Depression in Childhood and Early Adolescence: Parental Expressed Emotion and Family Functioning.

Across development depression is associated with impairments in interpersonal and family functioning. In turn, these impairments may predict a more negative depression course and outcome. This study examined family functioning and parental Expressed Emotion (EE) among depressed youth during middle childhood and early adolescence and their relationship to demographic and clinical factors. Data were drawn from pretreatment evaluations of 132 depressed youth ages 7-14 and their families enrolled in a randomized clinical trial comparing family to individual treatment for youth depressive disorders. Families completed semi-structured diagnostic interviews, self-report measures of family functioning, and the Five Minute Speech Sample EE measure. High parental EE was more common in one-parent, as opposed to two-parent families, and early adolescent youth were more likely than pre-adolescent youth to have high critical EE parents. Severity and chronicity of child depression, child comorbidity, functional impairment, and maternal depressive symptoms were not associated with parental EE. Parental high EE overall and critical EE in particular were associated with reports of higher conflict and lower cohesion by both parents and children when compared to low parental EE. Similar patterns of associations were evident for youth across pre-adolescent and early adolescent developmental periods. Single parent status may be an indicator of greater family stress; and higher levels of critical EE may reflect the higher levels of parent-child conflict characteristic of the transition from late childhood to early adolescence. Among youth with depression parental EE appears to reflect potentially important impairments in family functioning.

Depression in youth: psychosocial interventions.

Witnessed over the past 20 years are major advances in knowledge regarding depression in children and adolescents. Although additional research is needed, clinicians can now turn to treatment strategies with demonstrated efficacy. In this article we review the literature on psychosocial interventions for depression in youth and offer a working model to guide the treatment of depressed youth. We begin with a brief overview of the model, followed by a review of the treatment efficacy and prevention literatures. We offer some caveats that impact the ability to move from this treatment literature to the real world of clinical practice. We conclude by considering how extant research can inform treatment decisions and highlight critical questions that need to be addressed through future research.

Difficulty in implementing a family intervention for bipolar disorder: the predictive role of patient and family attributes.

Family affect was examined as a predictor of difficulty implementing a 9-month, manual-based, psychoeducational family therapy for recently manic bipolar patients. Prior to therapy, family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task. Following family treatment, both therapists and independent observers rated the overall difficulty of treating the family, and therapists also rated each participant's problem behaviors during treatment, in the areas of affect, communication, and resistance. Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family. Relatives' critical behavior toward patients during the pretreatment interaction task predicted both independent observers' ratings of overall treatment difficulty and therapists' perceptions of relatives' affective problems during treatment. Moreover, patients' residual symptoms predicted independent observers' ratings of overall difficulty and therapists' perceptions of patients' resistance to the family intervention. Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic, pretreatment family and clinical assessment.

Childhood-onset schizophrenia: a follow-up study.

This paper presents results from the UCLA Follow-Up Study of Childhood-Onset Schizophrenia Spectrum Disorders. Eighteen children with schizophrenia (SZ) were assessed 1 to 7 years following initial project intake. Results demonstrated significant continuity between SZ spectrum disorders in childhood and adolescence. Although not all children who presented initially with SZ continued to meet criteria for SZ spectrum disorder as they progressed through the follow-up period, rates of SZ spectrum disorders ranged from 78-89% across the first three follow-up years. Rates of continuing SZ ranged from 67% to 78% across the three follow-up years and rates of schizoaffective disorder ranged from 11% to 13% across the three follow-up years. Variability in levels of functioning were observed with 45% of the sample showing deteriorating course or minimal improvement and 55% of the sample showing moderate improvement or good outcomes. This variability in outcome is comparable to that seen in adults with SZ, suggesting that with current treatments childhood-onset does not ensure a more severe disorder.

Family interaction styles of children with depressive disorders, schizophrenia-spectrum disorders, and normal controls.

Family interaction processes during a problem-solving task were examined in children with depressive disorders, children with schizophrenia-spectrum disorders, and a normal control group of community children screened for the absence of psychiatric disorder. Major findings were: a) children with depressive disorders were more likely than children with schizophrenia-spectrum disorders and children with no psychiatric disorder to direct guilt-inducing comments toward their parents; and b) parents of children with schizophrenia-spectrum disorders were more likely to direct harsh critical comments toward the child than were parents of depressed children or parents of normal controls. In addition, children's and mothers' use of benign criticism was linked, while children's harsh criticism was associated with intrusion from the father, and children's self-denigrating comments were related to specific paternal criticism. Implications of these results for understanding transactional processes associated with childhood-onset depressive and schizophrenia-spectrum disorders are discussed.

