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Clinician-Based Cognitive Psychoeducational Intervention for Families

The Clinician-Based Cognitive Psychoeducational Intervention is intended for families with parents with significant mood disorder. Based on public health models, the intervention is designed to provide information about mood disorders to parents, equip parents with skills they need to communicate this information to their children, and open dialogue in families about the effects of parental depression. The intervention consists of 6-11 sessions that include separate meetings with parents and children, family meetings, and telephone contacts or refresher meetings at 6- to 9-month intervals. Sessions are conducted by trained psychologists, social workers, and nurses. The core elements of the intervention are (1) an assessment of all family members, (2) teaching information about affective disorders and risks and resilience in children, (3) linking information to the family's life experience, (4) decreasing feelings of guilt and blame in children, and (5) helping children to develop relationships within and outside the family to facilitate their independent functioning in school and in activities outside the home. In family meetings, parents talk about their own sessions, their treatment, and how they are working to build resilience and protect their children.

Descriptive Information

Areas of Interest	Mental health promotion
Outcomes	Review Date: October 2006 1: Child-related behaviors and attitudes toward parental illness as reported by parents 2: Children's understanding of parental illness 3: Internalizing symptomatology 4: Family functioning
Outcome Categories	Family/relationships Mental health
Ages	6-12 (Childhood) 13-17 (Adolescent) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	White Race/ethnicity unspecified
Settings	Outpatient Home Other community settings
Geographic Locations	Urban
Implementation History	The original trial of the Clinician-Based Cognitive Psychoeducational Intervention for Families involved over 100 families randomized to two active conditions (group discussions or the family talk intervention) in Boston, Massachusetts; after 4.5 years sustained effects were seen in both groups. Another randomized trial was conducted with low-income, single-parent mothers in Dorchester, Massachusetts, and an open-trial replication was conducted with Latino families at Children's Hospital in Boston. Clinician-Based Cognitive Psychoeducational Intervention for Families has been implemented in Holland as a regular part of prevention practice with two 2-day training seminars every year. In Finland, the approach has been employed for countrywide use, with over 650 clinicians and 80 master trainers trained since 2001. The intervention has been selected for countrywide implementation in Norway. Principles of the program have been used in Head Start and Early Head Start.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	The intervention or specific adaptations of the intervention have been implemented for single-parent families of color and single-parent Latino families in Boston, Massachusetts, and for families in Finland. A manual has been developed for work with African American families. Manuals are also available in other languages including Dutch, Finnish, German, and Spanish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Selective Indicated

Quality of Research

Review Date: October 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Beardslee, W. R., Gladstone, T. R., Wright, J., & Cooper, A. B. (2003). A family-based approach to the prevention of depressive symptoms in children at risk: Evidence of parental and child change. Pediatrics, 11(2), e119-e131.

Beardslee, W. R., Hoke, L., Wheelock, I., Rothberg, P. C., Van De Velde, P., & Swatling, S. (1992). Initial findings on preventive intervention for families with parental affective disorders. American Journal of Psychiatry, 149, 1335-1340.

Beardslee, W. R., Versage, E. M., Salt, P., & Wright, E. (1999). The development and evaluation of two preventive intervention strategies for children of depressed parents. In D. Cicchetti & S. L. Toth (Eds.), Rochester Symposium on Developmental Psychopathology, Volume IX, Developmental Approaches to Prevention and Intervention. Rochester, NY: University of Rochester Press.

Beardslee, W. R., Wright, E. J., Gladstone, T. R., & Forbes, P. (n.d.). Long-term effects from randomized trial of two public health preventive interventions for parental depression. Manuscript submitted for publication.

Supplementary Materials

Beardslee, W. R. (n.d.). Detailed presentation of data analyses for adaptation. Unpublished manuscript.

Chronology of work from 1979 to present

Podorefsky, D. L., McDonald-Dowdell, M., & Beardslee, W. (2001). Adaptation of preventive interventions for a low-income, culturally diverse community. Journal of the American Academy of Child and Adolescent Psychiatry, 40(8), 879-886.

Solantaus, T., Toikka, S., Alasuutari, M., Aronen, P., & Beardslee, W. R. (n.d.). The Effective Family Program: Adaptation of a preventive intervention for families facing mood disorders in Finland. Manuscript submitted for publication.

