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Couple Family Psychol. Author manuscript; available in PMC 2017 March 01. Published in final edited form as: Couple Family Psychol. 2016 March ; 5(1): 43–59. doi:10.1037/cfp0000055.

Pilot Effectiveness Evaluation of Community-Based Multi-Family Psychoeducational Psychotherapy for Childhood Mood Disorders Heather A. MacPherson, Ph.D., Departments of Psychology and Psychiatry and Behavioral Health, The Ohio State University

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Barbara Mackinaw-Koons, Ph.D., Department of Pediatrics, Nationwide Children’s Hospital Jarrod M. Leffler, Ph.D., and Departments of Psychiatry and Psychology, Mayo Clinic Mary A. Fristad, Ph.D. Departments of Psychiatry and Behavioral Health, Psychology, and Nutrition, The Ohio State University

Abstract

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Several psychosocial, family-focused Evidence-Based Treatments (EBTs) for youth with disruptive behavior have proven effective in practice settings. However, limited research has examined community implementation of EBTs for pediatric depression and bipolar disorder. This pilot open trial evaluated Multi-Family Psychoeducational Psychotherapy (MF-PEP) with 41 children ages 7 to 12 (54% male, 92% Caucasian) with mood disorders and their parents in an outpatient setting. MF-PEP is an 8-session, adjunctive EBT with parallel child and parent groups. Fourteen community therapists facilitated six MF-PEP groups at three agencies over two years. Developed checklists were used to evaluate adherence. Clinical outcomes were measured via clinician assessment and self-report questionnaires at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up, and analyzed via hierarchical linear modeling. Therapist group adherence ranged from 66.71% to 78.68% (M = 72.14%, SD = 4.85). Children experienced significant improvement in depressive and manic symptoms, and parents reported a significant increase in knowledge of mood disorders. Children with bipolar disorder and families with limited treatment history benefitted most from MF-PEP. Effect sizes (Cohen’s d) ranged from small to large for mood outcomes (d = 0.34 to 1.18), knowledge (d = 1.02), and treatment beliefs (d = 0.04 to 0.41). Limitations included small sample, missing data, and open design. Results suggest that MF-PEP may be impactful for families affected by pediatric mood disorders in the community, especially among youth with bipolar disorder and families novice to treatment. Randomized controlled trials are needed to provide more definitive evidence for the effectiveness of MF-PEP in practice settings.

Correspondence concerning this article should be addressed to Heather A. MacPherson, who is now at the Department of Psychology, Harvard University, 1048 William James Hall, 33 Kirkland Street, Cambridge, MA 02138. [email protected]. A treatment manual for MF-PEP is published by Guilford Press, MF-PEP workbooks are available from CFPSI, and JK Seminars offers audio-visual MF-PEP training materials. The final author (MAF) receives royalties from these materials.

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Keywords children; bipolar disorder; depression; family psychoeducation; effectiveness

Introduction

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In recent years, psychotherapy research has shifted focus from highly-controlled, efficacy evaluations of interventions to effectiveness studies of Evidence-Based Treatments (EBTs) in practice settings (Southam-Gerow, Marder, & Austin, 2008). Consistent with this aim, several EBTs have been successfully implemented in the community and broadly disseminated (Lambert, 2013; McHugh & Barlow, 2010). In the child mental health literature, family-based EBTs for youth with disruptive behavior have the strongest evidence of effectiveness. For example, Functional Family Therapy and Multisystemic Therapy for adolescents with behavioral problems, conduct disorder, substance misuse, and/or delinquency have well-established records of both efficacy and effectiveness (e.g., Hartnett, Carr, & Sexton, 2015; van der Stouwe, Asscher, Stams, Deković, & van der Laan, 2014). Similarly, Parent-Child Interaction Therapy, Incredible Years, and Triple P-Positive Parenting Program have demonstrated positive outcomes among preschoolers and schoolaged children with disruptive behavior in a variety of settings (e.g., Lanier et al., 2011; Menting, Orobio de Castro, & Matthys, 2013; Sanders, Kirby, Tellegen, & Day, 2014). Despite promising findings regarding the transport of family-focused EBTs for youth with externalizing problems to the community, comparatively less research has evaluated the efficacy and effectiveness of interventions for children and adolescents with mood dysregulation.

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Pediatric Mood Disorders

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Pediatric mood disorders are prevalent and serious conditions for which several EBTs have been developed, but limited effectiveness research exists. Depression and bipolar disorder each impact about 2% of children, with higher prevalence rates among adolescents (i.e., 4% to 8% for adolescent depression, 2.7% for adolescent bipolar disorder; Birmaher et al., 2007; Van Meter, Moreira, & Youngstrom, 2011). In addition to debilitating mood symptoms, these mental illnesses are characterized by considerable morbidity and mortality, including psychosocial impairment (Goldstein et al., 2009; Jaycox et al., 2009), poor quality of life (Freeman et al., 2009; Vitiello et al., 2006), and suicidality (Hauser, Galling, & Correll, 2013; Vitiello et al., 2009). Given the prevalence of and dysfunction associated with mood disorders in youth, researchers have investigated and developed efficacious interventions. While pharmacotherapy is often an important component of the treatment regimen, psychosocial interventions, including psychotherapy and school-based services, are also necessary for: teaching youth and families about symptoms, course, and treatment of mood disorders; instilling symptom management skills; and promoting psychosocial and academic success (Birmaher et al., 2007; McClellan et al., 2007).

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Efficacy and Effectiveness of Psychotherapy for Youth Depression

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Over the past several decades, numerous randomized controlled trials (RCTs) have demonstrated the efficacy of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for the treatment of adolescent depression (David-Ferdon & Kaslow, 2008; Tompson, Boger, & Asarnow, 2012). While CBT is the only well-established theoretical orientation for school-aged children with depression, a recent RCT reported promising findings for Family-Based IPT with this younger age group (Dietz, Weinberg, Brent, & Mufson, 2015). CBT teaches symptom management strategies, including scheduling and engaging in pleasant activities, identifying and challenging negative thoughts, relaxing the body, and effectively solving problems. In contrast, IPT targets depression by improving interpersonal functioning and enhancing communication skills within the context of grief, role/family disputes, role/family transitions, and interpersonal deficits (David-Ferdon & Kaslow, 2008). To date, an overwhelming majority of RCTs in the youth depression treatment outcome literature have been conducted with adolescent samples, while studies with school-aged children have included predominantly at-risk youth with elevated symptoms (David-Ferdon & Kaslow, 2008; Tompson et al., 2012). Thus, efficacy research for children under the age of 13 with a clinical diagnosis of depression is scarce.

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Compared with efficacy evaluations of CBT and IPT, few effectiveness trials have been conducted, and many with mixed findings. For example, while some RCTs demonstrated effectiveness of CBT in integrated primary care (Asarnow et al., 2005; Merry et al., 2012; Richardson et al., 2014) and IPT in school clinics (Mufson et al, 2004; Young et al., 2015), other studies in these same settings evidenced smaller effect sizes compared to efficacy trial results (Brunwasser, Gillham, & Kim, 2009; Clarke et al., 2005; Gillham, Hamilton, Freres, Patton, & Gallop, 2006; Roberts, Kane, Thomson, Bishop, & Hart, 2003; Young, Mufson, & Gallop, 2010; Yu & Seligman, 2002). As with efficacy research for youth depression, most of the aforementioned effectiveness studies were conducted with adolescents and/or at-risk samples; thus, the relevance and generalizability of findings to school-aged children with diagnosed depression is uncertain.

