Race/ethnicity and socioeconomic status as predictors of outcome following family therapy in youth at clinical high risk for psychosis.

AIM: There is limited research on the effects of sociodemographic and socioeconomic factors on treatment outcomes in youth at clinical high risk for psychosis (CHRp). This study examined sociodemographic factors that may affect functional outcomes within this population. Specifically, we investigated the influence of race/ethnicity (dichotomized as non-Hispanic whites [NHW] vs. people of colour [POC]), socioeconomic status (SES; operationalized as parental years of education), and their interaction on change in psychosocial functioning and symptoms over 6 months in a randomized trial of family-focused therapy. METHODS: CHRp youth (N = 128) participated in a randomized trial of family therapy (18 sessions of family therapy vs. 3 sessions of family psychoeducation). Sixty-four participants who self-identified as POC and 64 self-identified NHW participants completed baseline and 6-month follow-up measures of positive and negative symptoms and psychosocial (global, role, and social) functioning. Multiple regression models were conducted to test the main effect of race/ethnicity on changes in positive and negative symptoms and functioning, and whether this effect was moderated by parental education. RESULTS: There was a significant interaction between race/ethnicity and parental education, such that higher parental education was associated with greater improvement in global functioning in NHW participants, but there was no relationship between parental education and global functioning in POC. Additionally, higher parental education was associated with a decrease in negative symptoms in NHW participants but not in POC. There were no significant effects of race/ethnicity or parental education on positive symptoms, nor on social or role functioning. CONCLUSIONS: Clinicians may consider tailoring psychosocial treatments according to the needs of diverse families who vary in sociodemographic factors such as educational attainment and race/ethnicity.

Family communication and the efficacy of family focused therapy in individuals at clinical high risk for psychosis with comorbid anxiety.

AIM: Comorbid anxiety disorder is related to greater illness severity among individuals at clinical high risk (CHR) for psychosis, but its potential role in moderating response to Family Focused Therapy (FFT) for CHR is unexamined. We investigated whether comorbid anxiety disorder in CHR individuals is associated with less constructive communication during family problem-solving interactions, whether their communication skills differentially improve after FFT, and whether FFT is effective in reducing anxiety in this population. METHODS: Individuals recruited into the second phase of the 8-site North American Prodrome Longitudinal Study (NAPLS2) participated (N = 129). They were randomly assigned to 18-sessions of FFT-CHR or three-sessions of Enhanced Care (EC). Participants completed a diagnostic interview at pre-treatment, a family interaction task at pre-treatment and 6-months, and a self-report anxiety measure at pretreatment, 6 and 12-months. RESULTS: Individuals at CHR with comorbid anxiety engaged in more negative and fewer positive behaviours during family problem-solving interactions at pre-treatment than did those without comorbid anxiety. There was a significant interaction between anxiety diagnosis and time on interactional behaviour scores, such that individuals at CHR with an anxiety diagnosis showed a greater decrease in negative behaviours and increase in positive behaviours from baseline to 6-months than those without anxiety disorder(s) regardless of treatment condition. However, individuals' self-reported anxiety symptoms decreased more in FFT-CHR than in EC from pre-treatment to 12-month follow-up, regardless of anxiety diagnoses. CONCLUSIONS: Individuals at CHR with symptoms of anxiety benefit from family interventions in showing reductions in anxiety and improvements in family communication.

Family-focused therapy for individuals at high clinical risk for psychosis: A confirmatory efficacy trial.

