THE WORKING ALLIANCE INVENTORY: APPLICATIONS FOR WORKING WITH CHILDREN AND ADOLESCENTS WITH CHRONIC

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THE WORKING ALLIANCE INVENTORY APPLICATIONS FOR
WORKING WITH CHILDREN AND ADOLESCENTS WITH
CHRONIC ILLNESSES AND THEIR PARENTS

• Beth Ely, RN, PhD Leslie Alexander, PhD
• Marian Anderson Comprehensive Sickle Cell Center
  _at_ St. Christophers Hospital for Children Bryn
  Mawr University

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WORKING ALLIANCE INVENTORY (WAI)

• Widely used self-report measure of affective
  bonding and collaboration in mental health
  treatment.
• Parallel client and therapist versions.
• Demonstrated efficacy in predicting treatment
  participation and outcomes.

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• Use of the WAI to evaluate the helping alliance
  between the health care provider, chronically ill
  child/adolescent and their parent/guardian may
  help to
• Evaluate the strengths and limitations of the
  relationship(s)
• Predict treatment compliance, or
• Predict readiness to adopt self-care practices
  among older children and adolescents.

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ADAPTED WAI

• WAI was adapted into 12 different forms.
• Child relationship with NP and MD.
• Adolescent relationship with NP and MD.
• Parent/Guardian relationship with NP and MD.
• Parent/Guardians perception of their childs
  relationship with NP and MD.
• NP and MD relationship with Child/Adolescent.
• NP and MD relationship with Parent/Guardian.

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PURPOSE

• Test the feasibility, relevance, and
  reliability of the adapted Working Alliance
  Inventory (WAI) for use in a population of
  children with serious chronic blood disorders,
  their parents/guardians, and their health care
  providers.

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Format of the WAI

• Child Version
• Children 714 yrs.
• 12 Items
• Responses 15
• (never, not very often, sometimes, often, always)
• 3 subscales (4 items each) Task, Bond Goal

• Adolescent Version
• gt 14 yrs. adults
• 36 items
• Responses 1 7
• (never, rarely, occas., sometimes, often, very
  often, always)
• 3 subscales (12 items each) Task, Bond, Goal

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WAI QUESTIONS

• _____ and I work together to help me feel better
  and stay well.
• Child-MD NP Goal subscale
• I feel _____ cares about me even when I do
  things that he/she does not approve of.
• Adol.-MD NP Bond subscale
• What _____ and my child talk about gives my
  child new ways of looking at his/her disease.
• Child-MD NP by Parent Task subscale

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PROCEDURE

• Informed consent obtained from child or
  adolescent, parent/guardian, and health care
  providers (MD, NP).
• Phone contact established to set up an interview
  time and location.
• Interviews were conducted outside the clinical
  setting by a research assistant who was not part
  of the clinical treatment team.

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INTERVIEW PROCEDURE

• WAI forms administered separately during
  in-person interviews for patients and
  parents/guardians.
• Questions were read to participants, while the
  scoring scale was provided for reference.
• All inventories were administered by the same
  research assistant.
• MD and NP forms were completed independently.

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• Test-retest reliability was determined through
  re-administering the WAI to patients and
  parent/guardians.
• Second WAI was administered approximately 4 6
  weeks after initial administration using the same
  procedures.

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SAMPLE

• 34 children (4 sibling pairs)
• Age 7-14 yrs.(M10.5yrs.)
• Diagnoses SCD 88 (n30) hemophilia 17.6
  (n3)
• African American 88 (n32), Hispanic 6 (n2)
• Male 58.8 (n20)

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SAMPLE (cont.)

• 13 adolescents (1 sibling pair)
• Age 15 20 yrs (M16.8yrs.)
• Diagnoses SCD 53.8 (n7) hemophilia 30.0
  (n3) other hematology 30 (n3)
• African American 69.2 (n9), Hispanic 13
  (n3)
• Male 69 (n9)

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SAMPLE (cont.)

• 43 parent/guardians
• 39 mothers (90.7)
• 1 grandmother guardian
• 1 foster mother
• 1 father who completed the WAIs separate from
  his wife, but for the same child.
• 4 Health Care Providers
• 2 Hematologists
• 2 Nurse Practitioners

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RESULTS

• Internal Consistency Reliability estimates using
  Cronbach alpha ranged from alpha .79 to .98
  for the 12 versions of the WAI.
• Cronbach alpha for the newly developed 12 item
  child forms were
• Child with MD NP alpha .83
• Parent/guardian relationship with MD NP alpha
  .96
• Parent/guardians perception of their childs
  relationship with the MD NP alpha .92