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Similarly varied findings are apparent among effectiveness evaluations in community mental health agencies with clinically referred, mixed adolescent and child samples. For example, one RCT of CBT versus usual care found no group differences in depression improvement, though CBT was briefer, superior in parent-rated therapeutic alliance, less likely to require additional services (including medication), and less costly (Weisz et al., 2009). In addition, a modular, transdiagnostic approach that incorporated CBT for pediatric depression demonstrated promising findings compared to usual care and standardized EBT manuals (Weisz et al., 2012). Thus, despite the well-established efficacy of CBT and IPT for pediatric depression, mixed results from effectiveness trials offer inconclusive support for the transport of these EBTs to the community, especially among school-aged children with clinical depression.

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Efficacy and Effectiveness of Psychotherapy for Youth Bipolar Disorder

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Compared to the depression literature, psychosocial treatment outcome research is rarer among youth with bipolar disorder. Currently, family-focused psychoeducation and CBT approaches have the most empirical support (Fristad & MacPherson, 2014), with growing evidence for Dialectical Behavior Therapy with adolescents (Goldstein et al., 2015). Similar to CBT and IPT for depression, family-focused psychoeducation and CBT approaches for bipolar disorder include family involvement, offer psychoeducation about mood symptoms, and teach strategies for: effectively solving problems; enhancing communication; challenging maladaptive thoughts; and managing symptoms via emotion identification, relaxation techniques, and distraction. Four large, rigorous RCTs demonstrated efficacy of three treatments incorporating family-focused psychoeducation and CBT in combination with medication, or adjunctive to both pharmacotherapy and other psychosocial services, including: Multi-Family Psychoeducational Psychotherapy (Fristad, Verducci, Walters, & Young, 2009); Child- and Family-Focused CBT (West et al., 2014); and Family-Focused Treatment (Miklowitz et al., 2008; Miklowitz et al., 2013). Multi-Family Psychoeducational Psychotherapy (MF-PEP) has the most empirical support for school-aged children with bipolar disorder, though it is designed for use and has been evaluated among youth with mixed mood diagnoses. This brief, adjunctive, group treatment incorporates psychoeducation, family therapy, and CBT techniques (Fristad, GoldbergArnold, & Leffler, 2011). Psychoeducation about mood disorder symptoms and treatment, social support from group leaders and members, and family-level CBT skills are theorized to lead to a better understanding and management of mood disorders and attainment of more effective treatment, resulting in improved symptoms (Mendenhall, Fristad, & Early, 2009).

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MF-PEP has demonstrated efficacy in two RCTs (total N = 200) using a waitlist control (both groups adjunctive to treatment as usual). MF-PEP significantly improved children’s mood symptoms, parents’ knowledge of mood disorders and treatment beliefs, and parents’ ability to access services (Fristad, Goldberg-Arnold, & Gavazzi 2002, 2003; Fristad et al., 2009). MF-PEP also significantly improved: quality of services used, mediated by parents’ treatment beliefs; and children’s mood symptoms, mediated by quality of services used (Mendenhall et al., 2009). Thus, MF-PEP helps parents become better consumers of mental health services, and access to higher-quality services results in decreased mood symptoms (Fristad et al., 2009). In addition, children’s global functioning moderated the treatment effect, such that MF-PEP had the strongest impact on mood symptoms for the most impaired children (MacPherson, Algorta, Mendenhall, Fields, & Fristad, 2014a). Thus, MF-PEP is highly effective for severely impaired youth, and affects change by enhancing understanding, advocacy, and coping skills. Given empirical support for MF-PEP and the dearth of literature on community implementation of EBTs for childhood mood disorders, effectiveness research is warranted to determine whether positive effects from efficacy trials will generalize to practice settings. However, to date only one study has been conducted. In a small, open trial, communitybased MF-PEP demonstrated positive implementation outcomes (Proctor et al., 2011) of acceptability, adoption, appropriateness, feasibility, cost/affordability, penetration, and sustainability (MacPherson, Leffler, & Fristad, 2014b). Parents’ also reported significant Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

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improvement in knowledge of mood disorders at post-treatment, with effect sizes comparable to the efficacy RCT (Fristad et al., 2003). Preliminary results suggest that MFPEP may be implementable and effective in the community. However, evaluation of treatment adherence and longitudinal clinical outcomes is needed to determine therapists’ uptake of MF-PEP and lasting intervention effects for youth and families. Purpose of the Current Study

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Given limited research on effectiveness of EBTs for childhood mood disorders, especially for school-aged children with diagnosable depression and bipolar disorder, this pilot open trial examined therapist adherence and longitudinal clinical outcomes of children with mood disorders and their parents following participation in community-based MF-PEP. It was hypothesized that therapists would achieve adequate adherence (75% recommended by the treatment developer), children would experience significant improvement in mood symptoms and treatment beliefs, and parents would demonstrate significant improvement in knowledge of mood disorders and treatment beliefs. Exploratory analyses examined demographic, diagnostic, treatment completion, and service utilization variables as predictors of treatment response.

Method Participants and Procedures

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Parents and children—Forty-one children and their parents were referred to communitybased MF-PEP by their individual/family clinicians at three outpatient clinics. A Midwestern pediatric hospital’s Institutional Review Board oversaw the study. Inclusion criteria required that children were ages 7 to 12 and had a depressive or bipolar disorder diagnosis, per referring therapist evaluation. Parents and children were excluded if they had inadequate verbal skill and intellectual functioning, per judgment of the referring therapist, or if they could not communicate or write in English. As MF-PEP is an adjunctive treatment, participants were encouraged to continue other concurrent interventions, though these were not tracked in the current study.

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Children were predominantly male (54%) and Caucasian (92%); a majority of parents were biological mothers (75%). Most families had accessed prior mental health treatment for children (85%); 2% were novice to treatment; 12% did not provide information. Mood diagnoses were evaluated by a clinical psychology graduate student for 70% of participants, following receipt of additional funding. Mood diagnoses were not assessed for two MF-PEP groups (n = 12) that occurred prior to obtaining funds. Of those for whom mood diagnoses were gathered (n = 29), 58% had a depressive disorder and 41% had a bipolar disorder, per the DSM-IV-TR (American Psychological Association, 2000). See Table 1 for baseline demographic and diagnostic information. Six groups were conducted over two years at three child and adolescent outpatient community behavioral health clinics affiliated with a large Midwestern pediatric hospital. One group was conducted at each of two clinics, one an inner-city location and one in a suburban location; four groups were conducted at another suburban clinic. Number of

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families per group ranged from 5 to 9 (M = 6.83, SD = 1.47). Number of sessions attended ranged from 1 to 8 (M = 6.12, SD = 2.25). Thirty families (73%) completed ≥ 6 sessions (minimal dose recommended by the MF-PEP developer to be considered a treatment completer). Reasons for discontinuation included: scheduling/transportation difficulty (n = 9); complaints of redundant material with prior therapeutic services (n = 1); and incompatibility with other families (n = 1).

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After being referred to MF-PEP, families completed a one-hour prescreening interview with an MF-PEP group therapist to enhance buy-in and assess eligibility and compatibility with other group members, in accord with standard operating procedures for group therapy referrals at these clinics. Families subsequently met with an advanced graduate student to complete informed consent/assent, semi-structured assessments, and questionnaires. Families could participate in MF-PEP without consenting to the study (assessment and questionnaire completion). All but one approached family agreed to participate. Assessments and questionnaires were completed again at post-treatment and 6- and 12-months postbaseline (subsequently referred to as 6- and 12-month follow-ups) via phone and mail. Families received a $10.00 gift card at each time point. If contact was not established after one month of attempts, the family’s data were considered missing.

