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Cognitive and Behavioral Practice 15 (2008) 76–84

Psychosocial Family Treatment for a 10-Year-Old with Schizoaffective Disorder

Nicole M. Klaus, University of Michigan Mary A. Fristad, The Ohio State University

Catherine Malkin, Private Practice, Columbus, OH Barbara Mackinaw-Koons, Children’s Hospital, Columbus, OH

1077 © 2 Publ

Schizophrenia spectrum disorders are rare in childhood and little is known about their psychosocial treatment. Relevant findings from the adult and child literature are reviewed. The case of 10-year-old “Michael” is presented, who participated in a randomized clinical trial of a psychoeducational family treatment for mood disorders. Following treatment, quantitative and qualitative data show that Michael’s mood and social functioning improved, utilization of mental health services improved, the overall family emotional climate became more positive, and his parents felt supported. He no longer met criteria for a mood episode but continued to display psychosis. This family’s response suggests that group psychoeducation may be an effective treatment for families of children with emerging schizophrenia spectrum disorders.

SCHIZOPHRENIA SPECTRUMDISORDERS (schizotypal person-ality disorder, schizophrenia, or schizoaffective dis- order) in childhood are rare and little is known about effective psychosocial treatments. These disorders are par- ticularly rare in children below the age of 13, and available data suggest the prevalence of very early-onset schizophre- nia is 1 to 2 cases per 100,000 in the general population (Gillberg, 2001). Despite the low prevalence, research suggests that schizophrenia can be reliably diagnosed in children according to the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ; American Psychiatric Association, 2000) using systematic diagnostic interviews (Asarnow, Tompson, & McGrath, 2004). Differ- ential diagnosis and normal developmental patterns must be carefully considered whenmaking a diagnosis in this age group. Psychotic symptoms, including delusions or hallu- cinations, occur in up to 8% of clinically referred youth, in the context of mood, anxiety, and disruptive behavior disorders (Biederman, Petty, Faraone, & Seidman, 2004). Childhood-onset schizophrenia is often misdiagnosed in children and must be carefully distinguished from other conditions, particularly mood disorders with psychotic features (Calderoni et al., 2001; McClellan, McCurry, Snell, & DuBose, 1999). Normal childhood imaginative play and disorganized thinking can also make it difficult to diagnose these conditions in young children (Asarnow et al., 2004). There is consensus that longitudinal assessment

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is important to clarify diagnostic issues in children (Asarnow et al., 2004; McClellan et al., 1999). Diagnosis of schizoaffective disorder based on cross-sectional data can be particularly challenging given the need to establish the presence of delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms (Calderoni et al., 2001).

Studies suggest that schizophrenia spectrum diagnoses in childhood are largely stable over time and are associated with significant and chronic psychosocial impairment (McClellan et al., 1999). Schizoaffective disorder may be associated with the poorest outcome compared to schizo- phrenia or bipolar disorder alone (McClellan et al., 1999). The diagnostic criteria for schizoaffective disorder require experiencing core symptoms of schizophrenia as well as substantial episodes of depression, mania, or mixed mood episodes, and both types of symptoms are associated with considerable impairment. Effective intervention strategies are clearly needed for these children, but empirically va- lidated treatments are lacking for this age group.

Adult Treatment Studies

As few treatment studies have been conducted with children and adolescents, we will first consider findings from the adult treatment literature. Pilling and colleagues (2002a,b) recently completed a meta-analysis of rando- mized controlled psychological treatments for adults with schizophrenia. They found the strongest support for fa- mily psychoeducation, which reduced relapse, decreased hospitalizations, and improved medication compliance (Pilling et al., 2002a). The greatest effects were found for

