Psychoeducational Psychotherapy: A Model for Childhood Interventions?

Presentation Goals Attendees should contemplate

1.

2.

3.

The focus of psychoeducational psychotherapy The impact of psychoeducational psychotherapy Similarities and differences of consumer vs clinician led interventions

Prototypic Medication Trial

Benefical medicine Works while being taken Does not accrue benefit when d/cd Most child trials are acute (ie, < 12 wks)

70 60 50 40 30 20 10 0 Pre-Tx Post-Tx Follow-up Control Medicine

Prototypic Psychotherapy Trial

Benefical psychotx Begins to work as skills take hold Continues to work after tx ends, but decrement occurs Most child trials are acute (ie, < 6 mos)

70 60 50 40 30 20 10 0 Pre-Tx Post-Tx Follow-up Control Psychotx

How to Conceptualize Psychoeducational Psychotherapy

Historically, families Have been blamed Have not gotten useful information/support/skill building This can result in families being skittish or defensive about family-based intervention

Goals of Psychoeducation
Teach parents and children about The childs illness & its treatment Provide support Peers (Im not the only one) Professionals - understand the disorder Build skills problem-solving communication symptom management

MFPGTreatment Goal
If

you give a man a fish, he will eat for a day. If you teach a man to fish, he will eat for a lifetime.

Why Psychoeducation Makes Sense: Relevant Issues

Service Delivery Adherence/Barriers Expressed Emotion Concordance Father Involvement Caregiver Stress

Service Delivery Issues

Financial pressures: managed care/public sector How to perform the miracle of providing adequate services with very limited $$? Pragmatic issues How many sessions can/will a family attend? What do consumers want?

What Do Families Want?

Hatfield, '81 J Psychiatric Tx and Evaluation; '83, Family Therapy in Schizophrenia

Family members were asked directly what their needs were in caring for the patient 57%: understanding the symptoms 55%: specific suggestions for coping with behavior 44%: relating to people with similar experiences There was little congruence between what families wanted and what they received from professionals

Why Psychoeducation Makes Sense: Relevant Issues

Service Delivery Adherence/Barriers Expressed Emotion Concordance Father Involvement Caregiver Stress

Treatment Adherence

1/3 - 2/3 of children in child & adolescent psychiatry outpatient clinics do not keep scheduled appointments Brasic et al, 2001 Meta-analyses suggest treatment adherence is approximately 50% for most children with chronic health conditions Bryon, 1998

Why Psychoeducation Makes Sense: Relevant Issues

Service Delivery Adherence/Barriers Expressed Emotion Concordance Father Involvement Caregiver Stress

What is Expressed Emotion (EE)?

Refers to a construct initially coined by British researchers Criticalhostile--emotionally overinvolved Has been used in studies examining "big" outcomes for "big" disorders eg, relapse in schizophrenia, recurrent mood disorders Appears to measure a robust family characteristic ie, findings are often impressive

EE as Predictor of Adult Outcome

Butzlaff & Hooley, '98, Arch Gen Psychiatr

metaanalysis of 27 studies EE is a general predictor of poor outcome EE can be modified relapse rates for diagnostic groups: schizophrenia: 65% high EE; 35% low EE-findings strongest for chronic schizophrenia mood d/o's: 70% high EE; 31% low EE eating d/o's: 3 studies, effect size of .51 (medium to large effect)

Why Psychoeducation Makes Sense: Relevant Issues

Service Delivery Adherence/Barriers Expressed Emotion Concordance Father Involvement Caregiver Stress

Caregiver Concordance

Disagreement between parents/caregivers on child-rearing linked with higher rates of child problem behaviors (Jouriles et al, 1991) poorer marital quality (Lamb et al, 1989) lower levels of family problem-solving (Vuchinich et al, 1993) decreased parental effectiveness (Deal et al, 1989)

Why Psychoeducation Makes Sense: Relevant Issues

Service Delivery Adherence/Barriers Expressed Emotion Concordance Father Involvement Caregiver Stress

Father Involvement

Schock, Gavazzi, Fristad et al 02, Family Relations Pilot data indicate that fathers at baseline Know less about mood disorders Have less positive and more negative evaluations of their children following interventionmore like mothers Have a similar knowledge base Evaluate their child more positively and less negatively

Why Psychoeducation Makes Sense: Relevant Issues

Service Delivery Adherence/Barriers Expressed Emotion Concordance Father Involvement Caregiver Stress

Causes of Caregiver Stress

Hellander, Sisson, Fristad, in Geller & DelBello, 2003

Care of a high-needs child Need to advocate in schools Worry about the future Exhaustion Physical illnesses Financial strain Isolation Stigma Guilt and blame

Application of Psychoeducational Psychotherapy to Childhood Mood Disorders

The OSU Childhood Mood Disorders Research Program

Future Research DirectionsChildhood Mood Disorders Burns, Hoagwood, and Mrazek (1999) Paper based on summary prepared for US Surgeon Generals Report on Mental Health (2000) 5/11 specific recommendations pertain Study treatment efficacy for comorbid d/os Involve families in treatment Develop treatments for children < 9 Assess functional status to determine realworld benefits; and Use manualized interventions

Childhood Bipolar DisorderOn the Rise?