AIMS: Young people with attenuated psychotic symptoms (APS), brief intermittent psychosis, and/or genetic risk and functional deterioration are at high risk for developing psychotic disorders. In a prior trial, family-focused therapy for clinical high risk youth (FFT-CHR) was more effective than brief psychoeducation in reducing APS severity over 6 months. This 7-site trial will compare the efficacy of FFT-CHR to a psychoeducational and supportive intervention (enhanced care) on APS and social functioning in CHR individuals over 18 months. METHODS: Participants (N = 220, ages 13-25 years) with a CHR syndrome will be randomly assigned to FFT-CHR (18 1-h sessions of family psychoeducation and communication/problem-solving skills training) or enhanced care (3 1-h family psychoeducational sessions followed by 5 individual support sessions), both given over 6 months. Participants will rate their weekly progress during treatment using a mobile-enhanced online platform. Family communication will be assessed in a laboratory interactional task at baseline and post-treatment. Independent evaluators will assess APS (primary outcome) and psychosocial functioning (secondary outcome) every 6 months over 18 months. RESULTS: We hypothesize that, compared to enhanced care, FFT-CHR will be associated with greater improvements in APS and psychosocial functioning over 18 months. Secondarily, improvements in family communication over 6 months will mediate the relationship between treatment condition and primary and secondary outcomes over 18 months. The effects of FFT-CHR are predicted to be greater in individuals with higher baseline risk for psychosis conversion. CONCLUSIONS: Results of the trial will inform treatment guidelines for individuals at high risk for psychosis.

Depression, family interaction and family intervention in adolescents at clinical-high risk for psychosis.

AIM: The relationship between family behaviour and depression in adolescents at clinical high risk (CHR) for psychosis remains understudied despite high rates of depression in this population. This study examines the relationship between family problem-solving behaviours and depression in CHR adolescents and the impact of family interventions targeting subthreshold symptoms of psychosis on reducing symptoms of depression over 2-years. METHODS: Participants were a subset of the North American Prodrome Longitudinal Study who were randomized to 6-months of family focused therapy for individuals at CHR or family psychoeducational treatment. We evaluated the relationship between communication during family conflict discussion and adolescents' symptoms of depression before treatment. At follow-up assessments the family treatment groups were compared on depression. Finally, we compared those in family treatment with matched controls. RESULTS: Adolescents' constructive communication was associated with less severe symptoms of depression before treatment. Symptoms of depression improved for adolescents in both family treatment groups. However, there were no significant group by treatment interactions. When adolescents who participated in either type of family intervention were compared to CHR adolescent controls, symptoms of depression improved for adolescents in treatment and control groups, but there were no significant time by treatment interactions. CONCLUSIONS: The communication skills of CHR adolescents are related to both depression and their parents' communication skills pre-treatment. However, reductions in depression over the course of the treatment trial cannot be attributed to family treatment. It is imperative to incorporate interventions that directly target depression into future family treatment studies.

Family communication with teens at clinical high-risk for psychosis or bipolar disorder.

Previous research has found that family problem-solving interactions are more constructive and less contentious when there is a family member with bipolar disorder compared with schizophrenia. The present study extended this research by examining whether family problem-solving interactions differ between clinical high-risk (CHR) stages of each illness. Trained coders applied a behavioral coding system (O'Brien et al., 2014) to problem-solving interactions of parents and their adolescent child, conducted just prior to beginning a randomized trial of family-focused therapy. The CHR for psychosis sample included 58 families with an adolescent with attenuated positive symptoms, brief intermittent psychosis, or genetic risk and functional deterioration; the CHR for bipolar disorder sample included 44 families with an adolescent with "unspecified" bipolar disorder or major depressive disorder and at least one first or second degree relative with bipolar I or II disorder. When controlling for adolescent gender, age, functioning, and parent education, mothers of youth at CHR for psychosis displayed significantly more conflictual and less constructive communication than did mothers of youth at CHR for bipolar disorder. Youth risk classification did not have a significant relationship with youths' or fathers' communication behavior. The family environment among help-seeking adolescents may be more challenging for families with an adolescent at CHR for psychosis compared with bipolar illness. Accordingly, families of adolescents at clinical high-risk for psychosis may benefit from more intensive or focused communication training than is required by families of adolescents at clinical high-risk for bipolar disorder or other mood disorders. (PsycINFO Database Record

Family-focused therapy for individuals at clinical high risk for psychosis: treatment fidelity within a multisite randomized trial.