Evaluating therapist competency and adherence to behavioral family management with bipolar patients.

The present study assessed fidelity to the behavioral family management (BFM) model for treating bipolar disorder patients and their families. The BFM Therapist Competency/Adherence Scale (BFM-TCAS) was developed to evaluate clinicians' competency and adherence to BFM, as outlined by Miklowitz' (1989) BFM Manual for use with bipolar patients. Therapist competency and treatment adherence was also evaluated with regard to two family characteristics: overall level of family difficulty and family expressed emotion (EE) status. The BFM-TCAS was used to code 78 videotaped sessions of 26 families with a bipolar member, selected from a larger treatment study of bipolar disorder patients. The findings suggest that, overall, clinicians adhered closely to the BFM manual. Specific areas in which there was high competency and treatment adherence were (a) skill in conveying factual information about bipolar illness, (b) establishment of a therapeutic environment, and (c) ability to take command of therapy sessions. The one area in which there was less competency and relatively weak adherence to the manual was the use of between-session homework assignments to assist families in mastering the BFM exercises. Results of this study also suggest that, for the most part, therapist competency and adherence ratings were not related to overall level of difficulty or to family EE status.

Children with schizophrenia-spectrum disorders: thought disorder and communication problems in a family interactional context.

Thought disorder and communication patterns during an interactional task were examined in families of children with schizophrenia-spectrum disorders (schizophrenia and schizotypal personality disorder), depressed children, and normal controls. Children with schizophrenia-spectrum disorders showed significantly more thought disorder than their normal peers; levels of thought disorder among depressed children fell between those observed in the other two groups but did not differ significantly from either of them. Similarly, mothers of children with schizophrenia-spectrum disorders showed more thought disorder than mothers of normal control children but did not differ from mothers of depressed children. Children with schizotypal personality disorder did not differ from children with schizophrenia. These findings demonstrate that the thought disorder present in childhood-onset schizophrenia and schizotypal personality disorders is manifest in an important social context, the family.

Schizophrenic patients' perceptions of their relatives' attitudes.

Although the attitudes of family members as revealed by measures of expressed emotion (EE) have been shown to be associated with the course of schizophrenic illness, little is known about how the patients perceive these attitudes. A detailed interview was used to assess patients' perceptions of their family members' behaviors toward them. Family member's EE was assessed with the Five-Minute Speech Sample (FMSS). Overall, patients' perceptions of criticism were congruent with a component of the FMSS-EE that measures criticism. Results indicated that when family members had high EE/critical scores, patients perceived them as displaying more instances of critical behavior. All cases in which patients' perceptions of criticism were incongruent with measures of FMSS-EE occurred among ethnic minority group members. Although the FMSS-EE did not predict outcome in this study, patients who perceived their relatives as higher in criticism had more negative outcomes at 1 year. These findings suggest that when family environments are examined in patients from ethnic minority groups, the patients' perspective may be a more potent predictor of outcome than traditional measures of EE.

Childhood-onset schizophrenia: a followup study.

This article is an overview of our studies of childhood-onset schizophrenia. Data are presented demonstrating that (1) the majority of the sample showed continuing schizophrenia as they progressed through adolescence; (2) there was considerable variability in outcome, defined by global adjustment scores, with 56 percent of the sample showing improvement in functioning during a 2- to 7-year followup period and the other 44 percent showing minimal improvement or a deteriorating course; (3) schizophrenia in childhood could be diagnosed by the same criteria used for adults and was associated with severe dysfunction; and (4) some intrafamilial attributes found to be associated with schizophrenia in adults were also associated with schizophrenia in children, but there were some differences in the family environmental correlates of childhood- and later-onset schizophrenia. These data are consistent with the hypothesis that childhood- and later-onset schizophrenia represent the same illness or illnesses. Additional research is needed, however, to clarify the etiologic and clinical significance of the atypical early onset in childhood cases.