77Child Schizoaffective Disorder Treatment

single-family interventions versus multiple family group interventions (Pilling et al., 2002a). The literature on expressed emotion (EE) was influential in the develop- ment of family psychoeducational treatments. EE is a measure of emotionally overinvolved, critical, or hostile attitudes and behavior by a relative toward a patient (Brown, Birley, & Wing, 1972). Several studies have found EE to be a robust predictor of relapse in schizophrenia, beyond initial levels of impairment. A meta-analysis by Butzlaff and Hooley (1998) found a weighted mean effect size of.30 from 27 studies. Additionally, less time spent with a high EE relative has been shown to have a protec- tive effect (Brown, Birley, & Wing, 1972; Brown, Monck, Carstairs, & Wing, 1962). One goal of psychoeducation is to help family members develop a better understanding of the disorder and provide a supportive environment for the patient. Cognitive behavioral therapy (CBT) has also shown some beneficial effects for adults with schizophrenia, leading to significant reductions in symp- tom scores (Pilling et al., 2002a). No benefits have been found with the use of social skills training or cognitive remediation therapies in adults (Pilling et al., 2002b).

Child Treatment Studies and Guidelines

A small number of treatment studies have included adolescent patients. Rund and colleagues (1994) com- pared a psychoeducation-based treatment program to standard care, finding that the psychoeducational treat- ment was associated with lower relapse rates and was more cost-effective than standard care. Additionally, improve- ment was associated with decreases in levels of parental EE. Another study found that the addition of family treatment to standard care led to an average of 10 fewermonths spent in an institutional setting over the course of 5 years (Lenior, Dingemans, Linszen, DeHaan, & Schene, 2001). Although no studies of psychosocial treatments exist with child samples, family involvement may be particularly important in treatment for children who are more dependent on family members (Asarnow et al., 2004). Based on the adult research and similarity between child and adult forms of schizophrenia, the American Academy of Child and Adolescent Psychiatry has developed treatment guidelines for children, which recommend combining psychophar- macology with psychotherapy for the child and family and appropriate educational services (McClellan et al., 2001). These guidelines suggest that therapy should include psychoeducation, cognitive-behavioral strategies, and sup- port. Further research on psychosocial treatments for children with schizophrenia spectrum disorders is needed to guide clinical care (Asarnow et al., 2004).

The Case of Michael

The present study describes the case of a 10-year-old with schizoaffective disorder and his response to psycho-

educational group therapy. This child (called “Michael”) and his family participated in a randomized clinical trial of a psychosocial treatment designed for children with mood disorders. At enrollment, Michael presented with many manic and depressive symptoms as well as mood-incon- gruent psychosis. Michael was enrolled in the study, which had no a priori rule-out criteria for schizoaffective disorder. As the clarity of Michael’s schizoaffective disorder diag- nosis increased with longitudinal assessment, his data were removed from the dataset, although his family completed participation in the study. Here we present a case study, providing details of Michael’s clinical presentation, his family’s response to amanualized psychoeducational inter- vention, and follow-up data through 18 months.

Method

This case study is drawn from data gathered as part of the larger Multi-Family Psychoeducation Group (MFPG) study. TheMFPG study is a randomized controlled study of an 8-week psychoeducational therapy group for children withmood disorders and their families (Fristad, submitted for publication). Following baseline assessment, partici- pants (N=165) were randomized to receive immediate treatment or to a 1-year wait-list control condition.

Assessment Michael’s family participated in a pretreatment assess-

ment followed by group treatment. Follow-up assessments were completed 6months, 12months, and 18months after the initial assessment. Michael and both of his parents were interviewed separately at each assessment time. Teacher questionnaires were also obtained at the baseline assessment. The inclusion of multiple informants and longitudinal assessment is important in establishing a diagnosis of schizophrenia spectrum disorders in children (Asarnow et al., 2004). Both quantitative and qualitative data were used in evaluating his symptom progression and treatment response.

