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MULTI-FAMILY PSYCHOEDUCATION

GROUPS FOR CHILDHOODMOOD DISORDERS: A PROGRAMDESCRIPTION AND PRELIMINARYEFFICACY DATA

Mary A. FristadStephen M. GavazziKitty W. Soldano

ABSTRACT: Existing literature suggests family-based psychoeduca-tion effectively reduces relapse rates, thereby lowering costs and im-proving quality of life for adults with schizophrenia and major mooddisorders. However, similar programs for families with impaired chil-dren are lacking. This paper reports on efforts to develop, implement,and test the efficacy of a six-session, manual-driven multi-family psy-choeducation group therapy program for families of children or ado-

lescents with a mood disorder. In this paper we provide a clinical de-scription of the program along with pilot data, which suggest consumersatisfaction as well as improvement in family climate following par-ticipation in this multifamily psychoeducation program.

KEY WORDS: child; adolescent; family therapy; mood disorders; psychoeducation.

All authors are with The Ohio State University, Columbus, OH. Mary A. Fristad,PhD, i s with the Department of Psychiatry (Division of Child and Adolescent Psychia-try) and Department of Psychology. Stephen M. Gavazzi, PhD, is with the Departmentof Human Development and Family Science. Kitty W . Soldano, PhD, LISW, is with theDepartment of Psychiatry (Division of Child and Adolescent Psychiatry). Reprint re-quests should be sent to Mary A . Fristad, PhD, Department of Psychiatry, The OhioState University, 1670 Upham Drive, Suite 460G, Columbus, OH 43210-1250; e-mail:[email protected].

*Salary and support provided in part by grants from The Ohio Department of Men-tal Health (OSURF #734030).

Contemporary Family Therapy, 20(3), September 1998 1998 Human Sciences Press, Inc. 8


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first session, family members introduce themselves and share somecommon information (e.g., the child's grade in school, where they go toschool, their diagnosis), and the group leaders present an overview ofwhat family members can expect throughout the six sessions. Follow-ing this, the children or adolescents (groups are held separately fordifferent age groups) break off and meet in an adjacent room withtheir own therapist. Subsequent program sessions (two through six)also begin with all family members present in order to discuss a vari-ety of topics. These can include, but are not limited to: a description ofthe content area to be dealt with in that day's session; issues broughtup in the previous break-out sessions that were deemed by partici-pants necessary for all family members to hear about and discuss;and unanswered questions from the previous meeting.

During both the family segment and parent break-out sessions,slide presentations are used to introduce program material. Parentsare supplied with a workbook to follow along with the slide presenta-tions; these workbooks provide room for participants to make notesabout the material. Program sessions are run in a relatively informalmanner, and group leaders provide consistent encouragement for par-ticipants to ask questions, request clarification, or otherwise inter-rupt to seek additional information about the topic at hand. Groupsare scheduled to accommodate school, work, and other activity sched-ules, so generally are offered in the late afternoon on a weekday.Light refreshments are provided, given the time of day, as well as the

desire to facilitate a congenial atmosphere among group members.

Parents SessionsThe first session. Th e therapist begins by describing the role of

psychoeducation in assisting families. He or she presents our beliefthat if family members increase their understanding of their child'sdisorder, treatment adherence should increase and family conflict re-garding symptom management should lessen. If treatment adherenceincreases and family conflict lessons, the child should function better.

After the children leave to attend their group, the parents' groupleader provides more detailed objectives to the adult family members.

These objectives include: a better understanding of mood disordersymptoms; increased knowledge of the cause and course of mood dis-orders; "de-guiltifying" parents, who often come into group blamingthemselves for their child's mood disorder; increased knowledge of

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medications and side effect management; and the development of bet-ter coping techniques for the family.

A portion of the first session is spent debunking various mythsabout mood disorders. These include thinking that: mood disorderswill "go away on their own" if left alone; "everybody" gets this way; adepressed person "ought to just snap out of it"; getting treatment is a"sign of weakness"; people who talk about suicide are "just trying toget attention"; depressed kids are "bad" or "lazy"; and "all teenagersare moody" so depression is not really a problem.