AIM: Family psychoeducation is an effective adjunct to pharmacotherapy in delaying relapse among patients with schizophrenia and bipolar disorder. This study tested the treatment adherence and competence of newly trained clinicians to an adaptation of family-focused therapy for individuals at clinical high risk for psychosis (FFT-CHR). METHODS: The sample included 103 youth or young adults (ages 12-30 years) who had attenuated positive symptoms of psychosis. Families participated in a randomized trial comparing two psychosocial interventions: FFT-CHR (18 sessions over 6 months) and enhanced care (EC; 3 sessions over 1 month). Following a 1.5-day training seminar, 24 clinicians from eight study sites received teleconference supervision in both treatment protocols for the 2-year study period. Treatment fidelity was rated with the 13-item Therapy Competence and Adherence Scales, Revised. RESULTS: Supervisors classified 90% of treatment sessions as above acceptable fidelity thresholds (ratings of 5 or better on a 1-7 scale of overall fidelity). As expected, fidelity ratings indicated that FFT-CHR included a greater emphasis on communication and problem-solving skills training than EC, but ratings of non-specific clinician skills, such as maintaining rapport and appropriately pacing sessions, did not differ between conditions. Treatment fidelity was not related to the severity of symptoms or family conflict at study entry. CONCLUSIONS: FFT-CHR can be administered with high levels of fidelity by clinicians who receive training and supervision. Future studies should examine whether there are more cost-effective methods for training, supervising and monitoring the fidelity of FFT-CHR.

Decreases in perceived maternal criticism predict improvement in subthreshold psychotic symptoms in a randomized trial of family-focused therapy for individuals at clinical high risk for psychosis.

Perceived criticism (PC) is a measure of how much criticism from 1 family member "gets through" to another. PC ratings have been found to predict the course of psychotic disorders, but questions remain regarding whether psychosocial treatment can effectively decrease PC, and whether reductions in PC predict symptom improvement. In a sample of individuals at high risk for psychosis, we examined a) whether Family Focused Therapy for Clinical High-Risk (FFT-CHR), an 18-session intervention that consists of psychoeducation and training in communication and problem solving, brought about greater reductions in perceived maternal criticism, compared to a 3-session family psychoeducational intervention; and b) whether reductions in PC from baseline to 6-month reassessment predicted decreases in subthreshold positive symptoms of psychosis at 12-month follow-up. This study was conducted within a randomized controlled trial across 8 sites. The perceived criticism scale was completed by 90 families prior to treatment and by 41 families at 6-month reassessment. Evaluators, blind to treatment condition, rated subthreshold symptoms of psychosis at baseline, 6- and 12-month assessments. Perceived maternal criticism decreased from pre- to posttreatment for both treatment groups, and this change in criticism predicted decreases in subthreshold positive symptoms at 12-month follow-up. This study offers evidence that participation in structured family treatment is associated with improvement in perceptions of the family environment. Further, a brief measure of perceived criticism may be useful in predicting the future course of attenuated symptoms of psychosis for CHR youth.

Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial.

OBJECTIVE: Longitudinal studies have begun to clarify the phenotypic characteristics of adolescents and young adults at clinical high risk for psychosis. This 8-site randomized trial examined whether a 6-month program of family psychoeducation was effective in reducing the severity of attenuated positive and negative psychotic symptoms and enhancing functioning among individuals at high risk. METHOD: Adolescents and young adults (mean age 17.4 ± 4.1 years) with attenuated positive psychotic symptoms, brief and intermittent psychosis, or genetic risk with functional deterioration were randomly assigned to 18 sessions of family-focused therapy for individuals at clinical high risk (FFT-CHR) in 6 months or 3 sessions of family psychoeducation (enhanced care [EC]). FFT-CHR included psychoeducation about early signs of psychosis, stress management, communication training, and problem-solving skills training, whereas EC focused on symptom prevention. Independent evaluators assessed participants at baseline and 6 months on positive and negative symptoms and social-role functioning. RESULTS: Of 129 participants, 102 (79.1%) were followed up at 6 months. Participants in FFT-CHR showed greater improvements in attenuated positive symptoms over 6 months than participants in EC (F1,97 = 5.49, p = .02). Negative symptoms improved independently of psychosocial treatments. Changes in psychosocial functioning depended on age: participants more than 19 years of age showed more role improvement in FFT-CHR, whereas participants between 16 and 19 years of age showed more role improvement in EC. The results were independent of concurrent pharmacotherapy. CONCLUSION: Interventions that focus on improving family relationships may have prophylactic efficacy in individuals at high risk for psychosis. Future studies should examine the specificity of effects of family intervention compared to individual therapy of the same duration and frequency. Clinical trial registration information-Prevention Trial of Family Focused Treatment in Youth at Risk for Psychosis; http://clinicaltrials.gov/; NCT01907282.