Outcomes

Outcome 1: Child-related behaviors and attitudes toward parental illness as reported by parents
Description of Measures	Parent-reported changes in child-related behaviors and attitudes toward parental illness were measured by the Semistructured Interview About the Intervention (SII). The instrument was administered to each parent before and after the intervention. The SII contains a series of open-ended questions and rating scales that can be coded into changes in child-related behaviors and attitudes of parental illness. Interviewers used information from SII to identify specific changes in categories that most frequently reflect child-related behavior and attitude changes related to parental illness (i.e., increased talking with child about depression, increased understanding of risk and resiliency in children). All scoring was done by trained raters, and many ratings were reviewed by a master rater.
Key Findings	Parents receiving the intervention averaged higher scores in their reports of child-related behavior and attitude changes toward parental illness than parents receiving a group-format presentation (p < .0001). The number of reported changes increased across four follow-up assessments up to 4.5 years after the intervention (p < .0001).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 2: Children's understanding of parental illness
Description of Measures	Children's understanding of parental illness was measured using the Semistructured Child Interview (SCI). Similar to the adult SII, this instrument combines qualitative questions with Likert-type rating scales. Questions elicit information about the children's current functioning, their knowledge, feelings, and experience of their parent's mood disorder, their coping style, and their perceptions of any changes that might have taken place as a result of the intervention. From the data about child's perceptions of differences in the family occurring as a result of being in the project, raters assessed increased understanding of parental illness. Improved understanding was rated on a 5-point scale ranging from no awareness of illness (rating of "0") to 2 or more specific changes (rating of "4"). A score was generated for each child consisting of the mean of the child's rating of understanding and the rater score of improved understanding.
Key Findings	Children in families receiving the intervention improved slightly on measures of understanding of parental mood disorder compared with children in families receiving a group-format presentation (p < .05). Further improvement over time appeared to be affected more by developmental stage of the children than by variation in treatment.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 3: Internalizing symptomatology
Description of Measures	Children rated their own adaptive and maladaptive behaviors and psychopathology on the Youth Self-Report (YSR). Developed for children 11 to 18 years old, this instrument consists of 112 items and covers various adaptive and maladaptive behaviors and psychopathology during the past 6 months. The YSR includes behavior problems and social competence scales, along with measures of internalizing and externalizing behaviors. Assessors read the measure aloud to those children under the age of 11.
Key Findings	Both the intervention and an alternative treatment format decreased scores for internalizing symptoms from baseline. No significant difference between the two treatment formats was found after variation in baseline internalizing symptoms was considered.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 4: Family functioning
Description of Measures	Family functioning was assessed using the Family Relationship Inventory (FRI). The FRI is a 27-item instrument with three subscales (Cohesion, Expressiveness, and Conflict) of the relationship dimension of the Family Environmental Scale (FES), a widely used, empirically derived measure of family functioning. The FRI was administered to both parents and children.
Key Findings	Child and parent family functioning improved among families receiving the intervention and among families receiving an alternative treatment format. No significant difference between the two treatment formats was found after family variation in baseline functioning was considered.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	6-12 (Childhood) 13-17 (Adolescent) 26-55 (Adult)	57.3% Male 42.7% Female	94% White 6% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Child-related behaviors and attitudes toward parental illness as reported by parents	3.5	2.5	3.5	4.0	3.5	4.0	3.5
2: Children's understanding of parental illness	3.0	2.0	3.5	4.0	3.5	4.0	3.3
3: Internalizing symptomatology	4.0	3.5	3.5	4.0	3.0	4.0	3.7
4: Family functioning	3.5	3.0	3.5	4.0	3.0	4.0	3.5

Study Strengths

The methodology used in the study was impressive, very well thought out, and well described. The methods to ensure fidelity of intervention were outstanding, even across diverse populations and cultures. The developers presented a long-term follow-up study with strong, positive outcomes for the intervention group. Many of the measures are standardized and widely used. The developers' work to adapt intervervention to diverse populations/cultures is very impressive. Participation rates were exceptional, and attrition was very low and analyzed adequately. Authors adequately controlled for confounds. Analyses were well described and appropriately conducted.

Study Weaknesses

Since there was no "no-treatment" group, there was no comparison to the true counterfactual. The study also largely ignored the possibility of genetic/biological factors involved in intrafamily rates of mental illness. Additional information about the development of the Semistructured Child Interview (SCI)would have been helpful in order to better evaluate use of this as an outcome measure. More information about the Family Relationship Inventory (FRI) would have been helpful (i.e., if measures were assessed by independent investigators).