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Community therapists—Fourteen therapists employed at three agencies self-selected to enroll in the study. Three therapists each worked at one of the inner-city and suburban sites; eight therapists worked at the other suburban location. Clinicians had to participate in MFPEP training prior to facilitation; there were no exclusion criteria. Therapists continued to see other clients and fulfill employment obligations. Most therapists were female (79%). Regarding race, 86% were Caucasian, 7% were African American, and 7% were Asian. Regarding training, 57% were social workers, 21% were psychology interns, 14% were clinical psychologists, and 7% were social work interns. Study therapists’ demographic and training backgrounds were generally characteristic of clinicians at these agencies. Therapists received training via a one or two day workshop conducted by two licensed clinical psychologists employed at the community clinics who previously worked with the treatment developer and conducted MF-PEP efficacy groups. These therapists also facilitated groups in the current study (one child and two parent groups). Training included didactic presentations and handouts on the theory and research behind MF-PEP, and videotape review of efficacy groups with subsequent discussion. Supervision was provided as needed by therapists with experience facilitating MF-PEP, usually for 15 minutes during group setup and breakdown, but was not formally tracked. Therapists also received MF-PEP manuals and workbooks.

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As recommended in the manual, parent groups were facilitated by one therapist and child groups were facilitated by two therapists. One group employed five leaders (three for child group and two for parent group) due to interest in training new therapists at this suburban site. One therapist facilitated three groups and four therapists facilitated two groups. The remaining nine therapists facilitated one group each.

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Sessions were audio-recorded to assess therapists’ adherence to MF-PEP. Adherence checklists were created in collaboration with the MF-PEP developer and undergraduate research assistants were trained in their use via review of: MF-PEP manuals/workbooks; item content/criteria; and MF-PEP efficacy group videos. Each rater coded all available recordings (5 groups, 69 sessions, 72%). One family did not consent; thus, this group was not rated. Technical limitations (e.g., recorder malfunction) and therapist error (e.g., forgot or could not operate device) also resulted in missing recordings. Multi-Family Psychoeducational Psychotherapy

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MF-PEP is an adjunctive intervention consisting of eight 90-minute sessions with concurrent parent and child groups (Fristad et al., 2011). Families are supplied with workbooks and therapists follow a corresponding manual. Sessions begin with a multi-family check-in, during which homework is reviewed. Children and parents then participate in separate groups to learn skills. They rejoin at the end to review material and weekly projects. Sessions offer psychoeducation about mood disorders and comorbid conditions, and teach families how to: advocate for and access services; avoid dysfunctional family cycles; identify and regulate strong emotions; skillfully solve problems; change negative thinking patterns; and communicate in an effective way. Measures Measures were completed at pre-treatment, post-treatment, 6-month follow-up, and 12month follow-up, unless otherwise specified.

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Therapist adherence—MF-PEP Therapist Adherence Checklists were created for each of eight parent and child sessions. Number of items on measures range from 16 to 44 and are scored as 0 (absent) or 1 (present) with a “not able to rate” option due to technical limitations. Percentage scores, ranging from 0% to 100%, are computed for sessions and groups by dividing the number of “present” items by the total number of items minus any that were “not able to rate.” In this study, measures demonstrated adequate inter-rater reliability among undergraduate raters for items (k = .76) and percentages (r = .89), face validity (included procedures outlined in manuals/workbooks), and content validity (review/ approval of measures by the MF-PEP developer). Demographic information—Eight open-ended and multiple-choice questions administered pre-treatment asked the participating parent about his/her relationship to the child, and the child’s age, sex, race, and treatment history.

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Children’s depressive symptom severity—The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime VersionDepression Rating Scale (KDRS; Chambers et al., 1985) is a 12-item, semi-structured interview that assesses youths' depressive symptoms. Item responses are Likert-style on 6- or 7-point scales ranging from “none” to “extreme,” with total scores ranging from 0 to 61. The scale has good internal consistency (α = .72 to .87) and inter-rater reliability (r = .72 to .97), and is reliable when diagnosing depression (k = .54 to .88; Ambrosini, Metz, Prabucki, & Lee, 1989; Chambers et al., 1985).

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In the current study, the KDRS was used to evaluate children’s current mood symptoms (prior two weeks) and worst lifetime mood functioning (at baseline, to attain diagnoses). Only parents completed the KDRS to ease burden on families. Consensus diagnoses/ratings were determined via review by a licensed clinical psychologist with expertise in pediatric mood disorders. In this study, the KDRS had excellent internal consistency (α = .93) and inter-rater reliability (10% of interviews were coded by a second graduate student) for mood diagnoses (k = 1.00), items (r = .90), and scores (r = .94).

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Children’s depressive symptoms were also assessed via the child-report Children’s Depression Inventory (CDI: Kovacs, 2003) and the parent-report version (CDI-P: Kazdin, French, & Unis, 1983). Each questionnaire contains 27 items using a 3-point Likert-style scale with total scores ranging from 0 to 54. The CDI-P has good internal consistency (α = . 75), test-retest stability (r = .74), and content validity, and distinguishes depression from other disorders (Kazdin et al., 1983). The CDI has similarly good internal consistency (α = . 71 to .89) and test-retest stability (r = .50 to .87), and correlates with other depression measures at ≥ .5 (Kovacs, 20003). In this study, both the CDI-P (α = .94) and CDI (α = .95) demonstrated excellent internal consistency.

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Children’s manic symptom severity—The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-Mania Rating Scale (KMRS: Axelson et al., 2003) is a 13-item, semi-structured interview that assesses youths' manic symptoms. Item responses are Likert-style on a 5- or 6-point scale ranging from “none” to “extreme,” with total scores ranging from 0 to 64. The KMRS has high internal consistency (α = .94), inter-rater reliability (r = .97), and convergent validity, and can differentiate youth with and without clinical levels of mania with 87% sensitivity and 81% specificity (Axelson et al., 2003). As with the KDRS, the KMRS was conducted with parents only to evaluate children’s current and worst lifetime mood symptoms, and baseline consensus diagnoses were derived via review by a licensed clinical psychologist with expertise in pediatric mood disorders. In this study, the KMRS had excellent internal consistency (α = .97) and inter-rater reliability (10% of interviews were double-coded) for mood diagnoses (k = 1.00), items (r = .89), and scores (r = .94).

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Children’s manic symptoms were also assessed via the Child Mania Rating Scale-Parent (CMRS-P; Pavuluri, Henry, Devineni, Carbray, & Birmaher, 2006), a 21-item scale with Likert-style responses ranging from 0 (never/rarely) to 3 (very often) and total scores ranging from 0 to 63. The CMRS-P has good internal consistency (α = .96), test-retest reliability (r = .96), validity when compared to clinician-rated scales, and sensitivity/ specificity for differentiating mania from other/no disorders (Pavuluri et al., 2006). In this study, the CMRS-P demonstrated excellent internal consistency (α = .95). Parents’ knowledge of mood disorders—The Understanding Mood Disorders Questionnaire (UMDQ: Gavazzi, Fristad, & Law, 1997) is a parent self-report measure with 20 true/false and 19 yes/no questions assessing attributions about and understanding of mood symptoms and treatment. Higher scores reflect greater knowledge, with total scores

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ranging from 0 to 39. The UMDQ has good internal consistency (α = .73) and test-retest stability (r = .70), and is sensitive to changes in knowledge (Gavazzi et al., 1997; Mendenhall et al., 2009). In this study, the UMDQ demonstrated excellent internal consistency (α = .93).

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Parents’ and children’s treatment beliefs—The Treatment Beliefs QuestionnaireParent (TBQ-P) and Child (TBQ-C) are self-report questionnaires that assess parents’ and children’s positive beliefs about mental health treatment (Davidson & Fristad, 2006). The TBQ-P has 37 items and the TBQ-C has 19 items. Responses are Likert-style and range from 1 (strongly disagree) to 5 (strongly agree) with an option of “not-applicable.” Total scores are an average and also range from 1 to 5. Higher scores indicate a more favorable view of treatment and providers. Both measures have good internal consistency (TBQ-P α = .84 to .85; TBQ-C α = .82) and validity (convergent, discriminant, predictive), though testretest stability is higher for the TBQ-P (r = .71 to .80) than the TBQ-C (r = .43; Davidson & Fristad, 2006). In this study, both the TBQ-P (α = .99) and the TBQ-C (α = .93) demonstrated excellent internal consistency. Data Analysis Analyses were conducted with the intent-to-treat sample using SPSS 20.0. Given the pilot nature of the study, significance tests used p < .05 without correction for Type I error. Therapists’ adherence to community-based MF-PEP—Percentages for overall group adherence and descriptive statistics were calculated.