Children’s Interview for Psychiatric Syndromes—Child and Parent Versions (ChIPS and P-ChIPS). The ChIPS and P- ChIPS are structured clinical interviews which assess DSM- IV symptoms in children and adolescents (Weller, Weller, Rooney, & Fristad, 1999a,b). The reliability and validity of these measures have been established in both inpatient and outpatient populations. In this study, interviewers were trained by observing and rating several interviews until at least 80% agreement was reached. After the initial training period, 10% of all interviews were videotaped for reliability. Interrater reliability was excellent for the parent (weighted kappa= .784) and child (weighted kappa= .824) versions in this sample. The ChIPS and P- ChIPS were administered to Michael and his mother, respectively, at the initial interview and at 1-year follow-up.

78 Klaus et al.

Children’s Depression Rating Scale, Revised (CDRS-R). The CDRS-R is a 17-item clinician-rated scale that assesses the severity of child depressive symptoms (Poznanski & Mokros, 1996). The CDRS-R has been shown to be a reliable, valid, and sensitive measure of depressive symptoms in both inpatient and outpatient samples (Poznanski & Mokros, 1996). At each assessment, CDRS- R ratings were obtained from Michael and his mother for the past 2 weeks as well as the worst 2 weeks since the last assessment.

Mania Rating Scale (MRS). The MRS is an 11-item clinician-rated scale that assesses the severity of manic symptoms (Young, Biggs, Ziegler, & Meyer, 1978). The reliability and validity for adults and children have been shown to be acceptable (Fristad, Weller, & Weller, 1992; Fristad, Weller, &Weller, 1995; Young et al., 1978). At each assessment, MRS ratings were obtained from Michael and his mother for the past 2 weeks as well as the worst 2 weeks since the last assessment.

Mood Severity Index (MSI). A mood severity index was created for this study to combine the severity scores from the CDRS-R and MRS. Adjustments were made to account for the different lower boundary of scores (i.e., 1 on the CDRS-R and 0 on the MRS reflect no symptom present), the greater number of items on the CDRS-R, and the duplicated irritability score on the two scales. Therefore, the MSI is calculated by dividing the irritability score on each scale in half, and applying the following formula: (CDRS-R score – 17×11/17)+MRS score. Higher scores reflect greater symptom severity.

Kaufman Brief Intelligence Test (K-BIT). The K-BIT is a brief (15 to 30 minute) intellectual screening test that pro- vides nonverbal, verbal, and composite scores (Kaufman & Kaufman, 1990).Michael was administered theK-BITduring the 6-month follow-up interview.

Treatment utilization. At each assessment, Michael’s mother reported on the utilization of all mental health services (including medication, therapy, and school services) since the last interview. Information was gath- ered about any changes in services as well as satisfaction with each service. Following each assessment, treatment utilization was summarized on a 1-to-5 Likert scale by two experienced clinical psychologists through a masked consensus process.

Understanding Mood Disorders Questionnaire (UMDQ). The UMDQ was completed by both parents at each assessment to measure knowledge of mood disorders and their treatment (Gavazzi, Fristad, & Law, 1997).

Home and Community Social Behavior Scales (HCSBS). The HCSBS is a measure of a child’s social competence and antisocial behavior (Merrell & Caldarella, 1999) and was completed by both parents at each assessment.

Teacher Report Form (TRF). The teacher form of the Achenbach Behavior Scales was completed by Michael’s

teacher at the initial assessment time to assess a variety of child behaviors over the past 6 months (Achenbach, 1991). A list of behaviors were rated on a 0 (never) to 2 (always) scale. It is comprised of nine specific behavior scales: anxious/depressed, withdrawn/depressed, social problems, sleep problems, thought problems, attention problems, somatic complaints, rule-breaking behavior, and aggressive behavior.

Five Minute Speech Sample (FMSS). The FMSS is a brief measure of expressed emotion in which a relative is asked to speak for 5 minutes about the patient and how the two of them get along (Magaña et al., 1986). Tape-recorded speech samples were scored for levels of criticism and emotional overinvolvement by raters who were masked to the child’s diagnosis and the family’s treatment status. FMSS data were collected from both parents at all assessment times.