A randomized trial of family focused therapy with populations at clinical high risk for psychosis: effects on interactional behavior.

OBJECTIVE: This study investigated whether family focused therapy (FFT-CHR), an 18-session intervention that consisted of psychoeducation and training in communication and problem solving, brought about greater improvements in family communication than enhanced care (EC), a 3-session psychoeducational intervention, among individuals at clinical high risk for developing psychosis. METHOD: This study was conducted within a randomized controlled trial across 8 sites. We examined 10-min problem-solving discussions at baseline and 6-month reassessment among 66 adolescents and young adults and their parents. Trained coders who were blind to treatment and time of assessment achieved high levels of interrater reliability when evaluating family discussions on categories of calm-constructive and critical-conflictual behavior. RESULTS: Individuals at high risk and their family members who participated in FFT-CHR demonstrated greater improvement from baseline to 6-month reassessment in constructive communication and decreases in conflictual behaviors during family interactions than those in EC. Participants in FFT-CHR showed greater increases from baseline to 6 months in active listening and calm communication and greater decreases in irritability and anger, complaints and criticism, and off-task comments compared to participants in EC. These changes occurred equally in high-risk participants and their family members. CONCLUSIONS: A 6-month family skills training treatment can bring about significant improvement in family communication among individuals at high risk for psychosis and their parents. Future studies should examine the association between enhancements in family communication and reduced risk for the onset of psychosis among individuals at high risk.

A randomized trial of family focused treatment for adolescents and young adults at risk for psychosis: study rationale, design and methods.

AIM: This article outlines the rationale for a family-focused psychoeducational intervention for individuals at risk for psychosis and explains the design of a randomized multisite trial to test its efficacy. METHODS: Adolescents and young adults that meet criteria for a psychosis risk syndrome at eight participating North American Prodromal Longitudinal Study sites are randomly assigned to a 6-month, 18-session family-focused treatment for prodromal youth or a 3-session psychoeducational enhanced care control intervention and followed over 1 year. RESULTS: The results will determine whether the use of a family intervention is able to significantly improve functional outcomes, decrease the severity of positive symptoms and possibly prevent the onset of full psychosis, compared with enhanced care alone. Levels of familial criticism at baseline are hypothesized to moderate responses to family intervention. Improvements in knowledge about symptoms, family communication and problem solving will be tested as mediators in the pathways between treatment assignment and clinical or psychosocial outcomes in high-risk youth. CONCLUSIONS: The ongoing trial evaluates whether a non-invasive psychosocial approach can significantly enhance functional outcomes and prevent the ultra high risk patients from developing psychosis. The results will provide an important stepping stone in the movement of the field from refining early detection strategies to developing efficacious preventative treatments.

Predicting the longitudinal effects of the family environment on prodromal symptoms and functioning in patients at-risk for psychosis.