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Effectiveness of community-based MF-PEP—Descriptive statistics and Cohen’s d effect sizes were calculated. Two-level hierarchical linear models (HLMs) assessed changes in outcomes as a function of time, with repeated measures at level one nested within participant at level two. HLM was chosen because it accounts for changes over time in a nested dataset, allows for missing data via full maximum likelihood estimation, and models repeated measures with subject- and group-specific regression coefficients that are parameters allowed to vary over individuals and groups (Singer & Willett, 2003). Three- and four-level HLMs (with MF-PEP group at level three and agency at level four) were trialed but not used, as intraclass correlations calculated from four-level unconditional means models indicated that MF-PEP group (.00 to .08, ps > .05) and agency (.00 to .03, ps > .05) accounted for little random variation in outcomes.

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HLM assumes data are either missing at random or missing completely at random. Independent samples t-tests revealed one significant difference among those with missing versus complete data: families with complete data attended significantly more sessions than families with missing data [M = 7.28 versus 5.22, t(39) = −3.24, p = .002]. However, there were no significant baseline differences among those who completed MF-PEP (attended ≥ 6 sessions) versus those who did not in terms of demographics, service utilization, and clinical outcomes. Given only one significant difference among those with complete versus partial data, and as data were missing largely due to transportation difficulties (during treatment

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phase) and failure to return questionnaires or complete assessments (during follow-up phase), data were considered missing at random. A step-up model building strategy was used to evaluate outcomes separately (Singer & Willet, 2003). Random effects for intercepts and slopes were modeled using unstructured covariance matrices and retained when significant. Unconditional growth models examined time as the level one predictor, while conditional models evaluated level two predictors (i.e., age, sex, mood diagnosis, treatment completion, prior service use). Continuous variables were mean-centered and dichotomous items were entered as 1 = female, bipolar disorder, and treatment completer (attended ≥ 6 sessions). Maximum likelihood estimation was used and model fit was assessed via Akaike’s Information Criterion, Schwarz’s Bayesian Criterion, and −2 Log Likelihood. If predictors were not significant and/or did not improve model fit, they were removed from subsequent analyses.

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Results Therapists’ Adherence to Community-Based MF-PEP Overall group adherence ranged from 66.71% to 78.68% (M = 72.14%, SD = 4.85). Effectiveness of Community-Based MF-PEP

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Descriptive statistics and Cohen’s d effect sizes are outlined in Table 2. Effect sizes from baseline to 12-month follow-up ranged from small to large for depression (d = 0.34 to 1.18) and medium to large for mania (d = 0.40 to 0.70). Effect sizes were large for parents’ knowledge of mood disorders (d = 1.02), but small to medium for parents’ and children’s treatment beliefs (d = 0.04 and 0.41, respectively). See Figure 1 for trajectory of means. See Table 3 for final HLMs. Children’s depressive symptom severity—HLMs revealed significant improvement in children’s depressive symptoms via the time effect on the KDRS (F27.67 = 13.59, p = . 001, 95% CI [-1.87, −0.53]) and CDI-P (F29.64 = 5.91, p = .021, 95% CI [-1.45, −0.13]). On the CDI, the time effect was significant (F29.78 = 5.25, p = .029, 95% CI [-2.23, −0.13]) and sex was a significant predictor of slope (F28.41 = 4.60, p = .041, 95% CI [.07, 2.87]) but not intercept (F35.18 = 1.30, p = .261, 95% CI [-8.43, 2.36]). Though males and females initially had the same depression levels, males reported a significant decrease in symptoms, while females reported a significant increase.

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Children’s manic symptom severity—On the KMRS and CMRS-P, the overall time effect was not significant (KMRS F58.89 = 1.04, p = .312, 95% CI [-0.25, 0.76]; CMRS-P F56.02 = 2.16, p = .148, 95% CI [-1.49, 0.23]). Mood diagnosis was a significant predictor of intercept (KMRS F33.58 = 22.75, p = .000, 95% CI [6.68, 16.60]; CMRS-P F38.27 = 27.47, p = .000, 95% CI [10.60, 23.93]) and slope (KMRS F61.18 = 14.15, p = .000, 95% CI [-2.51, −0.77]; CMRS-P F61.45 = 5.26, p = .025, 95% CI [-3.49, −0.24]). Specifically, youth with bipolar disorder had more severe manic symptoms at baseline and exhibited significant improvement compared with depressed children.

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Parents’ knowledge of mood disorders—On the UMDQ, the time effect was significant (F82.39 = 18.00, p = .000, 95% CI [0.40, 1.10]), and prior service utilization was a significant predictor of both intercept (F60.96 = 10.97, p = .002, 95% CI [0.55, 2.22]) and slope (F87.61 = 4.12, p = .046, 95% CI [-0.49, −0.01]). Specifically, parents’ knowledge of mood disorders significantly improved, and this effect was most pronounced among parents of youth with limited prior service utilization. Parents of youth with minimal treatment history had lower knowledge levels at baseline and experienced a significantly faster rate of improvement compared with parents of youth who had engaged in extensive prior services.

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Parents’ and children’s treatment beliefs—On the TBQ-P and TBQ-C, the time effect was not significant (TBQ-P F24.72 = 0.10, p = .752, 95% CI [-0.05, 0.03]; TBQ-C F24.13 = 0.57, p = .457, 95% CI [-0.09, 0.04]). Thus, parents’ and children’s positive attitudes towards treatment did not change throughout the course of the study. On the TBQP, prior service utilization was a significant predictor of intercept (F35.81 = 10.41, p = .003, 95% CI [0.04, 0.19]) but not slope (F26.84 = 0.39, p = .54, 95% CI [-0.04, 0.02]) such that parents of youth with extensive treatment history had significantly more positive attitudes about treatment at baseline compared with parents of youth with minimal service use, and these attitudes remained steady during the study.

Discussion

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Despite advances in development of EBTs for pediatric mood disorders (David-Ferdon & Kaslow, 2008; Fristad & MacPherson, 2014; Tompson et al., 2012), limited research has examined the effectiveness of these interventions in practice settings, especially among school-aged children with clinical diagnoses. This pilot study adds to the literature on effectiveness of psychosocial EBTs for youth depression (Asarnow et al., 2005; Brunwasser, et al., 2009; Clarke et al., 2005; Gillham et al., 2006; Merry et al., 2012; Mufson et al, 2004; Richardson et al., 2014; Roberts et al., 2003; Weisz et al., 2012; Weisz et al., 2009; Young et al., 2015; Young et al., 2010; Yu & Seligman, 2002). In addition, this trial marks the second evaluation of a psychosocial EBT exclusively for children under the age of 13 with diagnosed depression or bipolar disorder in the community (MacPherson et al., 2014b). MF-PEP therapists generally demonstrated satisfactory treatment adherence on dichotomous measures. Children’s mood symptoms significantly decreased, and parents’ knowledge of mood disorders significantly increased. Gains were most pronounced for youth with bipolar disorder and limited service use. Findings are reviewed within the context of other treatment effectiveness trials and study limitations. Clinical implications and future directions are also discussed.