Expressed Emotion Adjective Checklist (EEAC). The EEAC is a parent self-report measure of positive and negative emotion expressed by the parent and child toward each other (Friedmann & Goldstein, 1993). EEAC data were collected from both parents at all assessment times.

Treatment

Treatment consisted of three main components: edu- cation, support, and skill building. This treatment was developed for families of children with mood disorders to improve symptom management, individual coping, and family functioning (Fristad, Gavazzi, & Mackinaw-Koons, 2003). This treatment was adjunctive and families were encouraged to continue any medication or psychotherapy they were receiving in their communities.

Treatment followed a psychoeducational model, con- sisting of eight 1 1/2 hour group sessions. Seven families participated in this treatment group. Parents and children met separately to cover new material, but came together at the beginning of each session to review homework projects and at the end of each session to discuss projects for the upcoming week. Children and parents were given books with information presented in their sessions to follow along and use as a resource later. Group discussions applied this information to the child or family’s specific situation and answered questions posed by group members.

Child group content includeddevelopmentally appropri- ate information about symptoms, disorders, andmedication; distinguishing symptoms from self; affect management; problem solving; and communication (Goldberg-Arnold & Fristad, 2003). Children were taught about symptoms of depression, mania, anxiety, and psychosis. Side effects of medications were discussed and children were encouraged to report symptom changes or bothersome side-effects to their parents and doctors. These symptoms were presented as distinct from the child’s personality using the “Naming the

79Child Schizoaffective Disorder Treatment

Enemy” family project (Fristad, Gavazzi, & Soldano, 1999). Children were then helped to build a “tool kit” of coping strategies touse inmanaging symptoms.Theywereprompted to use these strategies in vivo when symptoms were apparent during group. The interaction between thoughts, emotions, and behaviors was introduced using an activity called “Thinking-Feeling-Doing.” Helpful thoughts and behaviors were identified using several group examples. Children were also helped to challenge negative thoughts that came up as group progressed. Problem solving was taught using a five- step model and applied to several group examples. Effective verbal and nonverbal communication strategies were taught and practiced in group. For additional information on child groupcontent and thehomeworkprojects used, seeGoldberg- Arnold and Fristad (2003). Points were used in session to encourage participation and prosocial behaviors. Children spent 15 minutes at the end of each session participating in cooperative games, with therapists available to foster appro- priate coping skills and social interactions as needed.

Parent group content mirrored the content of child groups and also covered mood monitoring, school issues and special education laws, treatment utilization, parent- ing strategies, and management of mood symptoms (Fristad & Goldberg-Arnold, 2003). As many parents feel blamed and alone in their experiences of raising a child with a mood disorder, the parent group leader helped foster an environment of encouragement and support for all participants in the difficult role of raising a child with a serious mental illness. Mothers and fathers were also helped to develop a more similar understanding of their child’s illness and need for treatment (Fristad et al., 2003). Parents were helped to identify which child behaviors reflected symptoms and which behaviors were under the child’s control. Parents were presented with information on how to adjust their expectations and parenting strategies when the child’s mood symptoms become more intense. Families were also helped to develop emergency plans to use during a crisis situation, such as if a child needs to be hospitalized. For additional information on parent group content and the homework projects used, see Fristad and Goldberg-Arnold (2003).

Results

Clinical Presentation

The progression of Michael’s psychopathology, accord- ing to his mother’s report, indicates that irritability and explosive behavior preceded the development of psycho- tic symptoms. He began having excessive tantrums and explosive behavior beginning by age 3 and began therapy for social problems andmood symptoms in the first grade. Psychotic symptoms began in the second grade and he was prescribed lithium and Risperdal. Michael underwent several subsequent medication changes, and at the time of the initial interview he was taking Depakote, Neurontin,

Zoloft, Trazodone, and Risperdal. Michael’s worst period of mood symptoms occurred throughout the fourth grade, which is when his initial study assessment took place. His mother reported that Michael had experienced many behavior problems at school and was only attending school for half days at that time. His psychiatrist had diagnosed Michael with bipolar disorder and his mother indicated that her relationship with Michael had improved since beginning to learn about bipolar disorder.