In place of these incorrect notions, factual information aboutmood disorders in children, adolescents, and adults is presented. Par-ents are reminded that depression is among the most common ofmental disorders (10-25% of women in their lifetime, 5-12% of menin their lifetime, 5% of teenagers at any given time and 2% of childrenat any given time have depression), and that no one is immune fromdepressionit strikes individuals of all ages, income levels, ethnicgroups, and cultural backgrounds. Unfortunately, only a minority ofaffected individuals ever seek treatment. Thus, program participantsare immediately placed in a position of strengththey have recog-nized their child's mood disorder, and they are taking effective actionto deal with it.

Mood disorders are described as a condition for which the causeis probably biological (i.e., there must be a physiological propensity tobecome depressed, otherwise, when stressed, another bad outcome

might occur, but not depression). At the same time, the leader assertsour belief that the course of a mood disorder is highly associated withenvironmental events. The goal of effective intervention is to "treatthe symptoms," not "cure the illness."

During this first session, symptoms of major depression, dysthy-mic disorder, seasonal affective disorder, mania, and psychosis are de-scribed, with particular emphasis on how they appear in the agegroup pertinent to the families attending group (e.g., child scenariosfor parents of children, adolescent scenarios fo r parents of adoles-cents). Risk factors for suicidal behavior are discussed, including tim-ing (e.g., immediately following an inpatient hospitalization, during acrisis), warning signs (e.g., giving away prized possessions), and otherissues (e.g., self-destructive behavior, substance use) of which parents

should be aware. W e briefly discuss how other problems frequentlyco-occur with depression and manic depression, and encourage par-ents to think of each of these problems as its own "pile." In subse-quent group discussions about symptom management, we then ad-

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dress the various "piles" family members may be facing. Finally, werespond to questions raised by the above-mentioned materials. Often,questions raised during this first session (e.g., how to differentiatemanipulation from "true" suicidal behavior) will repeat themselves ina "variation on a theme" manner throughout the subsequent sessions.

The second session. In the second session, information about med-ication and medication management is reviewed. First, the grouptherapist presents some general information about the role of medica-tion in the child's overall treatment (e.g., it can stop or lessen currentsymptom severity and prevent or decrease future symptom severity,it cannot solve other preexisting problems such as shyness or long-standing parent-child conflicts). Next, the therapist presents informa-tion generic to any medication (e.g., a full response doesn't necessarilymean one should stop the medication, an abrupt discontinuation ofmedication can result in unwanted reactions). Techniques to increaseregular treatment adherence (e.g., a pill box, routinized places, andtimes to store and take medications) are shared. The "cost-benefit"analysis for weighing the positives of taking medication (i.e., symp-tom relief) against the negatives of taking medication (i.e., the cost,the stigma, the hassle, the side effects) is presented. Family membersare particularly encouraged to share positive experiences and ventnegative experiences with the group. Throughout this discussion,there is an emphasis on being an active partner in treatment, rather

than a passive recipient of care.After this more general discussion, a child/adolescent psychiatryfellow who routinely attends this second session presents informationspecific to each class of medications. "Older" medications are brieflypresented (i.e., the tricyclic antidepressants and monoamine oxidaseinhibitors) but more attention is paid to discussing the selective se-rotonin reuptake inhibiters (i.e., SSRIs, including Prozac, Zoloft,Paxil, and Effexor) and mood stabilizers (i.e., Depakote, Lithium,Tegretol). For each medication, the generic and trade names areprovided, information about typical dosage schedules, polypharmacyconcerns (e.g., what over-the-counter drugs might interact negativelywith the prescribed medication) are reviewed, monitoring techniquesand common side effects are presented, and tips on side effect man-

agement are shared.This session typically leads to many individualized questions

from the parents. Additionally, families often share "war stories"about their difficulties locating treatment providers who would work

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effectively with them. As many parents also are on medications fortheir own mood disorders, the discussion frequently leads to whatmedications have worked for the parents, as well.