The current study examined the relationship between the family environment and symptoms and functioning over time in a group of adolescents and young adults at clinical high risk for psychosis (N=63). The current study compared the ability of interview-based versus self-report ratings of the family environment to predict the severity of prodromal symptoms and functioning over time. The family environmental factors were measured by interviewer ratings of the Camberwell Family Interview (CFI), self-report questionnaires surveying the patient's perceptions of criticism and warmth, and parent reported perceptions of their own level of criticism and warmth. Patients living in a critical family environment, as measured by the CFI at baseline, exhibited significantly worse positive symptoms at a 6-month follow-up, relative to patients living in a low-key family environment. In terms of protective effects, warmth and an optimal level of family involvement interacted such that the two jointly predicted improved functioning at the 6-month follow-up. Overall, both interview-based and self-report ratings of the family environment were predictive of symptoms and functioning at follow-up; however patient's self-report ratings of criticism had stronger predictive power. These results suggest that the family environment should be a specific target of treatment for individuals at risk for psychosis.

Family problem solving interactions and 6-month symptomatic and functional outcomes in youth at ultra-high risk for psychosis and with recent onset psychotic symptoms: a longitudinal study.

This study prospectively examined the relationship between social problem solving behavior exhibited by youths at ultra-high risk for psychosis (UHR) and with recent onset psychotic symptoms and their parents during problem solving discussions, and youths' symptoms and social functioning six months later. Twenty-seven adolescents were administered the Structured Interview for Prodromal Syndromes and the Strauss-Carpenter Social Contact Scale at baseline and follow-up assessment. Primary caregivers participated with youth in a ten minute discussion that was videotaped, transcribed, and coded for how skillful participants were in defining problems, generating solutions, and reaching resolution, as well as how constructive and/or conflictual they were during the interaction. Controlling for social functioning at baseline, adolescents' skillful problem solving and constructive communication, and parents' constructive communication, were associated with youths' enhanced social functioning six months later. Controlling for symptom severity at baseline, we found that there was a positive association between adolescents' conflictual communications at baseline and an increase in positive symptoms six months later. Taken together, findings from this study provide support for further research into the possibility that specific family interventions, such as problem solving and communication skills training, may improve the functional prognosis of at-risk youth, especially in terms of their social functioning.

Gender differences in symptoms, functioning and social support in patients at ultra-high risk for developing a psychotic disorder.

Gender differences have been widely observed in the clinical presentation, psychosocial functioning and course of illness in first-episode and chronic patients suffering from schizophrenia. However, little is known about gender differences in the psychosis prodrome. This study investigated gender differences in symptoms, functioning and social support in individuals at ultra-high-risk for developing a psychotic disorder. Sixty-eight ultra-high-risk patients were assessed at baseline, and twenty-seven returned for follow-up assessments approximately 6 and 12 months later. Clinical symptoms and functioning were assessed by clinical interview; social support was measured using a self-report questionnaire. There were no gender differences in demographic variables, symptoms or functioning at baseline. Males were found to have significantly higher levels of negative symptoms and marginally lower levels of functioning when baseline and follow-up time points were considered collectively. Additionally, females reported higher levels of social support at baseline. Differences in negative symptoms were found to mediate differences in functioning between male and female patients. This study suggests that gender based differences in symptom presentation and functional outcome may predate conversion to psychosis. Follow-up studies should examine the relationship between symptoms, functioning and social support in this population.

Parent attitudes and parent adolescent interaction in families of youth at risk for psychosis and with recent-onset psychotic symptoms.

AIM: This study investigated the behavioural correlates of caregiver attitudes among parents of youth at risk for psychosis and with recent-onset psychotic symptoms. METHODS: Forty adolescents identified as ultra-high-risk (UHR) for psychosis using the Structured Interview for Prodromal Syndromes, and their primary caregivers, participated in the Family Interaction Task (FIT), a 10-minute discussion of meaningful shared experiences that allowed families to demonstrate supportive as well as conflict-engaging behaviour. At the same assessment, caregivers were administered the Camberwell Family Interview (CFI). We examined cross-sectional relationships between these measures, as well as their association with youth symptom severity and functioning at 4-month follow-up. RESULTS: As predicted, caregivers who provided more positive remarks regarding their UHR and recent-onset adolescents during the CFI were also more likely to exhibit constructive behaviour during the FIT. Similarly, CFI critical comments were positively associated with caregivers' conflict-engaging behaviour during the FIT. Parents' positive remarks predicted a decrease in negative symptoms, and parent warmth predicted an increase in social functioning at follow-up assessment. CONCLUSIONS: The ability to maintain a constructive attitude and approach towards youth predicted symptomatic and functional improvement, and may be a teachable skill.