At the time of study enrollment, ChIPS and P-ChIPS interviews indicated that Michael met criteria for major depressive and manic episodes. Michael and his mother reported comorbid anxiety and oppositional behavior problems. Symptoms of psychosis were also endorsed by both parent and child. On the P-ChIPS, paranoia was endorsed. On the ChIPS, Michael endorsed paranoia as well as auditory and visual hallucinations. While a diag- nosis of schizoaffective disorder was suspected based on his baseline presentation, longitudinal assessment was considered important in establishing a firm diagnosis for Michael.

Upon assessment, Michael’s mood was irritable and his affect labile. He frequently screamed when frustrated and displayed several instances of inappropriate laughter, clapping, or singing during the interview. He also dis- played hallucinations, loose associations, and paranoia. His speech was tangential and sometimes referred to topics that had been discussed several minutes earlier. For example, he responded, “I want to hurt God,” when asked about his appetite and asked random questions, such as, “When was World War II?” During the interview he reported hearing thunder and seeing two flashes on the wall. He was visibly frightened by these experiences and reported worrying that the computer was going to blow up and that the lightning was trying to harm him. He often checked the interviewer’s notes tomake sure his responses were recorded correctly.

Michael’s teacher completed several questionnaires at the initial assessment time. She commented, “Michael is not able to function in a normal classroom. He becomes frustrated very easily and is unable to control his angermost of the time. He yells at other children and does not interact well with other classmates....He is very creative in his writing and artwork when he is not in a bad mood. For the past fewmonths, though, Michael has not enjoyed writing or art at all.”Her responses on theTRFplacedMichael’s behavior in the clinical range, with scores above the 97th percentile compared to boys his age, in the areas of thought problems (t=86), withdrawn/depressed behaviors (t=78), attention problems (t=77), aggressive behavior (t=77), anxious/ depressed behaviors (t=74), and social problems (t=74). According to his teacher, Michael’s academic performance was below grade level in all subjects. Michael had average intellectual functioning, with a composite score of 102 on

80 Klaus et al.

the K-BIT. His verbal and nonverbal ability scores were similar (vocabulary=100, matrices=103).

Michael’s family history was assessed with a three- generation genogram. His family history was significant for depression in one grandparent, one relative with symptoms of alcoholism, and one relative with symptoms of an anxiety disorder.

Treatment Participation

Behavioral observations. Michael’s family participated in the psychoeducational group treatment during the summer following his fourth grade year. Michael dis- played irritability and depressive thoughts during treat- ment. He became extremely angry and agitated over minor problems, such as difficulty getting his straw into his juice box. He reported negative thoughts, including “My mom hates me,” “I act dumb,” and “I think I might have depression forever.” Psychotic symptoms were also prominent throughout treatment and appeared to con- tribute to Michael’s agitation. He screamed at random times during group, had loose associations, made odd facial expressions, and displayed inappropriate affect. For example, during independent work on a written activity, Michael worked quietly for a while, but began screaming when he made a mistake. Then he suddenly started laughing and yelled, “Kill all the babies in the world.” In addition, he reported the presence of “green things on my feet” and delusions about the police coming to arrest him. He had difficulty with social interactions, despite a desire to be included. His psychotic symptoms interfered with social interactions and Michael was verbally and physically aggressive toward peers at times.

