J Child Fam Stud (2008) 17:809–822

DOI 10.1007/s10826-008-9191-4

ORIGINAL PAPER

Family-based Psychoeducation for Children

and Adolescents with Mood Disorders

Say How Ong Æ Annalise Caron

Published online: 15 January 2008

! Springer Science+Business Media, LLC 2008

Abstract Psychoeducation is often used for family members of adult patients with
mood disorders. An increase in family’s knowledge of the patient’s illness course
and outcome is thought to improve treatment compliance and may reduce relapse
rates through identification of early symptoms and risks. While studies on family-
based psychoeducation of adult patients with mood disorders have been reviewed, a
similar review has not been conducted in patients who are children and adolescents.
We conducted a systematic review of studies published between 1980 and 2006
on independently standing psychoeducation programs for families with children
suffering from mood disorders. Results revealed eight treatment and preventive
psychoeducation studies for families of affectively ill children or children at risk for
depression. Findings indicate that psychoeducation models typically adopt a
workshop approach incorporating didactic teachings and interactive discussion
sessions, with or without specific skills training. Given the paucity of randomized
controlled trials and lack of comparability between psychoeducation models, con-
clusions about the true efficacy of each program as a treatment or an adjunct to the
treatment of mood disorders in children and adolescents cannot be made. Further
research into psychoeducation for families of children with mood disorders is
warranted.

Keywords Family-based psychoeducation ! Children and adolescents !

Mood disorders ! Delivery format ! Efficacy

S. H. Ong (&)
Department of Child & Adolescent Psychiatry, Child Guidance Clinic,
Health Promotion Board Building, 3 Second Hospital Avenue, #03-01,
Singapore 168937, Singapore
e-mail: say_how_ONG@imh.com.sg

A. Caron
Department of Psychiatry, Genetic and Clinical Epidemiology,
New York State Psychiatric Institute, New York, NY, USA

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Introduction

A number of recent reviews have focused on psychoeducation programs for family

members of adult psychiatric patients (Anderson et al. 1986; Daley et al. 1992;
Miklowitz and Hooley 1998; Murray-Swank and Dixon 2004; Rothbaum and Astin
2000). Psychoeducational efforts are aimed to increase family members’ knowledge
of the symptoms, risks, clinical course and treatment options of the specific disorder.
Psychoeducational programs for parents of children with mood disorders are far less
studied. Given the reliance of children on families for access to treatment, treatment
compliance, and emotional support, psychoeducation for families of psychiatrically
ill children is critical. Family-focused psychoeducation was found to be superior to
an individual patient-focused treatment in adult studies (Rea et al. 2003). Addition-
ally, a combination of psychoeducation delivered to both patients and their families
was found to be more beneficial than when it was delivered solely to either patients or
their families (Glick et al. 1994).
Mood disorders are chronic, recurrent and are associated with high morbidity and
some level of mortality. Epidemiological studies suggest that up to 2.5% of children
and up to 8.3% of adolescents in the United States suffer from major depression
(Birmaher et al. 1996), which has a high relapse rate of 70% at 5 years (Birmaher et al.
1998). Long-term follow-up studies have shown that childhood and adolescent
depression recurs through adulthood (Weissman et al. 1999, 2006). For bipolar
disorder, the onset commonly occurs before age 18 (Perlis et al. 2004) and the
condition tends to run a relapsing clinical course, with an earlier onset associated with
a more severe form of the disorder. The costs of both childhood depression and bipolar
disorder are high given the associated increased risk of comorbid mental health
problems, academic decline, substance use, and suicide (Goldstein and Levitt 2005;
Saluja et al. 2004; Weissman et al. 1999). Therefore, studying the role of psycho-
education for Major Depressive Disorder (MDD) and Bipolar Disorder (BPD) in
younger populations affected by these illnesses may be particularly important for
developing sound treatment plans and setting positive treatment trajectories at earlier
stages of the disorder.
The chronicity and morbidity associated with a mood disorder in a child can be
overwhelming to family members. The family environment affects the course and
prognosis of childhood mood disorders and thus has been targeted by psychoedu-
cational interventions. For example, high ‘‘expressed emotion’’ (i.e., emotional
overinvolvement, criticalness, and hostility of family members towards the patient)
has been found to be associated with higher relapse rates in a variety of childhood
psychiatric disorders (Butzlaff and Hooley 1998). The impact of psychoeducation has
been substantial in reducing high expressed emotion, similar with findings in families
who have adult family members with depression (Anderson et al. 1986; Holder and
Anderson 1990) and bipolar disorder (Honig et al. 1997; Miklowitz and Goldstein
1990). Asarnow and colleagues (1993, 1994) have found that high expressed emotion
in families of children with depression or schizophrenia is associated with a slower
course of recovery. Some specificity has been found with high expressed emotion as a
specific risk factor for depression in youth (Asarnow et al. 2001). Psychoeducation
for mood disorders can help children and family members better understand the