The third session. During this session, the interpersonal natureof mood disorders is explored, with emphasis on how depression andmania can "mess up" family life. This session borrows heavily fromconcepts previously articulated by Holder and Anderson (1990). Dis-cussion focuses on how depression functions as an interpersonal ill-ness, in that mood symptoms can wreak tremendous havoc on rela-tionships with family members and friends. The therapist describesways in which depression can result in interpersonal disruption: theimpaired family member may become overly sensitive and preoc-cupied with him or herself; attempts at reassurance from other familymembers do not help; negative behavior associated with the mood dis-order often seems to be done "on purpose" to bother and annoy otherfamily members; expectations large and small often are not met; thedepressed family member wants to be in control but in actuality isfailing to meet his or her regular responsibilities; and the entire fam-ily may feel as if they are walking "on eggshells."

Often at this point in the discussion, if both parents are attend-ing the session, they start to elbow each other, nod their heads, whis-per such things as "she must be looking in our living room window atnight," and report feeling reassured they "are not the only ones" with

these difficulties. After painting this painful picture of how inimicallife can get and what not to do in response, the therapist begins adiscussion of what to do as a caring family member. This includes anarticulation of behaviors to actively avoid (i.e., too rapid reassurance,attempting to be constantly available and positive, feeling guilty fornot meeting your child's every need, allowing the disorder to takeover family life, and making big decisions, such as about custody ordivorce during an episode), as well as a discussion of techniques thatare particularly important in parenting a mood disordered child.These techniques include recognizing multiple realities (e.g., "I under-stand you see the situation that way. This is how I see it . . .") anddistinguishing between the child and the disorder (cf., Fristad, Ga-vazzi, & Soldano, in press), with special emphasis on the need for

parents to be supportive and patient without trying to "analyze" theirchild. Additionally, parents are reminded about self-preservation, giv-ing legitimacy to their need to "recharge their batteries". This is par-

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MARY A . FRISTAD, STEPHEN M, GAVAZZI, A ND KITTY W. SOLDANO

ticularly important from the more long-range perspective of treat-ment planning, as many mood disordered children experience impair-ment for sustained periods of time. Parents can become exhausted ifthey remain on "red alert" for too long.

Following these points, some basic principles of good communica-tion with children and teenagers are reviewed. There is heightenedneed for good communication in families having a mood disorderedmember, as the symptoms of a mood disorder often elicit the oppositeof what is considered healthy communication. In particular, parentsare urged to: listen towithout "correcting"their child's feelingsand concerns; ask if their child wants feedback/suggestions beforeproviding such feedback; and talk directly with their child about mat-ters of concern (with special emphasis on addressing issues whenthey are small instead of letting them build up and become more ex-plosive later on).

The importance of having simple and clear rules and keeping be-havioral expectations reasonable is emphasized. Questions and exam-ples from participants about supervision/monitoring and disciplinestrategies are used in order to make these points. Concurrently, theimportance of giving praise and positive feedback whenever legiti-mate is emphasized ("catching your child doing something right"),with a reminder that clinical improvement occurs gradually. Parentsare reminded to deliver criticism in a calm voice, make positive re-quests for change (using a format of "when you do XX, I feel YY,

therefore next time I would like you to ZZ instead"). The importanceof nonverbal communication is discussed, and parents are remindednot to use other family members, particularly other children, as anoutlet for frustration.

General principles of stress management are reviewed. Followingan acute episode, parents are advised to gradually increase the stressthey "take on" in their family's life. It is recommended they avoidsituations that may precipitate a relapse (e.g., the return to an unad-justed, overcommitted schedule), as well as encourage all familymembers to take good care of themselves (i.e., sleep enough, eat well,plan fun activities).

In addition to good communication and stress management skilldevelopment, the need for adequate social support is critical. The im-

portance of extended family, friends, and groups (e.g., sports, church,Scouts) is validated. Also, when children have a mood disorder, otherfamily members often have a mood disorder of their own, sometimes

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undiagnosed at the time of program participation. Thus, evaluationand treatment referrals are commonly made for other family mem-bers (both parents and siblings).

The fourth, fifth, and sixth sessions. These sessions a re devoted toan expansion of issues presented in the first three sessions. Referenceis made to specific content from the earlier sessions, particularly rec-ognizing symptoms, discussing symptoms within a family context asproblems to be solved, and using clear communication and straight-forward problem solving strategies to manage symptoms. Althoughthese sessions continue to be guided by the group leader, group mem-bers increasingly are encouraged to contribute their favorite tips/tech-niques/solutions and to share encouragement with one another tokeep trying. Depending on the comfort level and size of the group, therole playing of newly acquired skills may also occur.