Child participation. When Michael displayed psychotic symptoms and agitation in group, therapists prompted him to identify strategies from his tool kit to help calm down. He was willing to try new coping strategies, such as distraction, taking a walk, or using a stress ball during group sessions, which helped reduce agitation.He was also able to challenge negative cognitions with prompting. For example, when he made negative comments about him- self, he was helped by therapists and peers to developmore helpful thoughts. Michael developed insight into his symptoms as treatment progressed and reported despair over his depressive symptoms and medication side effects. He reported frustration with “my brain” and complained “my medicine takes away my talent.” Therapists empa- thized with his reports of symptoms and prompted him to develop strategies to cope with them. For example, it was suggested that he talk to his doctor about medication side- effects. His peers were supportive by offering empathetic statements or offers to share a stuffed animal when Michael appeared upset. Michael’s parents and therapists utilized many opportunities throughout group to prompt appropriate social skills. For example, his mother pro-

vided gentle coaching through introductions during the first group. When Michael was verbally or physically aggressive with peers, therapists set clear limits and helped Michael use strategies taught in group, such as problem solving or communication, to repair social interactions.

Parental participation. Both of Michael’s parents attended parent group sessions. His parents found the information about symptoms, medications, and strategies to cope with symptoms very helpful. They asked many questions about these topics and provided support and information to other parents. While the psychoeducational information presented focused on mood disorders, comorbid conditions, including psychosis, were also discussed. Michael’s parents asked questions about psy- chosis and bipolar disorder, which were clarified in session. Through the information presented in group his parents began to understand that they were not simply struggling with a mood disorder and found the diagnostic informa- tion helpful as they worked to understand him. Michael’s parents were provided a separate individual feedback session to discuss his unique symptompresentation. During that session, it was recommended that neurological, metabolic, and endocrine evaluations be obtained to rule out an organic cause for his psychosis. They also found very useful the information on how to be assertive, informed consumers and work together with their mental health and medical providers. During a session focusing on commu- nication and family interactions, his parents expressed concerns about Michael’s negative attributions regarding his siblings and were given suggestions about how to prompt more positive interactions at home. During the final group session, his parents expressed that they had obtained good information in group and felt better prepared to seek out additional support and information. His parents also indicated that they appreciated the support and camaraderie in group. His parents had expressed feeling isolated and alone in their struggles with Michael and were able to form supportive relation- ships in group with parents of other children with significant mental illnesses.

Homework. His family was able to utilize homework projects to differentiate Michael’s symptoms from his personality, examine and improve their treatment team, monitor medication for treatment response and adverse side effects, develop coping strategies, solve problems, and improve communication. Although these projects were developed to address mood symptoms, the skills taught seemed applicable to the range of symptoms Mi- chael experienced. Examples of homework assignments completed by the family are shown in Figures 1 and 2.

Treatment Response and Symptom Progression. Michael’s parents found this treatment very helpful for their family. Michael’s father reported, “All in all, this program was a huge benefit in numerous ways: it provided a framework

Figure 1. “Naming the Enemy” homework assignment, which helps children and families distinguish the child’s characteristics from his symptoms.

Figure 2. Problem-solving homework assignment, in which fami- lies are asked to use a structured problem-solving strategy to address a current problem.

Figure 3. Parent and child reports of mood symptom severity in the past 2 weeks at each assessment time. Due to poor con- centration, child reported mood ratings could not be obtained at 18-months.

81Child Schizoaffective Disorder Treatment

to understand the problem, it confirmed for us that we were pursuing the best options for our son, it pointed us to additional resources and above all it let us know that we are not alone.”

Mood symptoms. Michael’s mood symptoms improved and remained under control through the 18-month follow- up assessment. He continued to display agitation, which appeared related to his disorganized thought processes. By the 12-month follow-up, Michael’s mother reported no prolonged periods of irritability. Mood symptom severity is shown in Figure 3. He no longer met criteria for a mood episode at the 12-month and 18-month follow-ups.