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Therapists’ Adherence to Community-Based MF-PEP Therapists exhibited adequate adherence to MF-PEP on dichotomous measures, though the average group adherence was slightly less than the level recommended by the treatment developer. Findings suggest that therapists can implement a manualized EBT for pediatric mood disorders with satisfactory adherence given limited training, though additional instruction may enhance learning and implementation. Emphasis on common treatment elements and experiential training may improve implementation, as recent effectiveness Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

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work suggests that integrative approaches lead to better outcomes (Weisz et al., 2012) and experiential training methods (feedback, consultation, supervision, behavioral rehearsal, role-plays) aid in therapist uptake and delivery (Beidas & Kendall, 2010; Herschell, Kolko, Baumann, & Davis, 2010). In addition, individualized training plans and measurement of provider knowledge and outcomes are also important (Leffler, Jackson, West, McCarty, & Atkins, 2013). Nevertheless, in the current study briefly trained therapists were able to implement MF-PEP with a reasonable degree of adherence. Effectiveness of Community-Based MF-PEP

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Children’s depressive symptom severity—Youths’ depressive symptoms improved on primary outcomes, and effect sizes for the KDRS (d = 1.18) and CDI-P (d = 0.76) were comparable to the overall mood severity effect in the treatment group of the efficacy RCT (d = 0.72; Mendenhall et al., 2009). On the CDI, males endorsed improved depression, while females reported a worsening. Though depression prevalence is equivalent across sex in prepubescent youth, it is more common in girls during adolescence (Birmaher et al., 2007). Thus, an increase in symptoms over one year would be expected in females as they transitioned to puberty, which may have occurred for some girls in the study. Also, psychoeducation may have enhanced youths’ ability to report mood symptoms. Though often an underappreciated approach, psychoeducation is an essential element in treatment of pediatric mood disorders, as it teaches children and families how to identify mood disturbances, determine triggers and protective factors, manage exacerbation of symptoms, implement appropriate coping skills, and access necessary assistance or emergency services (David-Ferdon & Kaslow, 2008; Fristad & MacPherson, 2014). Importantly, depression improved on primary clinician-administered (KDRS) and parent-report (CDI-P) outcomes, regardless of sex; thus, differential trajectories on the CDI should be interpreted with caution. Children’s manic symptom severity—Effect sizes for mania on the KMRS (d = 0.49) and CMRS-P (d = 0.70) were also comparable to the overall mood severity effect in the treatment group of the efficacy RCT (d = 0.72; Mendenhall et al., 2009). In the current study, children with bipolar disorder demonstrated significantly higher symptoms of mania and a significantly faster rate of improvement than depressed youth, likely due to a floor effect for depressed children.

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Thus, community-based MF-PEP appears to ameliorate children’s depressive symptoms regardless of mood diagnosis, and is particularly effective for reducing mania among youth with bipolar disorder. Indeed, much of the MF-PEP content is geared towards pediatric bipolar disorder. In addition, as improvement in parental advocacy skills is implicated as a mechanism of change in MF-PEP (Mendenhall et al., 2009), and youth with bipolar disorder often require more extensive supports compared with depressed youth (Mendenhall et al., 2011), parents’ ability to procure services for children was likely more impactful for youth with bipolar disorder over time in the current study (though not specifically measured). Consistent with the initial RCT, children with bipolar disorder presented with more severe symptoms (Fristad et al., 2002). Moderator analyses in the larger RCT demonstrated that the

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MF-PEP treatment response was not affected by mood diagnosis, but MF-PEP had the strongest impact for children with moderate to severe functional impairment (MacPherson et al., 2014a). Global functioning was not measured in the current study, but children with bipolar disorder and more severe symptoms were likely more impaired, and thus may have benefited more from the structured, targeted MF-PEP content. These pilot results not only add to the literature on effectiveness of EBTs for youth depression, but also extend prior MF-PEP implementation work (MacPherson et al., 2014b) by demonstrating significant improvement in mood symptoms following treatment in a community agency. These results are promising, as mood effect sizes were comparable with efficacy results (Fristad et al., 2009; Mendenhall et al., 2009), which is not always the case for effectiveness evaluations of EBTs (e.g., Brunwasser et al., 2009; Gillham et al., 2006; Weisz et al., 2009).

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Parents’ knowledge of mood disorders—Consistent with efficacy (Fristad et al., 2002, 2003; Mendenhall et al., 2009) and effectiveness (MacPherson et al., 2014b) trials, parents’ knowledge of mood disorders significantly improved following MF-PEP. The effect size (d = 1.02) was comparable to the knowledge effect in the treatment group of the efficacy RCT (d = 0.92; Mendenhall et al., 2009). Improvement was more pronounced among parents of youth with less mental health service use, as parents of youth who had engaged in prior treatment initially had higher knowledge and experienced slower and less improvement. Parents of youth with more supports likely had a strong knowledge base and thus less room for growth. Findings suggest that MF-PEP may be effective for improving parents’ knowledge of mood disorder symptoms and treatment in both university and practice settings, especially for families with limited service use.

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Parents’ and Children’s Treatment Beliefs—Contrary to efficacy work (Fristad et al., 2002, 2003; Mendenhall et al., 2009), parents’ and children’s positive beliefs about treatment did not improve. Initially, parents of youth with more extensive treatment history had more favorable views than parents of youth with minimal services. Families who engaged in prior treatment likely benefitted, leading to a more positive outlook. Though families’ attitudes did not improve, they were moderately high initially and remained stable. Thus, pilot results indicate that community-based MF-PEP may be effective for pediatric mood disorders and associated with improved clinical outcomes, though impact on treatment beliefs is likely minimal. Limitations

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Despite these positive findings, shortcomings should be noted. Several limitations refer to adherence measurement and therapist training. For adherence measures, the dichotomous nature of items limited sensitivity of checklists and score variability. In addition, limited score range across the small number of groups precluded examination of group-level adherence as a predictor of clinical outcomes. Also, number of items on measures varied, as items tapped session details rather than broader treatment components. For therapist training, methods were mostly didactic; however, experiential strategies are associated with

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improved adherence and outcomes (Beidas & Kendall, 2010; Herschell et al., 2010; Leffler et al., 2013). Thus, passive teaching approaches may have led to limited uptake.

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Other limitations refer to the study design, data collection, and participants. As this open study did not employ a control, it is unclear whether improvements were related to MF-PEP, the passage of time, mood episodes, concurrent treatment, or other variables. Indeed, treatment completion was not a significant predictor, which may be due to the disproportionate number of completers (n = 30) versus non-completers (n = 11), and since non-completers still received some of the intervention. Importantly, concurrent treatment was not measured but may have accounted for at least some of the improvement observed in the current trial. In addition, the sample was small with some missing data. As those with complete data attended more sessions than those with incomplete data, and therapists selfselected to receive MF-PEP training, results may be favorably biased. For example, families with better attendance may have benefitted from MF-PEP and provided more data, and only interested, invested therapists may have enrolled in the study. Also, the mostly Caucasian sample limits conclusions about the generalizability of results. Finally, MF-PEP was implemented in one geographic area at agencies with ties to the university where the intervention was developed. These therapists, especially those who previously worked with the treatment developer, were invested and skilled in implementation of MF-PEP, while clinicians at other agencies may be resistant to learning and using EBTs. Despite these limitations, results are promising and warrant future research. Future Directions

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Given positive findings, additional research should replicate results and address shortcomings. Development of more sensitive, stream-lined adherence instruments with a Likert-scale tapping broad treatment components and clinician competency would better assess how thoroughly topics are covered and increase score variability to more closely examine the integrity-outcome relationship. Future work should also employ experiential methods and ongoing consultation to improve therapist training, uptake, and implementation.