Common problems are listed on posters and used as startingpoints for discussion. They include: how to ensure medication compli-ance (i.e., Who is in charge? How is that person accountable?); how todeal with the stigma (i.e., Who should be toldschool/friends/family?How and by whom should they be told?); how to handle irritability(When is it a "controllable" versus "uncontrollable" symptom? Whenshould it be consequenced versus ignored?); how to set up appropriaterules (i.e., What is too much? What is too little?); how and when toadjust expectations (i.e., How do parents decide which "battles" are

worth "fighting"?); how to keep sleep schedules regular (i.e., Who isresponsible? What happens if ... ?); how to reduce stress? [i.e.,Should parents protect their child from ba d news? (D o family secretsever "work?")]; how should children be appropriately monitored?; howto handle suicide threats and attempts [i.e., Take suicidal talk /ges-tures seriously. Remove available methods (e.g., get guns out of thehouse)]; when is hospitalization appropriate (i.e., If the child is at riskto self/others. Hospitalization should not be used for punishment orrespite.); what to do about atypical medication responses/serious sideeffects (i.e., Always know how to contact the doctor/therapist.); how tocope with an acute episode (i.e., Decrease expectations temporarilybut don't "baby" your child. Recognize this is an illness from whichyour child needs to recover. Provide realistic support and reinforce-

ment. Provide activity and structure. Remain hopeful )The overall content of the previous five sessions is summarized in

the sixth and final program session as follows: The cause of mooddisorders in children and adolescents probably has a biological origin,

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but the course of illness is probably affected tremendously by psycho-social events. Thus, parents can contribute to their children's mentalhealth by: understanding the disorder and its treatment; not blamingtheir child for this condition; assisting their child to remain treatmentadherent; being an active partner in the treatment team; returning to"active" treatment if warning signs recur; and using effective commu-nication, limit setting, and problem solving strategies at home.

Many families request sharing names/telephone numbers/ad-dressees with one another by the final session. To facilitate this, pa-per and pens are circulated and family members who feel comfortableproviding this personal information are asked to write it down, thenthe information is copied and distributed to all members whose namesare on the list.

Children s Sessions

There are three main goals for the children's sessions. First, chil-dren have the opportunity to meet others alike in age who strugglewith issues similar to their own. This provides them with some senseof relief in knowing they "aren't the only one" with these problems(and that others sometimes "have it worse" ). "Team building" exer-cises (i.e., a physical activity that requires cooperative interaction,such as having the children keep a balloon in the air by one childhitting it into the air then calling out another child's name to hit it

next, until each child has had a turn, then starting all over again) areused in the initial sessions to help children get to know each otherand to build group cohesiveness.

For cohesiveness to develop, however, group membership needsto be carefully predetermined. Developmental status, comorbidity,and current symptom severity of the child need to be taken into ac-count when organizing group membership. Some children may optout of the group if they feel "too different" from the others. This mostfrequently occurs when a child's symptoms are well managed at thetime group is run, and therefore he or she feels little in common withchildren who are experiencing more severe problems. When this oc-curs, we encourage parents to continue participation in the parents'group regardless of their child's attendance at group.

Second, group participation promotes an increased awareness ofsymptoms, symptom management, and the ability to complete a "cost-benefit" analysis of treatment (e.g., how well does the medicine helpcontrol my bad feelings versus how unpleasant is it to take). Children

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frequently have questions about their medications, in particular, andappreciate the chance to air any questions they might have in thecomfortable atmosphere of the group.

Third, as children often do not fully develop age appropriate so-cial skills due to the impairment caused by their disorder, a particu-lar emphasis is placed on social skills building, especially learning to"read" nonverbal communication. Role playing is used extensively topractice affect recognition and response, initiating and maintainingconversations, and becoming included in social interactions. Conflictmanagement skills are reviewed, with particular emphasis on the ap-plication of these skills in peer, school and family situations. The cli-nician helps children develop skills in each step of conflict manage-ment, including: defining the problem (e.g., How do I see it? H ow doother people see it?); brainstorming and evaluating possible solutions(e.g., What good thing might happen if I try this? What bad thingmight happen if I try this?); then choosing and evaluating a solution(e.g., Did it work for me? Did it work for the others involved?). Partic-ular emphasis is placed on: using a stop/think/plan/check format;using "I messages"; and not blaming the other person. As previouslydescribed, children begin each session with their parents. In addition,they end each session by rejoining the parents' group to give a briefreport of their session's activities.