Psychotic symptoms. Michael continued to display psy- chotic symptoms throughout the follow-up period. ChIPS and P-ChIPS interviews at 12-month follow-up indicated that psychosis was still present, while his mood symptoms were minimal. At each assessment he displayed and/or his mother reported auditory and visual hallucinations, dis- organized thought processes, tangential speech, and bi- zarre behavior. During each treatment and assessment session, Michael displayed one or more symptoms of psychosis. He experienced varying levels of impairment associated with these symptoms. At times he was able to participate in group discussions and games, while at other times his symptoms impaired his social interactions. Hewas unable to complete several portions of the 18-month follow-up assessment due to tangential responses and bi- zarre behaviors. For example, he talked about thinking his body parts were sending him messages. At the 18-month follow-up assessment, his mother reported that his mood had been stable but he continued to have problems with anxiety and psychosis. She noted that she was changing her ideas about Michael’s diagnosis after consulting with his treatment team, and thought his primary diagnosis was likely schizoaffective disorder. As part of this study, two experienced clinical psychologists reviewed all ofMichael’s assessment data through a masked consensus process

following each assessment, and also agreed that a diagnosis of schizoaffective disorder was most appropriate.

Knowledge. Following treatment, both parents’ knowl- edge about mood disorders increased to the maximum UMDQ score (39) and remained stable throughout follow- up, as shown in Figure 4.

Service utilization. Following treatment, the family’s utili- zation of treatment services improved, as shown in Figure 5. The same psychiatrist managed Michael’s medication throughout the study and the family was very happy with this provider. Michael underwent several medication changes between baseline and 6 months. At the baseline interview, Michael was prescribed Depakote and Neuron- tin for mood stabilization, Risperdal for psychotic symp- toms, Trazodone for sleep difficulties, and Zoloft for tics. At the 6-month follow-up, he was prescribed Depakote,

Figure 4. Parental knowledge about mood disorders and their treatment.

Figure 6. Expressed Emotion Adjective Checklist total scores as rated by each parent.

82 Klaus et al.

Risperdal, Seroquel, and Luvox, which he continued to take through the 18-month follow-up, with several dosage increases. By parent report, his mood, psychosis, and an- xiety symptoms improved with these medications; how- ever, he experienced problems with side effects, including tics, drooling, and cognitive blunting, which his family continued to work with his psychiatrist on reducing. At the 12-month follow-up, his father noted, “With medica- tion, his responses are more controlled and appropriate, however his senses are so dulled that he experiences frustration with his lack of motor skills.”

Michael received individual therapy throughout the study. Between 6 and 12 months, he switched therapists to receive more specialized treatment of his comorbid an- xiety symptoms.

Regarding school services, Michael had an Individua- lized Education Plan throughout the study and switched to a Severe Behaviorally Handicapped classroom between the baseline and 6-month assessments. He functioned better in the smaller classroom environment with more individualized attention. He was able to attend full days of school, which had not been possible at the baseline as- sessment due to disruptive behavior. By his mother’s re- port, Michael was getting along well with teachers and was doing well behaviorally and academically at the 12- and 18-month assessment times, but he continued to have difficulty with social interactions at school.

EE. Scores for criticism and emotional overinvolve- ment on the FMSS were low for both parents at the initial assessment and remained low throughout the follow-up

Figure 5. Utilization of medication, therapy and school services as rated by two experienced clinicians who were masked to treatment status.

period. Michael’s father expressed dissatisfaction with Michael’s overall level of functioning and treatment response throughout the study on the FMSS. His mother expressed dissatisfaction at the initial assessment, but not at any of the follow-up assessments.

His mother’s report of positive family emotion on the EEAC increased over the follow-up period, as shown in Figure 6. Her report of increased overall positive family emotion reflected an increase in the positive emotion and decrease in the negative emotion she perceived Michael displaying toward her. Her self-reported expression of both positive and negative emotions toward Michael re- mained relatively stable over time. Michael’s father’s re- port of the positive and negative emotions he andMichael expressed toward each other remained relatively stable over time.

Social behavior. His parents rated Michael’s social com- petence as increased and his antisocial behavior as de- creased over the follow-up period, as shown in Figures 7 and 8. Although both parents reported slight increases in Michael’s social competence over time, he remained in the at-risk level of social functioning compared to other children his age throughout the follow-up period. Both parents also reported a decline in Michael’s antisocial behavior over time. While his mother’s report indicated that his antisocial behavior remained in the at-risk level of functioning throughout follow-up, his father’s responses placed him in the normal range of functioning by the 12- and 18-month follow-up assessments.