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TEST-RETEST RELIABILITY CHILD FORMS (12 ITEMS)
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TEST-RETEST RELIABILITY ADOLESCENT FORMS (36
ITEMS)
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Child Scale Scores
Possible Score Range 12-60 (1Never to
5Always)
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Adolescent Scale Scores
Possible Score Range 36-252 (1Never to
7Always)
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Correlations Child or Adolescent Scores with
Parent/Guardian

• Child-MD with Parent view of Child-MD r 0.59,
  p lt .02
• Child-NP with parent view of Child-NP r 0.75,
  p lt .001
• Adolescent-MD with Parent view of Adol.-MD r
  0.59, plt.06
• Adolescent-NP with Parent view of Adol.-NP
  r0.70, plt .01

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CONCLUSIONS

• Each of the versions of the adapted WAI have
  strong internal consistency.
• Test-retest reliabilities are generally strong,
  although 4 of the 24 scales were nonsignificant.
• The child-NP, adol. MD and NP, parent of
  adol. with NP versions need more scrutiny.

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Conclusions

• Alliance scores were relatively high on all
  measures.
• Parents view of their childs or adolescents
  relationship with both the MD and NP correlates
  significantly with the scores given by the child
  or adolescent.
• Children ages 7 and 8 were unable to understand
  the meaning of some items.

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IMPLICATIONS

• Consider how the WAI could be used to predict
  treatment compliance.
• A stronger perceived alliance may influence the
  adoption of illness prevention, self-management
  skills in children with chronic hematologic
  conditions over time.
• Health Care Providers can evaluate their
  effectiveness in providing ongoing care to the
  child and family.

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Family Centered Care

• Partnership with the parents with the goal of
  benefiting the child.
• Health care providers understand the environment
  in which the childs care will take place and
  what will happen that might cause pain and/or
  fear.
• Parents have knowledge about their childs usual
  coping skills, strengths and weaknesses.

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• To Have Great Pain is to Have Certainty, To Hear
  That Another Has Pain is to Have
  Doubt.(Scarry, The Body in Pain, 1985, p. 7)

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Chronic Illness Managing Pain Issues

• Sources of pain include past experiences- fear
  and anxiety.
• Diagnostic tests and procedures- adequate
  preparation and knowledge is key.
• Symptom management- exacerbations and remissions.

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Pain Assessment Issues

• Type of pain
• Presence of anxiety or fear contributing to the
  pain response.
• Cognitive development of the child- understanding
  and communication of pain.
• Childs previous experience with pain.
• Usual pain behaviors of the child

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Assessing pain in adolescents Expect to probe
for information
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Pain Assessment Issues (cont.)

• Environmental factors eg. Others crying,
  observing needles/blood.
• Ethnicity/culture of the child and family.
• Presence of parent or other adult support person
  to comfort and advocate for the child.

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How to Help?

• Assess childs developmental level and
  understanding
• Discuss patient and family goals for pain
  management
• Consider effects of previous pain experience on
  current goals and expectations
• Communication- listen to concerns
• Preparation- age appropriate Knowing what to
  expect is key to coping
• Repetition Rehearsal
• Control Issues-shared decision making
• Resources-availability

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The Meaning of Fear for Young Children
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Procedure Related Pain Issues

• Type of procedure
• Duration
• Anticipated pain intensity
• Previous pain experience
• Availability of Support Persons
• Preparation and knowledge
• Concerns/ Level of anxiety
• Expectations of the child and family
• Childs conception of the test and why it is
  being done.
• Childs usual coping skills and temperament.
• Type and timing of preparation.

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Cognitive-Behavioral Physical StrategiesInfants

• Infants are preverbal and rely mainly on parents/
  care givers for comfort and protection.
• Parent preparation complete, descriptive,
  honest.
• Recognize this may be their first experience with
  the procedure.
• Physical strategies
• Skin to skin contact
• Nonnutritive sucking
• Tactile stimulation
• Swaddling/positioning

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Cognitive-Behavioral Physical StrategiesYoung
Children

• Hands-on play simulate the experience
• Distraction techniques
• Blowing bubbles Books- pop-up, musical Favorite
  video
• 60 of young children benefit from distraction
  during procedures (Kleiber Harper, 1999)
• Parental presence Actively involve them in the
  distraction.

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Intervention StrategiesSchool- Aged Children
Adolescents

• Learn and cope through doing, asking questions,
  and experimenting
• Hands-on Rehearsal
• Multisensory information details
• Use of analogy
• Be aware of nonverbal cues
• Parental role coach and helper
• Identify effective past coping strategies
• Control Provide choice of techniques and images
  used
• Rehearse the techniques when possible.

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• Guided imagery
• Superpower to protect/cope
• Imagery incompatible with the pain
• Progressive relaxation
• Breathing techniques
• Provide choice of techniques and images used
• Consider active techniques such as TENS,
  breathing, biofeedback to increase control.
• Distraction
• Music- headphones
• Virtual reality computer simulation

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The End- Thanks for Your Attention