While parent sessions are relatively consistent in their content,the process by which these three goals are addressed in the children's

sessions varies tremendously, based on the participants' emotionaland cognitive development, as well as their comorbid conditions. It iscritical that the children's group leader be adept in adjusting the con-tent and process of sessions to the developmental and clinical needs ofthe participants. For example, a majority of children with mood disor-ders have co-occurring behavior and/or anxiety disorders. This be-comes particularly relevant if a number of the children participatinghave comorbid attention deficit hyperactivity disorder (ADHD), as theeffects of their stimulant medications are usually beginning to wearoff or are gone by the time group is held (groups typically are sched-uled from 5:15 to 6:30 pm on a week night). Because of this, we havefound it useful to conduct a portion of these sessions in a gym setting,where some practice can occur in a naturalistic environment. This

portion of the session follows an expanded interpretation of Green-span's work with younger children, namely "floortime" (1989), inwhich the adult follows the lead of the young child in terms of contentof play, while providing corrective guidance in interactions.

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Adolescents Sessions

A s with the children, there are several main goals for sessionswith adolescents. First, participants have the opportunity to meetother teenagers who are struggling with issues that are at least insome ways similar to their own. Teenagers particularly abhor feeling"different" from their peers and thus are appreciative of opportunitiesto meet others of their own age who are faced with similar concerns.While adolescents typically express little interest in being "topic" fo-cused (i.e., on their mood disorders, per se), they are often more in-vested in participating in discussions that focus on difficulties theymay be having with peers, at school, and/or at home that stem fromor are exacerbated bytheir mood disorder symptoms. Thus, whilethe therapist gives ample room for the participants to set their ownagenda, a common set of issues tends to emerge over the course of sixsessions.

One such common issue centers on peer issues that are specific tothe use of cigarettes, alcohol, and recreational drugs. For teenagerswho are experiencing benefit from their psychotropic medications,there tends to be particular interest in understanding the interactioneffects between "your drug" and "my drug." Information about alter-ation of treatment response based on cigarette, alcohol and substanceuseas well as the dangers associated with decreased inhibition andits link to increased suicidal behaviorare shared in a matter-of-fact

and nonalarmist manner.Another common issue centers on the adolescents' concept of self,including how they feel about themselves and their present life situa-tion. As a complication of identify development, these adolescents of-ten have a particularly difficult time separating their mood symptomsfrom "the person they are becoming." The clinician works to facilitatedifferentiation of mood disorder "symptoms" from the "self that expe-riences them (Fristad et al., in press c). Additionally, since conflictswith peers, family members, and school personnel are typical issuesfaced by all adolescents, the therapist assists teenage participantstease out when and where these issues are exacerbated by the indi-vidual's mood symptoms. This is meant to empower the adolescents tosee not only how things are right now, but also how things can be

different in the future when their symptoms are being managed moreadequately. This message is meant to convey the very personal stakeeach teenager has in treatment adherence (as opposed to "because myparents are making me do this").

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Still another common issue surrounds the threat of harm to self.Most adolescent participants have experienced suicidal ideation, andmany have made prior suicide attempts. Parental response to suicidalbehavior frequently includes increased monitoring of their teenager'sbehavior. Unfortunately, this occurs at the very time that these ado-lescents are wrestling with issues of separation/individuation, andthis added scrutiny often is seen as particularly onerous to the adoles-cent ("I'm not a baby anymore, so why do my parents try to treat melike one all of the time"). In the group, these issues can lead to discus-sions about how adolescents can clearly communicate concerns aboutsymptom severity levels to their parents without provoking develop-mentally inappropriate levels of parental involvement.