Figure 7. Michael’s social competence as rated by each parent (mean=50).

Figure 8. Michael’s antisocial behavior as rated by each parent (mean=50).

83Child Schizoaffective Disorder Treatment

On interview, Michael’s parents reported continued concern over his social functioning. At the 18-month follow-up, his mother noted, “While Michael is a beauti- ful, dynamic child individually, his social behavior is lacking. He does not readily pick up on social cues as ‘normal’ children would. However, I am seeing an improvement due to school counseling and continued teaching efforts at home.”

Discussion

Many improvements were seen for Michael and his family following psychoeducational group treatment for mood disorders, including improved child mood symp- toms and social behavior, increased knowledge and social support for parents, improved utilization of services, and improved family emotional climate. His psychotic symp- toms, however, remained present throughout the follow- up period. At the 18-month follow-up, Michael’s mother continued to believe that the psychoeducational group had been helpful for their family. Over the follow-up period, Michael’s family was able to utilize school and mental health services effectively to address difficulties with Michael’s mood, anxiety, social, and family function- ing. Medication changes seemed helpful in decreasing his psychotic symptoms, but side-effects continued to be a significant problem.

The single-case design of this study limits the conclu- sions that may be drawn. The benefits that this child and family experienced cannot conclusively be attributed to the psychoeducational therapy without the benefit of a control group. The improvements seen over the course of follow-up may be the result of nonspecific factors, spon- taneous remission, or other concurrent treatments. Addi- tionally, this particular family was resourceful and high functioning at the time of study enrollment, which may limit generalizability to families that do not share these characteristics. As this study was designed to treat mood disorders, measures specifically designed to assess psy- chosis in detail were not included in the assessment bat- tery. However, lengthy clinical interviews were conducted with the family over a long follow-up period, providing increased confidence in the diagnostic impression. Many of the outcomes were parent reported and may be biased

by parent satisfaction with treatment. Clinical observa- tions of the child over time, however, increase confidence in Michael’s symptom improvement.

With these limitations in mind, an examination of this family’s response to treatment provides valuable and previously unavailable information regarding the feasi- bility and potential benefit of psychoeducational treat- ments for young children with schizoaffective disorder. As the onset of schizoaffective disorder in children is rare, research is not available about the efficacy of psychosocial treatments in this age group. The combination of treatments used by this family (psychoeducation, medica- tion, individual therapy, and school services) is consistent with current treatment guidelines (McClellan et al., 2001) and this family’s appropriate use and benefit from these services provides additional support for those guidelines.

Michael’s family’s positive response suggests that group psychoeducation may be an effective adjunctive treatment for families of children with emerging schi- zoaffective disorder. The data presented here suggest that psychoeducational group treatment may be particularly beneficial in providing information and support for families, helping families optimize their treatment utiliza- tion, and improving family emotional climate. As child- hood schizoaffective disorder is extremely rare, it is also notable that it was feasible to include Michael’s family in a group of families with mood disorders. The skills for coping with symptoms taught in this group were general- izable to Michael’s symptoms and his family interactions. As the MFPG therapy was designed for families of children with mood disorders, future research should explore adaptations that may make it more applicable to, and possibly more beneficial for, schizophrenia spectrum disorders.

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Asarnow, J. R., Tompson, M. C., & McGrath, E. P. (2004). Annotation: Childhood-onset schizophrenia: Clinical and treatment issues. Journal of Child Psychology and Psychiatry, 45, 180–194.

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This paper was supported by a grant to Mary Fristad from the National Institute of Mental Health (NIMH-740975).

Address correspondence to Mary A. Fristad, Ph. D., The Ohio State University, 1670 Upham Drive, Suite 460G, Columbus, OH 43210, USA; e-mail: [email protected].

Received: March 22, 2006 Accepted: December 7, 2006 Available online 12 February 2008