Psychoeducational multi-family group treatment with adolescents at high risk for developing psychosis.

AIM: In this study, we investigate the feasibility and acceptability of a 9-month psychoeducational multi-family group (PMFG) intervention for adolescents who are at ultra-high-risk (UHR) for developing psychosis. METHODS: The treatment programme was adapted from those previously shown to be effective in patients with established psychotic illness, but emphasizes content relevant to adolescence and to a pre-onset phase of illness. RESULTS: Participants report that psychoeducational presentations are highly useful, they attend the PMFG group sessions regularly and report feeling comfortable in meetings and benefiting from them, and adolescents demonstrate improvement in symptoms and functional outcome. CONCLUSIONS: This study was not a randomized controlled trial and multiple interventions were introduced simultaneously; thus, changes in outcome cannot be attributed to the PMFG intervention per se. Nonetheless, these results establish the acceptability of PMFG to adolescents and families, and encourage further research into the potential positive impact of PMFG with this at-risk population.

Positive family environment predicts improvement in symptoms and social functioning among adolescents at imminent risk for onset of psychosis.

This study investigated whether family factors, such as criticism, emotional over-involvement (EOI), warmth, and positive remarks, as measured by the Camberwell Family Interview (CFI), predict symptom change and social outcome for individuals identified as at imminent risk for conversion to psychosis. Twenty-six adolescent patients were administered the Structured Interview for Prodromal Syndromes and the Strauss-Carpenter Outcome Scale at baseline and follow-up assessment approximately three months later. Patients' primary caregivers were administered the CFI at baseline. After controlling for symptom severity at baseline, there were significant associations between caregivers' EOI at baseline and improvement in high-risk youths' negative symptoms and social functioning at follow-up. Similarly, caregivers' positive remarks at baseline were associated with improvement in negative and disorganized symptoms at follow-up, and warmth expressed by caregivers was associated with improved social functioning at follow-up. Although family members' critical comments were not related to patients' symptoms, the majority of critical remarks were focused on patients' negative symptoms and irritability/aggression, which may be important targets for early intervention. These preliminary results provide a first glimpse into the relationship between family factors and symptom development during the prodrome and suggest that positive family involvement predicts decreased symptoms and enhanced social functioning at this early stage. The finding that four-fifths of the youth enrolled in this early intervention clinical research program have shown symptomatic improvement by the three-month assessment point is very encouraging from an early detection/early intervention standpoint.

The psychosis prodrome in adolescent patients viewed through the lens of DSM-IV.

OBJECTIVE: Recently developed research criteria have made it possible to identify adolescents at imminent risk for psychosis. However, the array of symptomatology in these patients is broad and has not yet been systematically characterized using established diagnostic and assessment tools. METHOD: The authors characterized 24 adolescent research participants at the UCLA Center for the Assessment and Prevention of Prodromal States (CAPPS) using structured interviews for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV), the Child Behavior Checklist (CBCL), and information regarding psychiatric treatment histories. Two composite cases are also presented. RESULTS: The most common DSM-IV diagnosis at study entry was major depression, followed by anxiety disorder not otherwise specified (NOS), and social phobia. Most participants met criteria for at least one subthreshold condition, including obsessive-compulsive disorder (OCD), psychosis, mania or hypomania, and generalized anxiety. CBCL data revealed high rates of affective disturbance and broad-ranging symptomatology, as did participants' diagnostic and treatment histories. CONCLUSIONS: Consistent with retrospective studies of patients with first-episode psychosis, findings revealed frequent mood and anxiety disturbance during the prodromal phase of illness. The DSM-IV does not offer a clear framework for describing the widespread subthreshold symptomatology that characterizes putatively prodromal patients. The authors consider whether the psychosis prodrome merits designation as a recognized clinical entity.