Lofthouse & Fristad, 2004, Clinical Child & Family Psychology Review

Literature review174 articles/chapters 26 before 1980 36 during the 1980s 66 during the 1990s 46 from 2000-2002 Amazon search18 books 15 from 2000 to 2003 Websites5 since 1999 Timecover article, Aug 19, 2002

2005 Google Internet Search

Leffler & Fristad (2005)

Topic childhood mood disorders adolescent mood disorders childhood depression adolescent depression childhood bipolar disorder adolescent bipolar disorder childhood mania adolescent mania

Number 517,000 577,000 3,100,000 3,630,000 483,000 757,000 248,000 645,000

ODMH Study
Fristad, Goldberg-Arnold & Gavazzi, JMFT, 2003 35 children and their parents 54% depressive; 46% bipolar disorders M=3.6 comorbid diagnoses/child (range, 1-7) C-GAS=51 at baseline 29/35 (83%) on meds 8-11 years old (average, 10.1 yrs) 77% boys 6 month wait-list design 6 sessions, 75 minutes/session, manual-driven treatment

ODMH Findings
Fristad, Goldberg-Arnold & Gavazzi, JMFT, 2003 Parents Increased knowledge of mood disorders Increased positive family interactions Increased efficacy in seeking treatment Improved coping skills Increased social support Improved attitude toward child/treatment Children Increased social support from parents Increased social support from peers (trend)

The OSU Psychoeducation Program

Orientation Nonblaming/growth-oriented Biopsychosocialuses systems and cognitive-behavioral techniques Education + Support + Skill Building Better Understanding Better Treatment + Less Family Conflict Better Outcome Two formats groups of families (MFPG) single families (IFP)

MFPG Session Format

Children aged 8-11 (any mood disorder) 8 sessions, 90 minutes each Begin/end with parents/children together Middle (largest) portion-separate groups Children receive in vivo social skills training (in gym) after formal lesson is completed Therapists: 1-parents; 2-children Families receive projects to do between sessions

8 Session Outline--Parents
1. 2. 3. 4. 5. 6. 7.

8.

Welcome, symptoms & disorders Medications Systems: school/treatment team Negative family cycle, WRAP-UP 1st Problem solving Communication Symptom management WRAP-UP 2nd of program & graduate

8 Session Outline--Children
1.
2. 3.

4.
5.

6.
7. 8.

Welcome, symptoms & disorders Medications Tool kit to manage emotions Connection between thoughts, feelings and actions (responsibility/choices) Problem solving Nonverbal communication Verbal communication Review & GRADUATE!

Our Mottos
The CAUSE of mood disorders is fundamentally biological, their COURSE can be greatly affected by psychosocial events We dont get to pick the genes we get or the genes we pass on Its not your fault but its your challenge

Many Contributors

Parent Group Therapists Jill S. Goldberg-Arnold, PhD* Catherine Malkin, PhD Kitty W. Soldano, PhD, LISW Child Group Therapists Barb Mackinaw-Koons, PhD Nicholas Lofthouse, PhD Colleen Quinn, MS Jarrod Leffler, PhD Graduate Student Interviewers/ Co-Therapists/Lab Members Kate Davies Smith, PhD Kristen Holderle Davidson, PhD Dory Phillips Sisson, PhD Nicole Klaus, MA Jenny Nielsen, MA Matthew Young, BA Ben Fields, MEd Colleen Cummings, BA Radha Nadkarni-DeAngelis, BA

Data Analysis/Management Joseph S. Verducci, PhD Cheryl Dingus, MS Kimberly Walters, MS Elizabeth Scheer, BS Hillary Stewart, BA Christina Theodore-Oklata, BA 693 Students Graduate Student Interviewers/ Co-Therapists Kristy Harai, PhD Anya Ho, PhD Rita Kahng, MA Becky Hazen, PhD Kari Jibotian, MA Lauren Ayr, MA 165 Families *Consensus Conference Reviewer

NIMH Study Design, N=165

Groupa Time 1 Month 0 Time 2 Month 6 Time 3 Month 12 Follow-up Time 4 Month 18 Follow-up

MFPG + TAUb WLC + TAUc

aFamilies

Baseline: Follow-up Pre-treatment Baseline Follow-up

Pre-treatment

Follow-up

were enrolled in 11 sets of 15 (7-MFPG/8-WLC) = 165 families bMultifamily Psychoeducation Group + Treatment As Usual cWait-List Control + Treatment As Usual