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As MF-PEP effectiveness cannot be concluded from this open trial, future research should examine community-based MF-PEP in a large RCT, using usual care or other active comparisons, with practitioners of diverse training background and clinically referred youth. In addition, mood symptoms, comorbid problems, family functioning, and concurrent service utilization should be assessed longitudinally via child-, parent-, and clinician-report to determine the most effective and efficient methods for outcome monitoring in the community. It will be especially important to implement and evaluate MF-PEP in novel clinics and regions that do not have close ties to the treatment developer, to determine its effectiveness in new settings and geographic locations with racially diverse families. If future studies support the effectiveness of MF-PEP, mediator and moderator analyses should be conducted to determine whether community-based MF-PEP affects change in the same way (i.e., by improving understanding, advocacy, and coping skills) for the same subgroups (i.e. most impactful for severely impaired youths) as university-based MF-PEP. In addition, as the current study suggests that MF-PEP in community settings may be Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

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especially effective for youth with bipolar disorder and minimal treatment use, these variables should be analyzed in future work and these subgroups should be targeted for enrollment into MF-PEP. To improve the reach and dissemination of MF-PEP, brief versions of MF-PEP in integrated primary care and computerized treatment may be particularly helpful for families in rural settings with limited access to mental health services. Finally, given the promise of modular, transdiagnostic treatments in the community (Weisz et al., 2012), a modular approach for treatment of pediatric mood disorders may offer flexible implementation of individualized intervention components to address specific mood symptoms, comorbid conditions, and familial dysfunction on a case-by-case basis.

Conclusions Author Manuscript

Despite growing evidence supporting the efficacy of psychosocial treatments for pediatric mood disorders, limited research has examined the effectiveness of EBTs in practice settings, especially among school-aged children with diagnosable disorders. Effectiveness studies with depressed youth showed promise, though some demonstrated reduced impact of treatments compared with efficacy trials. This pilot trial adds to the literature on treatment effectiveness for depressed youth, and marks the second community implementation of an EBT for children with diagnosed depression or bipolar disorder.

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Therapists generally demonstrated adequate adherence to MF-PEP, though there is room for improvement. Following MF-PEP, children’s mood symptoms and parents’ knowledge of mood disorders significantly improved. In addition, MF-PEP appears to be particularly impactful for youth with bipolar disorder and among parents of youth novice to treatment. Despite limitations, results from this open trial are promising and suggest that MF-PEP may be implementable in community settings and associated with clinical improvements for families affected by pediatric mood disorders, though additional research is needed.

Acknowledgments The project described was supported by Award Number KL2 RR025754 from the National Center for Research Resources. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

References

Author Manuscript

Ambrosini PJ, Metz C, Prabucki K, Lee J. Videotape of the third revised edition of the K-SADS. Journal of the American Academy of Child and Adolescent Psychiatry. 1989; 28(5):723–728. [PubMed: 2793800] American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th. Washington, DC: American Psychiatric Association; 2000. text rev Asarnow JR, Jaycox LH, Duan N, LaBorde AP, Rea MM, Murray P, Wells KB. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: A randomized controlled trial. Journal of the American Medical Association. 2005; 293(3):311–319. [PubMed: 15657324] Axelson D, Birmaher BJ, Brent D, Wassick S, Hoover C, Bridge J, Ryan N. A Preliminary Study of the Kiddie Schedule for Affective Disorders and Schizophrenia for school-age children Mania

Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

MacPherson et al.

Page 16

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Rating Scale for children and adolescents. Journal of Child and Adolescent Psychopharmacology. 2003; 13(4):463–470. [PubMed: 14977459] Beidas RS, Kendall PC. Training therapists in evidence-based practice: A critical review of studies from a systems-contextual perspective. Clinical Psychology: Science and Practice. 2010; 17(1):1– 30. [PubMed: 20877441] Birmaher B, Brent D. the American Academy of Child Adolescent Psychiatry Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 2007; 46(11):1503–1526. [PubMed: 18049300] Brunwasser SM, Gillham JE, Kim ES. A meta-analytic review of the penn resiliency program’s effect on depressive symptoms. Journal of Consulting and Clinical Psychology. 2009; 77(6):1042–1054. [PubMed: 19968381] Chambers WJ, Puig-Antich J, Hirsch M, Paez P, Ambrosini PJ, Tabrizi MA, Davies M. The assessment of affective disorders in children and adolescents by semistruc-tured interview: Test-retest reliability of the Schedule for Affective Disorders and Schizophrenia for school-age children, present episode version. Archives of General Psychiatry. 1985; 42(7):696–702. [PubMed: 4015311] Clarke G, Debar L, Lynch F, Powell J, Gale J, O’Connor E, Hertert S. A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child and Adolescent Psychiatry. 2005; 44(9):888–898. [PubMed: 16113617] David-Ferdon C, Kaslow NJ. Evidence-based psychosocial treatments for child and adolescent depression. Journal of Clinical Child and Adolescent Psychology. 2008; 37(1):62–104. [PubMed: 18444054] Davidson KH, Fristad MA. The Treatment Beliefs Questionnaire (TBQ): An instrument to assess beliefs about children’s mood disorders and concomitant treatment needs. Psychological Services. 2006; 3(1):1–15. Dietz LJ, Weinberg RJ, Brent DA, Mufson L. Family-based interpersonal psychotherapy for depressed preadolescents: Examining efficacy and potential treatment mechanisms. Journal of the American Academy of Child and Adolescent Psychiatry. 2015; 54(3):191–199. [PubMed: 25721184] Freeman AJ, Youngstrom EA, Michalak E, Siegel R, Meyers OI, Findling RL. Quality of life in pediatric bipolar disorder. Pediatrics. 2009; 123(3):e446–e452. [PubMed: 19254981] Fristad MA, Goldberg-Arnold JS, Gavazzi SM. Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Bipolar Disorders. 2002; 4(4):254–262. [PubMed: 12190715] Fristad MA, Goldberg-Arnold JS, Gavazzi SM. Multi-family psychoeducation groups in the treatment of children with mood disorders. Journal of Marital and Family Therapy. 2003; 29(4):491–504. [PubMed: 14593691] Fristad, MA.; Goldberg-Arnold, JS.; Leffler, JM. Psychotherapy for children with bipolar and depressive disorders. New York, NY: Guilford Press; 2011. Fristad MA, MacPherson HA. Evidence-based psychosocial treatments for child and adolescent bipolar spectrum disorders. Journal of Clinical Child and Adolescent Psychology. 2014; 43(3): 339–355. [PubMed: 23927375] Fristad MA, Verducci JS, Walters K, Young ME. Impact of multifamily psy-choeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry. 2009; 66(9):1013–1020. [PubMed: 19736358] Gavazzi SM, Fristad MA, Law JC. The Understanding Mood Disorders Questionnaire. Psychological reports. 1997; 81(1):172–174. [PubMed: 9293206] Gillham JE, Hamilton J, Freres DR, Patton K, Gallop R. Preventing depression among early adolescents in the primary care setting: A randomized controlled study of the penn prevention program. Journal of Abnormal Psychology. 2006; 34(2):203–219. Goldstein TR, Birmaher B, Axelson D, Goldstein BI, Gill MK, Esposito-Smythers C, Keller M. Psychosocial functioning among bipolar youth. Journal of Affective Disorders. 2009; 114(1–3): 174–183. [PubMed: 18715651]

Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

MacPherson et al.