Readiness for Dissemination

Review Date: October 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Adult Post-Intervention Assessment Form (Spanish version)

Avery, M., Ayoub, C., Watts, C., & Beardslee, W. (n.d.). The Family Connections Project: A manual for fostering resilience, increasing positive interactions, and recognizing parental depression in Head Start. Boston: Family Connections Project.

Beardslee, W., & Gladstone, T. (n.d.). Health prevention and promotion. Boston: Children's Hospital Boston.

Beardslee, W. (1998). Prevention and the clinical encounter. American Journal of Orthopsychiatry, 68(4), 521-533.

Beardslee, W. (2006). When a parent is depressed: How to protect your children from the effects of depression in the family. Boston: Little, Brown, and Company.

Beardslee, W., Swatling, S., Hoke, L., Rothberg, P., van de Velde, P., Focht, L., et al. (1998). From cognitive information to shared meaning: Healing principles in prevention intervention. Psychiatry, 61, 112-129.

Children's Hospital Boston. (n.d.). Miller Family Teaching Tape [DVD].

Llerena-Quinn, R., Shapiro, R., Bravo, M., Lora, A., D'Angelo, E., & Beardslee, W. (2006). Adapted manual for the Prevention of Depression in Families Program for use with Latino families. Boston: Children's Hospital Boston.

Podorefsky, D., & Beardslee, W. (2006). An overview to the psychoeducational prevention intervention training 25-minute videotape [Handout].

Podorefsky, D., McDonald-Dowdell, M., & Beardslee, W. (2001). Adaptation of preventive interventions for a low-income, culturally diverse community. Journal of the American Academy of Child and Adolescent Psychiatry, 40(8), 879-886.

Preventive Intervention Project. (n.d.). Hope, meaning, and continuity: A program for helping families when parents face depression. Boston: Judge Baker Children's Center.

Solantaus, T., & Toikka, S. (2006). The Effective Family Programme: Preventive services for the children of mentally ill parents in Finland. International Journal of Mental Health Promotion, 8(3), 37-43.

Solantaus, T., Toikka, S., Alasuutari, M., Aronen, P., & Beardslee, W. (n.d.). The Effective Family Prevention Program: Adaptation of a preventive intervention for families facing mood disorders. Manuscript submitted for publication.

Toikka, S., & Solantaus, T. (2006). The Effective Family Programme II: Clinicians' experiences of training in promotive and preventative child mental health methods. International Journal of Mental Health Promotion, 8(3), 27-33.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.2	3.3	3.3	3.2

Dissemination Strengths

The implementation manual was strongly grounded in a broad variety of theoretical orientations, particularly a public mental health approach that included practitioners from nursing, social work, psychology, and psychiatry in the design and implementation from the beginning. The manual is available in several different languages. Guidelines and principles are provided to implementers for adapting the intervention from one setting to another while maintaining core principles of the program. Training of master trainers aids in dissemination and creates "early adopters" who lead the local implementation process. The training model includes extensive supervision and support for master trainers in training others. Consultation is offered by program developers. The quality assurance protocol includes adult and child pretest and posttest intervention assessment forms in English and Spanish. Developers also provide specific procedures to follow for adapting this program outside of the university/research setting. The use of the "train the trainer" model also contributes to fidelity on the local level.

Dissemination Weaknesses

The implementation manual could be laid out in a clearer, easier-to-read fashion with better formatting of materials. The manual also does not contain specific, didactic content to be used by implementers, such as specific information on depression. It is unclear how users access training and support. No specific fidelity measure is provided.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Implementation manual	Free	Yes
Training CD	$10 each	Yes
2-day initial training	$500 per day	Yes
Follow-up training	Contact the developer	No
Ongoing biweekly supervision and consultation	$100 per hour	Yes
Quality assurance forms	Contact the developer	Yes

Additional Information

Delivery of the intervention requires 7-10 hours of clinician time per family, including parent, child, and family sessions.

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Podorefsky, D. L., McDonald-Dowdell, M., & Beardslee, W. R. (2001). Adaptation of preventive interventions for a low-income, culturally diverse community. Journal of the American Academy of Child and Adolescent Psychiatry, 40(8), 879-886.

Contact Information

To learn more about implementation or research, contact:
William R. Beardslee, M.D.
(617) 919-4629
william.beardslee@childrens.harvard.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.