MFPG RecruitmentN=165

225 families screened 203 (90%) passed the screen 171 (84%) arrived at baseline assessment 165 (96%) met study criteria Referral sources: 62% health care providers 19% media 19% other Rural/geographically remote, 22% (round trip, 5664 mi; range=2-344 mi)

Study Sample - Family Characteristics

Variable MFPG MFPG+TAU (n=78) Family Structure Married bio par Step-family Married adop par Single bio par Single adop par Other Income 46% 17% 5% 21% 1% 10% <20K to >100K M=40-59K WLC+TAU (n=87) 40% 23% 7% 17% 1% 12% <20K to >100K M=40-59K

Demographics: MFPG Total Sample & BPD Sub-Sample

Variable Comorbid D/O Anxiety Behavior ADHD Two-parent families
(includes step-families)

TOTAL N=165 67% 97% 87% 74% 56 mi (range: 2-344)

BPD N=115 70% 95% 80% 65% 70 mi (range: 14-344)

Average round trip

DemographicsVarious Samples
Variable BPD n=115 Treated BPD n=89

Age
% Male % White

9.8
72 91

9.7
69 94 55 72 83

% Fam Hx- 53 Mania % Fam Hx- 73 Depression % Fam Hx- 84 Either

Questions
1. Does MFPG work for BPD? Bipolar Subsample Immediate Treatment Group=55 Waitlist Group=60 2. How does MFPG work for just those families who actually receive it (ie, those who complete treatment) Bipolar Subsample Immediate treatment group=54 (lose 1) Waitlist control group=35 (lose 25)

Outcome Measures

MSI=Mood Severity Index CDRS-R + MRS (equal contributions) <10: minimal symptoms 11-20: mild symptoms 21-35: moderate symptoms >35: severe symptoms

Outcome Measures

Rage Index MRS irritability + disruptive-aggressive items <3: minimal symptoms 4-8: mild symptoms 9-12: moderate symptoms 13-16: severe symptoms

Mood Severity Index (Parent, Current) MFPG BPD Sample

N=115, all BPD n=55 Immediate n=60 Wait List Pre-post Imm=WLC

35 30 25 20 15
os as el in os M M 12 18 6 M os e B

Immediate
Dr. Fristad--R01 MH61512

Wait List

Mood Severity Index (Parent, Current) MFPG Treated BPD Sample

N=89 n=54 Immediate n=35 Wait List Pre-Post Imm=WLC

35 30 25 20 15
os as el in os M M 12 18 6 M os e B

Immediate
Dr. Fristad--R01 MH61512

Wait List

Rage Index (Parent, Current) MFPG BPD Sample

N=115 n=55 Immediate n=60 Wait List Pre-post Imm=WLC

10 9 8 7 6 5
os as el in os M M 12 18 6 M os e B

Immediate
Dr. Fristad--R01 MH61512

Wait List

Rage Index (Parent, Current) MFPG Treated BPD Sample

N=89 n=54 Immediate n=35 Wait List Pre-post Imm=WLC

10 9 8 7 6 5
os as el in os M M 12 18 6 M os e B

Immediate
Dr. Fristad--R01 MH61512

Wait List

Anecdotal Evaluations--Parents

No matter how bad the situation isthere is hope and treatment. Dont give up. This program was an eye opener for me. I also was encouraged and relieved to find out that I was not alone. Listen to what they are saying. They can really help you. Learn what is going on with your child. Stay focused on what is going with your child and do not give up on your child.

Anecdotal Evaluations--Children

You get to meet new people you never knew before. They help you with your symptoms. Theyre nice and theyre helpful. And you guys support us and give us snacks. Youve been nice to us and treated us with respect. It really helps out if you let it.

Hand-to-Hand Evaluation
Davidson & Fristad, 2004, Child & Adolescent Psychopharmacology News, 9(2): 7-9.

46 parents Assessed twice (n=18) Baseline (Time 1, T1, pre-class) 8 weeks (Time 2, T2, post-class) Findings Parents stressed Stress diminishes after H-to-H (p<.05), improved ratings for: Less time for marriage/Sig other Dealing w/ personal depression Getting child to do chores/self-care Witness self-harm/suicidal acts Feeling embarrased by childs public rages

Comparisons of Consumer vs Clinician Led

Hand-to-Hand Pros Free Community-based In the trenches Modeling Hand-to-Hand Cons Burn-out How to deal with clinical content?

MFPG/IFP Pros Evidence-based Work directly with children & parents Can address clinical content MFPG/IFP Cons Availability

What to Do?

BOTH! H-to-H and MFPG should work well together Models are supportive of each other Information will overlap but reinforce Each will contain some unique content