Page 17

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Goldstein TR, Fersch-Podrat RK, Rivera M, Axelson DA, Merranko J, Yu H, Bir-maher B. Dialectical Behavior Therapy for adolescents with bipolar disorder: Results from a pilot randomized trial. Journal of Child and Adolescent Psychopharmacology. 2015; 25(2):140–149. [PubMed: 25010702] Hartnett D, Carr A, Sexton T. The effectiveness of Functional Family Therapy in reducing adolescent mental health risk and family adjustment difficulties in an Irish context. Family Process. 2015 Advance online publication. Hauser M, Galling B, Correll CU. Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: A systematic review of prevalence and incidence rates, correlates, and targeted interventions. Bipolar Disorders. 2013; 15(5):507–523. [PubMed: 23829436] Herschell AD, Kolko DJ, Baumann BL, Davis AC. The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clinical Psychology Review. 2010; 30(4):448–466. [PubMed: 20304542] Jaycox LH, Stein BD, Paddock S, Miles JNV, Chandra A, Meredith LS, Burnam MA. Impact of teen depression on academic, social, and physical functioning. Pediatrics. 2009; 124(4):e596–e605. [PubMed: 19736259] Kazdin AE, French NH, Unis AS. Child, mother, and father evaluations of depression in psychiatric inpatient children. Journal of Abnormal Child Psychology. 1983; 11(2):167–180. [PubMed: 6619431] Kovacs, M. Children’s Depression Inventory (CDI): Technical manual update. North Tonawanda, NY: Multi-Health systems; 2003. Lambert, MJ., editor. Bergin and Garfield’s handbook of psychotherapy and behavior change. 6th. New York, NY: John Wiley & Sons, Inc; 2013. Lanier P, Kohl PL, Benz J, Swinger D, Moussette P, Drake B. Parent-Child Interaction Therapy in a community setting: Examining outcomes, attrition, and treatment setting. Research on Social Work and Practice. 2011; 1(6):689–698. Leffler JM, Jackson Y, West AE, McCarty CA, Atkins MS. Training in evidence-based practice across the professional continuum. Professional Psychology: Research and Practice. 2013; 44(1):20–28. MacPherson HA, Algorta GP, Mendenhall AN, Fields BW, Fristad MA. Predictors and moderators in the randomized trial of Multi-Family Psychoeducational Psychotherapy for childhood mood disorders. Journal of Clinical Child and Adolescent Psychology. 2014a; 43(3):459–472. [PubMed: 23795823] MacPherson HA, Leffler JM, Fristad MA. Implementation of Multi-Family Psychoeducational Psychotherapy for childhood mood disorders in an outpatient community setting. Journal of Marital and Family Therapy. 2014b; 40(2):193–211. [PubMed: 24749838] McClellan J, Kowatch R, Findling RL. the Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2007; 46(1):107–125. [PubMed: 17195735] McHugh RK, Barlow DH. The dissemination and implementation of evidence-based psychological treatments: A review of current efforts. The American Psychologist. 2010; 65(2):73–84. [PubMed: 20141263] Mendenhall AN, Demeter C, Findling RL, Frazier TW, Fristad MA, Youngstrom EA, Horwitz SM. Mental health service use by children with serious emotional and behavioral disturbance: Results from the LAMS study. Psychiatric Services. 2011; 62(6):650–658. [PubMed: 21632735] Mendenhall AN, Fristad MA, Early TJ. Factors influencing service utilization and mood symptom severity in children with mood disorders: Effects of multifamily psy-choeducation groups (MFPGs). Journal of Consulting and Clinical Psychology. 2009; 77(3):463–473. [PubMed: 19485588] Menting AT, Orobio de Castro B, Matthys W. Effectiveness of the Incredible Years parent training to modify disruptive and prosocial behavior: A meta-analytic review. Clinical Psychology Review. 2013; 33(8):901–913. [PubMed: 23994367]

Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

MacPherson et al.

Page 18

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Merry SN, Stasia K, Shepherd M, Frampton C, Fleming T, Lucassen MF. The effectiveness of SPARX, a computerized self help intervention for adolescents seeking help for depression: Randomised controlled non-inferiority trial. British Medical Journal. 2012; 344:e2598. [PubMed: 22517917] Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD, Brent DA. FamilyFocused Treatment for adolescents with bipolar disorder: Results of a 2-year randomized trial. Archives of General Psychiatry. 2008; 65(9):1053–1061. [PubMed: 18762591] Miklowitz DJ, Schneck CD, Singh MK, Taylor DO, George EL, Cosgrove VE, Chang KD. Early intervention for symptomatic youth at risk for bipolar disorder: A randomized trial of FamilyFocused Therapy. Journal of the American Academy of Child and Adolescent Psychiatry. 2013; 52(2):121–131. [PubMed: 23357439] Mufson L, Dorta KP, Wickramaratne P, Nomura Y, Olfson M, Weissman MM. A randomized effectiveness trial of Interpersonal Psychotherapy for depressed adolescents. Archives of General Psychiatry. 2004; 61(6):577–584. [PubMed: 15184237] Pavuluri MN, Henry DB, Devineni B, Carbray JA, Birmaher B. Child Mania Rating Scale: Development, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry. 2006; 45(5):550–560. [PubMed: 16601399] Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Hensley M. Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research. 2011; 38(2): 65–76. [PubMed: 20957426] Richardson LP, Ludman E, McCauley E, Lindenbaum J, Larison C, Zhou C, Katon W. Collaborative care for adolescents with depression in primary care: A randomized clinical trial. Journal of the American Medical Association. 2014; 312(8):809–816. [PubMed: 25157724] Roberts C, Kane R, Thomson H, Bishop B, Hart B. The prevention of depressive symptoms in rural school children: A randomized controlled trial. Journal of Consulting and Clinical Psychology. 2003; 71(3):622–628. [PubMed: 12795585] Sanders MR, Kirby JN, Tellegen CL, Day JJ. The Tripe P-Positive Parenting Program: A systematic review and meta-analysis of a multi-level system of parenting support. Clinical Psychology Review. 2014; 34(4):337–357. [PubMed: 24842549] Singer, JD.; Willett, JB. Applied longitudinal data analysis. New York, NY: Oxford University Press, Inc; 2003. Southam-Gerow, MA.; Marder, AM.; Austin, AA. Dissemination of evidence-based manualized treatments for children and families in practice settings. In: Steele, RG.; Elkin, TD.; Roberts, MC., editors. Handbook of evidence-based therapies for children and adolescents: Bridging science and practice. New York, NY: Springer Science + Business Media, LLC; 2008. p. 447-469. Tompson MC, Boger KD, Asarnow JR. Enhancing the developmental appropriateness of treatment for depression in youth: Integrating the family in treatment. Child and Adolescent Psychiatric Clinics of North America. 2012; 21(2):345–384. [PubMed: 22537731] van der Stouwe T, Asscher JJ, Stams GJ, Deković M, van der Laan PH. The effectiveness of Multisystemic Therapy (MST): A meta-analysis. Clinical Psychology Review. 2014; 34(6):468– 481. [PubMed: 25047448] Van Meter AR, Moreira AL, Youngstrom EA. Meta-analysis of epidemiologic studies of pediatric bipolar disorder. Journal of Clinical Psychiatry. 2011; 72(9):1250–1256. [PubMed: 21672501] Vitiello B, Rohde P, Silva S, Wells K, Casat C, Waslick B, March J. Functioning and quality of life in the Treatment for Adolescents with Depression Study (TADS). Journal of the American Academy of Child and Adolescent Psychiatry. 2006; 45(12):1419–1426. [PubMed: 17135987] Vitiello B, Silva SG, Rohde P, Kratochvil CJ, Kennard BD, Reinecke MA, March JS. Suicidal events in the Treatment for Adolescents with Depression Study (TADS). Journal of Clinical Psychiatry. 2009; 70(5):741–747. [PubMed: 19552869] Weisz JR, Chorpita BF, Palinkas LA, Schoenwald SK, Miranda J, Bearman SK. Research Network on Youth Mental Health. Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: A randomized effectiveness trial. Archives of General Psychiatry. 2012; 69(3):274–282. [PubMed: 22065252]

Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

MacPherson et al.