One final common issue focuses on school performance, especiallywith regard to perceptions (real or imagined) about the teenager'slack of achievement motivation, as well as actual lowered perfor-mance caused by the impaired concentration that often accompaniesdepression. These disorder driven difficulties compound the normalteenage questioning of "Why am I here?" and "Why do I have to dothese assignments that seem so irrelevant to my life?" Again, thetherapist is able to assist participants differentiate the portion oftheir struggles due to "normal" boredom with school from the tempo-rary impairment caused by their mood disorder, and/or possibly unde-tected long-standing academic impediments (the rate of learning dis-abilities in depressed students is quite high, cf. Fristad, Topolosky,

Weller, & Weller, 1992).As with the children's group, however, the focus of a teenagegroup will vary, again based on the developmental level and comorbidconditions of the teenagers in the group. Groups that are fairly ho-mogenous in terms of members' developmental status and limited inthe amount of "borderline features" present (e.g., as might be seen in"slashers" who compete with one another around self-mutilation is-sues) are most likely to succeed. Young adolescents are more likely tostruggle with issues surrounding dependency and working with versusrebelling against authority figures. Middle adolescents commonlyfocus on the identity issues described above. Older adolescents aremore likely to focus on future oriented issues, such as the impact oftheir disorder on vocational goals, educational plans, and romantic

partnerships, as well as their ability to further differentiate them-selves from their family of origin.

In summary, while adolescents tend to shy away from an up-front discussion of their mood symptoms with one another, the the-

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matic content of their group discussions clearly indicates their explo-ration of how their development has been affected by their symptoms.We now turn our attention to some preliminary evidence regardingthe efficacy of MFPG.

PRELIMINARY EVIDENCE REGARDINGPROGRAM EFFICACY

MethodParticipants. Data were obtained from nine families (grouped as

families of children, n = 3; and adolescents, n = 6) who participatedin the first two groups to experience the pilot MFPG program de-scribed above. All children/adolescents were prescribed one or morepsychotropic medications and all had participated concurrently in in-dividual and/or family therapy at the time of their participation inthe MFPG program.

Procedure. Informed assent/consent w as obtained from al l par-ents and children/adolescents in the study prior to data collection.Data collection was completed by a graduate research assistant whowas not one of the group therapists.

Instruments. Parents and children/adolescents completed an anon-

ymous group evaluation

form at the end of

treatment. Both Likert

styled and open ended questions were included, in an attempt to elicitfeedback on the specific content of the group, as well as more globalpositive and negative comments about group participation. This formwas based on the second author's previous experience in conductingpost-participation interviews (cf., Gavazzi, 1995; Gavazzi, Alford, &McKenry, 1996).

Additionally, parents were assessed at baseline and post-treat-ment using a paper-and-pencil method and in a four month phonefollow-up using the Expressed Emotion Adjective Checklist (EEAC:Friedman & Goldstein, 1993). The EEAC lists 20 positive and nega-tive descriptors of criticism and emotional overinvolvement. Parentsfirst record their attitudes and behavior toward their child, then re-

cord their perceptions of their child's attitudes and behavior towardthem. The EEAC has been reported to be a reliable instrument thatmeasures EE in comparable fashion to other established instruments(Friedman & Goldstein, 1993).

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ResultsSatisfaction with intervention. Thirteen participants (three chil-

dren, one adolescent, and nine parents) from the first group com-pleted the evaluation form. Participants rated their satisfaction withthe group using a range of responses that included strongly agree(1.0), somewhat agree (2.0), neutral (3.0), somewhat disagree (4.0),and strongly disagree (5.0). Mean responses to each of the questionsasked of participants were as follows:

"Attending this group has increased my understanding of mooddisorders": 1.7

"Attending this group has increased my understanding of medica-tions for mood disorders": 2.1

"Attending this group has increased my awareness of positive in-teractions to do in my family": 1.5

"Attending this group has increased my awareness of negativeinteractions to avoid in my family": 1.5

"There were topics we did not cover that I wished we would havecovered": 2.7

"There were topics that we spent too much time discussing": 3.2These results indicate a relatively strong endorsement of the pro-

gram by participants, as family members reported increased under-standing of mood disorders and medications, increased awareness ofpositive and negative family interactions, and believed that the topics

dealt with in the sessions were both appropriate and well-covered.This endorsement is evidenced further by the mean (4.0) of partici-pant responses to the question "Overall, my satisfaction with the pro-gram is (very satisfied = 5; very unsatisfied = 1) , indicating thatparticipants on average were at least "somewhat satisfied" with theentire program.

