child- but not parent-reported TPA severity. These results indicate that youth with higher self- reported depression, on average, have larger changes in TPA severity over the course of treatment. On the other hand, results indicate that parent-reported pre- treatment symptoms of youth depression did not affect change in TPA severity.

Although the child findings (but not the parent) are inconsistent with that of Kennedy and colleagues (2018), who found that baseline depression symptoms were not predictive of treatment outcomes, they are consistent with the larger literature indicating that predictors of cognitive-behavioral therapy (CBT) outcomes vary (McLellan et al., 2018; Kennedy et al., 2018; Akerblom et al., 2020). Within the CBT literature, there is growing evidence to suggest that patients with more severe symptoms exhibit a more significant gain from treatment (Lopez & Basco, 2014). There is also evidence to suggest that greater pre-treatment parental psychopathology can lead to greater anxiety reductions in youth mediated by greater improvements in family functioning and caregiver strain (Schleider et al., 2015). However, clients who endorse heightened depressive severity at baseline may be associated with lower pre-treatment outcome expectation (Vîslă et al., 2021). Therefore, identifying pre-treatment factors may be particularly important because it can help guide the development of more effective psychotherapy (Knight et al., 2014).

An additional sub-goal of the third aim was to assess if early treatment response (ETR) significantly predicted change in TPA severity. We found that, for both parent and child, ETR significantly predicted change in TPA severity ratings. These results suggest that youth who exhibited significant reductions in both parent- and child-reported TPA severity within the first four sessions of treatment, on average, exhibited larger differences in TPA severity between the first and last sessions. These findings expand upon the results of Milgram and colleagues (2021), who examined the prevalence and clinical correlates of ETR in the UP-C/A, to demonstrate that such a classification of treatment response has power in terms of predicting treatment outcomes. This is consistent with the literature and suggests that evaluating treatment responses at various timepoints can offer predictive utility for clinicians to re-assess caregiver and client treatment goals (Queen et al., 2014; Milgram et al., 2021; Skriner et al., 2019; Kennedy et al., 2020).

However, the present study is not without limitations. To begin, our conclusions are limited by the fairly small and primarily White and Hispanic sample. Such sample demographics limit the generalizability of the results to other, more diverse populations given that past work has demonstrated systemic differences in outcomes among various populations (Ehrenreich-May et al., 2010; Weisz et al., 2015). Second, to capture change across multiple top problems, we created an average score for the first session, fourth session, eighth session, and last session. This may have limited our analyses as it may not be sensitive to the trajectory of change of individual problem types. Lastly, we did not control for the modality of the UP-C/A (e.g., individual vs. group therapy and telehealth vs. in- person) and thus our results may be confounded by treatment format. Despite these limitations, the present study implements a novel approach to examining the effectiveness of the UP-C/A through use of an idiographic assessment.

Future studies should address the aforementioned limitations by analyzing individual TPA severity ratings instead of session averages to assess the trajectory of change for individual problems. This can allow for a more nuanced approach to improving individual client concerns in clinician-guided therapy. Future studies should also assess the relationship between the specific modules of the UP-C/A to examine how TPA severity changes as a function of specific therapeutic content.

Future work could also use the TPA to assess the impact of non-response on treatment outcomes across the UP-C/A. Assessing the relationship between TPA improvement, non-response, and specific UP-C/A modules could provide novel information on the aspects of the UP-C/A that are particularly successful in treating certain problem domains. Finally, future studies could also assess the degree of concordance among treatment goals for the client, clinician, and parent and the role of such concordance in predicting treatment outcomes. There is evidence to suggest that agreement on diagnoses and presenting problems can predict treatment outcomes in youth mental health (Jensen-Doss & Weisz, 2008).

The current study is the first to examine symptom improvement in youth over the course of the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C and UP-A; Ehrenreich-May et al., 2018) using the Top Problems Assessment (TPA; Weisz et al., 2011). Our results showed a significant reduction in both top problem severity and symptom severity in youth. This work contributes to a growing literature demonstrating not only the effectiveness of the UP-C/A in treating psychopathology in youth but also the ability for idiographic measures, such as the TPA, to capture treatment outcomes and trajectories of change. To conclude, we demonstrated that the Top Problems assessment is a suitable solution for complementing standardized measures in assessing treatment response, as it uses a person-centered approach, can account for cultural differences, and can sufficiently capture client progress over the course of transdiagnostic treatments.