Page 19

Author Manuscript

Weisz JR, Southam-Gerow MA, Gordis EB, Connor-Smith JK, Chu BC, Langer DA, Weiss B. Cognitive-behavioral therapy versus usual clinical care for youth depression: An initial test of transportability to community clinics and clinicians. Journal of Consulting and Clinical Psychology. 2009; 77(3):383–396. [PubMed: 19485581] West AE, Weinstein SM, Peters AT, Katz AC, Henry DB, Cruz RA, Pavuluri MN. Child- and familyfocused cognitive-behavioral therapy for pediatric bipolar disorder: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2014; 53(11):1168–1178. [PubMed: 25440307] Young JF, Benas JS, Schueler CM, Gallop R, Gillham JE, Mufson L. A randomized depression prevention trial comparing Interpersonal Psychotherapy-Adolescent Skills Training to group counseling in schools. Prevention Science. 2015 Advance online publication. Young JF, Mufson L, Gallop R. Preventing depression: A randomized trial of Interpersonal Psychotherapy-Adolescent Skills Training. Depression and Anxiety. 2010; 27(5):426–433. [PubMed: 20112246] Yu DL, Seligman MEP. Preventing depressive symptoms in Chinese children. Prevention and Treatment. 2002; 5(1)

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Trajectory of means for clinical outcomes. KDRS = Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-Depression Rating Scale; CDI-P = Children’s Depression Inventory-Parent; CDI = Children’s Depression Inventory; KMRS = Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-Mania Rating Scale; CMRS-P = Child Mania Rating Scale-Parent Version; UMDQ = The Understanding Mood Disorders Questionnaire; TBQ-P = Treatment Beliefs Questionnaire-Parent; TBQ-C = Treatment Beliefs Questionnaire-Child.

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Table 1

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Baseline Demographic and Diagnostic Information Demographics (n)

M (SD) or %

Children’s Age and Sex (n = 41) Age

10.48 (1.53)

Male

54

Children’s Race (n = 36) Caucasian

92

Biracial

6

Asian

3

Children’s Baseline Mood Diagnosis (n = 29)

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Major Depressive Disorder

48

Bipolar I Disorder

21

Bipolar Disorder NOS

13

Depressive Disorder NOS

10

Cyclothymic Disorder

7

Children’s Previous/Current Treatment (n = 36)

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Outpatient Therapy

97

Pharmacotherapy

81

School-Based Therapy

31

Inpatient Psychiatric Care

22

Emergency Room for Mood or Behavior Problems

19

Residential/Day Treatment

11

Home-Based Therapy

8

Occupational Therapy

6

Online Support Groups

3

Parent/Caregiver Informant (n = 36) Biological Mother

75

Adoptive Mother

17

Biological Father

6

Maternal Biological Grandmother

3

Note. NOS = Not Otherwise Specified. Diagnoses defined via DSM-IV-TR criteria (American Psychiatric Association, 2000). Categories are mutually exclusive except for Children’s Previous/Current Treatment.

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Author Manuscript 17.81 (7.57) 3–36, n=36 15.41 (8.64) 2–37, n=34

CDI-P

CDI

3.68 (0.58) 2.32–4.72, n=33

TBQ-C

3.71 (0.68) 2.17–5.00, n=27

4.00 (0.39) 3.26–4.84, n=26

36.11 (3.85) 26–39, n=27

19.22 (12.14) 0–42, n=27

7.25 (5.97) 0–23, n=20

11.78 (8.09) 0–26, n=27

16.33 (7.70) 2–32, n=27

8.50 (7.00) 0–22, n=20

Post-Treatment M (SD) Range, n

3.63 (0.54) 2.78–4.76, n=20

3.90 (0.54) 2.61–4.76, n=21

35.64 (3.95) 25–39, n=22

15.32 (9.30) 0–34, n=22

7.80 (8.52) 0–30, n=20

12.00 (8.67) 0–29, n=21

16.23 (10.43) 0–39, n=22

7.80 (7.94) 0–35, n=20

3.38 (0.87) 1.00–4.79, n=19

3.80 (0.59) 1.89–4.57, n=20

36.25 (2.95) 30–39, n=20

12.48 (11.02) 0–46, n=21

6.56 (6.06) 0–21, n=18

12.48 (8.49) 0–28, n=21

12.43 (6.52) 0–25, n=21

4.28 (5.34) 0–20, n=18

12-Months M (SD) Range, n

0.41

0.04

1.02

0.70

0.49

0.34

0.76

1.18

Overall Cohen’s d

Note. KDRS = Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-Depression Rating Scale; CDI-P = Children’s Depression InventoryParent; CDI = Children’s Depression Inventory; KMRS = Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-Mania Rating Scale; CMRS-P = Child Mania Rating Scale-Parent; UMDQ = The Understanding Mood Disorders Questionnaire; TBQ-P = Treatment Beliefs Questionnaire-Parent; TBQ-C = Treatment Beliefs Questionnaire-Child.

3.82 (0.42) 3.03–4.51, n=36

TBQ-P

Treatment Beliefs

UMDQ

31.25 (6.29) 14–39, n=36

20.53 (12.03) 0–46, n=36

CMRS-P

Knowledge

10.45 (9.48) 0–28, n=29

KMRS

Manic Symptoms

12.10 (7.73) 0–32, n=29

KDRS

Depressive Symptoms

Pre-Treatment M (SD) Range, n

6-Months M (SD) Range, n

Author Manuscript

Measure

Author Manuscript

Descriptive Statistics for Clinical Outcomes

Author Manuscript

Table 2 MacPherson et al. Page 22

Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

Author Manuscript

Author Manuscript −0.79 (0.32)*

— — −1.20 (0.33)***

Service Use

Complete Tx

— — — —

Sex*Time

Diagnosis*Time

Service Use*Time

Complete Tx*Time

—

—

—

—

—

—

—

— —

— —

—

−1.87 (0.81)*

−1.64 (0.44)***

—

—

—

—

—

−0.63 (0.43)

—

1.47 (0.68)*

0.26 (0.25)

—

—

17.26 (3.29)***

11.64 (2.44)*** —

—

—

14.17 (2.12)***

CMRS-P β (SE)

—

—

5.15 (1.56)**

KMRS β (SE)

—

−1.18 (0.51)*

—

—

—

−3.03 (2.66)

—

15.39 (1.84)***

CDI β (SE)

—

−0.01 (0.01)

−0.25 (0.12)* —

—

—

—

−0.01 (0.02)

—

—

—

0.75 (0.18)***

—

0.12 (0.04)**

1.39 (0.42)** —

—

—

—

3.90 (0.06)***

TBQ-P β (SE)

—

—

—

32.96 (0.68)***

UMDQ β (SE)

—

—

—

—

—

−0.02 (0.03)

—

—

—

—

—

3.69 (0.09)***

TBQ-C β (SE)

Couple Family Psychol. Author manuscript; available in PMC 2017 March 01.

p < .001.

p < .01;

***

**

p < .05;

*

~ p < .10;

Note. A step-up model building strategy was employed, with predictors entered individually. All examined predictors are listed under Fixed Effect. Only final models are displayed, which included only significant predictors. KDRS = Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-Depression Rating Scale; CDI-P = Children’s Depression Inventory-Parent; CDI = Children’s Depression Inventory; KMRS = Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-Mania Rating Scale; CMRS-P = Child Mania Rating Scale-Parent; UMDQ = The Understanding Mood Disorders Questionnaire; TBQ-P = Treatment Beliefs Questionnaire-Parent; TBQ-C = Treatment Beliefs QuestionnaireChild; β = Parameter Estimate; SE = Standard Error; Tx = Treatment.

—

Age*Time

Time

—

—

Diagnosis

—

—

—

—

17.75 (1.25)***

11.20 (1.27)*** —

CDI-P β (SE)

KDRS β (SE)

Sex

Age

Intercept

Fixed Effects

Author Manuscript

Final Hierarchical Linear Models for Clinical Outcomes

Author Manuscript

Table 3 MacPherson et al. Page 23