Additionally, when participants were asked via an open-endedquestion what they found most helpful about the group, they respondedwith the following: having separate groups for parents and children/adolescents (n = 11); creating the opportunity to get support from peers(n = 3); learning about mood disorders (n = 2), problem solving ( n= 1) ,anger management (n = 1) ; snacks (n = 2), recommended books ( n = 2) ,and the staff (n = 1). When asked via an open-ended question what

suggestions they had for future groups, participants named: includingsiblings (n = 4), have more participants in each group (n = 2). Thesewere two adolescents who participated in a subgroup with no additionalmembers), and holding booster sessions (re = 1).


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Finally, participants were asked one open-ended question abouttheir ideas regarding possible improvements that could be made tothe program. Interestingly, there were conflicting ideas about suchimprovements. Some participants (n = 2) wanted more factual infor-mation from the group leaders, while others (n = 3) wanted less. Fur-ther, some participants (n = 2) wanted less conjoint time (i.e., parentsand children together) while one participant stated that more suchtime was desired.

Changes in family emotional climate. Data were obtained fromone parent per family in each of the nine participant families. Fivemothers and four fathers completed questionnaires. When we com-pared baseline and post-treatment responses, 8/8 comparisons werein the predicted direction (see Figures 1 and 2, W ilcoxin signed ranktest, p < .01). Mothers and fathers each reported an increase in posi-tive attitude/behavior toward their child and a decrease in negativeattitude/behaviors toward their child. Likewise, mothers and fatherseach reported increased positive attitude/behaviors of their child to-ward them and decreased negative attitude/behaviors of their child

Mothers' and Fathers' Ratings of Their Behavior Toward Their ChildPrior to, Immediately Following, and Four Months After Treatment

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FIGURE 1


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Mothers' and Fathers' Ratings of Their Child's BehaviorToward Them Prior to, Immediately Following, and

Four Months After Treatment

toward them. From post-test to follow-up, 4/8 measures indicated con-tinued improvement, 1/8 measures indicated essentially no change,and 3/8 measures indicated a decline in function, although not to thepoint of returning to baseline values (see Figures 1 and 2). Addi-tionally, some interesting gender differences appeared, suggesting fa-thers may particularly benefit from this intervention. This is in ac-cord with a previous finding from our research group, in whichfathers benefited to a greater degree than mothers following a single1 1/2 hour psychoeducational workshop while their son or daughterwas psychiatrically hospitalized (Fristad et al., in press b).

Given the small sample size of this pilot study, we used poweranalysis (Cohen, 1988) to determine the sample size necessary to pro-duce significant findings in a replication study, assuming a similareffect size and using settings of a = .01 and , (3 = .05. Results sug-gest a replication study of 20 families would provide sufficient power

to adequately test the hypothesis that participation in MFPG resultsin significantly reduced EE in families.

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DISCUSSION

We previously discussed the relevance of multi-family psycho-education groups (MFPG) as an adjunctive treatment for children andadolescents with mood disorders. Here we present a description ofMFPG with accompanying preliminary data that suggest consumersatisfaction with the intervention. Additionally, uncontrolled pilotdata from parent participants suggests an improvement in family cli-mate immediately and four months following intervention. This im-provement is particularly notable for fathers. Improvements in familyclimate cannot, however, be directly attributed to MFPG participa-tion, as participant families received multiple interventions and fol-low-up comparison data were not available for nonparticipant fami-lies. In addition, the number of families from whom we obtained pilotdata is quite small.

We are currently conducting a controlled trial of MFPG for 36families of children aged 8-11 with mood disorders, and are awaitingthe implementation of a parallel study for 30 families of children aged12-14 with mood disorders. Following completion of those studies,more extensive data will be available to determine the efficacy of thisintervention, as well as to clarify the individual, family, and access tocare variables that mediate response to treatment.

REFERENCES

Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ:Lawrence Erlbaum.

Fristad, M., Gavazzi, S. M., Centolella, D., & Soldano, K. (1996). Psychoeducation: Anintervention strategy for families of children with mood disorders. ContemporaryFamily Therapy, 18, 371-383.

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