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causes and maintenance factors of depressive and bipolar illness, thereby possibly
serving to decrease blame and negative familial interaction patterns (e.g., high
expressed emotion) associated with slower recovery. The efficacy of psychoeduca-
tion for family members of adult patients with affective disorders has been reviewed
(e.g., Colom and Vieta 2004; Rothbaum and Astin 2000; Rouget and Aubry 2007). In
contrast, psychoeducational programs for childhood affective disorders are less
studied.
There are several different definitions of psychoeducation. We limited it to
educating patients and families on facts of the illness, its symptoms and signs,
clinical course, treatment options, and prognosis, including improving coping and
communication skills to assist in recovery (Fristad et al. 1996). The purpose of
psychoeducation is to enable family members make informed treatment decisions
with the patient; reduce anxiety about the illness; and help families and patients cope
with the illness and its complications. The definition has been derived from several
sources, one of which was Goldman’s (1988, p. 666) definition that described
psychoeducation as ‘‘…education or training of a person with a psychiatric disorder
in subject areas that serve the goals of treatment and rehabilitation, e.g., enhancing
the person’s acceptance of his illness, promoting active cooperation with treatment
and rehabilitation, and strengthening the coping skills that compensate for
deficiencies by the disorders’’. Psychoeducation thus provides a theoretical and
practical approach toward understanding and coping with consequences of an illness.
Psychoeducation is frequently included as a component of empirically-supported
therapies such as cognitive behavioral therapy (CBT). For example, the ‘‘Child- and
Family-Focused Cognitive-Behavioral Therapy (CFF-CBT)’’ (Pavuluri et al. 2004), the
‘‘Penn Prevention Program (PPP)’’ (Jaycox et al. 1994) and the ‘‘Adolescent Coping
with Depression Course’’ (Clarke et al. 1990; Lewinsohn et al. 1985) utilized
psychoeducation as part of their treatment approach, but also included an extensive
use of other cognitive and behavioral therapy techniques. Two of the programs (Jaycox
et al. and Lewinsohn et al.) had adolescents as sole recipients, without the involvement
of families or parents. Although these programs did contain a psychoeducation
component, there were other important CBT treatment foci such as cognitive
restructuring and social problem solving. Our goal was to review the potential effects
of independently standing psychoeducation programs (i.e., not with other CBT
components), and see how that affects treatment outcome for children and families. A
review of CBT programs, although important, would address a different goal than our
review. This paper will review trials and efficacy data for psychoeducation programs
used as both intervention and prevention for childhood depression and bipolar mood
disorder, followed by a discussion of their delivery formats.

Methods

Literature Search

A literature review was systematically performed using MEDLINE database,

Cochrane database and PsychInfo from a 27-year period (1980–2006). The authors

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used a search strategy with MeSH (Medline Subject Heading) terms ‘‘Psychoeduca-
tion’’ and ‘‘Mood Disorders’’ with MeSH terms ‘‘Child’’ or ‘‘Adolescent’’. Included are
other MeSH terms and keywords: ‘‘Patient Education’’, ‘‘Family Education’’, ‘‘Health
Education’’, ‘‘Evaluation’’, ‘‘Efficacy’’, ‘‘Effectiveness’’, ‘‘Major Depressive Disor-
der’’, ‘‘Bipolar Disorder’’ and ‘‘Dysthymia’’. Other relevant bibliographies examined
included articles from books, chapters and dissertations.

Inclusion and Exclusion Criteria for Studies Reviewed

Papers addressing non-mood related psychiatric conditions and those describing

mood disorders secondary to psychoses, adjustment disorders, bereavement and
drug-induced conditions were excluded. Papers that heavily utilized CBT principles
in their psychoeducation programs (and hence not primarily psychoeducation) or had
a predominant CBT component (other than psychoeducation, e.g., cognitive
restructuring, behavioral modification and activation) in their psychosocial inter-
vention for children and adolescents were excluded. Similarly, literature describing
self-help materials (e.g. books, leaflets, videotapes available commercially describ-
ing mood disorders) without ongoing professional help were excluded.
Of the 18 papers addressing family-based psychoeducation for childhood and
adolescent mood disorders, 10 were excluded as they described predominantly CBT
approaches or had adolescents as the sole recipients of psychoeducation without
family involvement. Eight papers were included in the final review. Seven studies
examined psychoeducation as treatment and one examined psychoeducation as a
prevention strategy. Of the 8 papers, 3 described the same psychoeducation program
(MFPG, Multi-Family Parent Group).

Results

A description of the reviewed psychoeducation programs is presented in Table 1.

Psychoeducation Programs as Treatment

There are seven studies on the use of psychoeducation as a treatment modality for
children and adolescents already diagnosed to have mood disorders. Fristad et al.
(2002, 2003) and Goldberg-Arnold et al. (1999) separately conducted 3 series of
randomized controlled trials on Multi-Family Parent Group (MFPG), a 8-week
psychoeducational program, using a similar cohort of children and adolescents aged
8–12 years, from a predominantly Caucasian population, with BPD and MDD/
Dysthymic Disorder. They compared immediate MFPG + Treatment-as-usual
(TAU) with a 6-month waiting list + TAU control group. After the parents and
children were introduced in the first session, they were separated into different
rooms. The parents attended slide presentations and received workbooks that
allowed for note-taking as part of didactic information. The information covered

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 Table 1 Overview of studies on psychoeducation as treatment and prevention for childhood and adolescent mood disorders
Authors/year/design
Brent et al. (1993) Survey on acceptability
and efficacy
Goldberg-Arnold et al. (1999) RCT,
simultaneous parent and child groups
running in weekly program
Fristad et al. (2002) RCT, quasi-masked.
(1) Immediate MFPG + TAU: 6-week
program. (2) Wait-list (6-month wait for
MFPG) + TAU
Fristad et al. (2003) RCT, Longitudinal.
(1) Immediate MFPG + TAU: 6 sessions,
led by group leaders, separate parent and
children groups followed by rejoining of
family. (2) 6-month wait-list + TAU
Beardslee et al. (2003) RCT, Longitudinal, Family-based, manualized approach
medical-center based. (1) Lecture group:
2 parents-only meetings. (2) Clinician-
facilitated group: 6–11 sessions, separate to both groups. For clinician-facilitated
meetings for parents and children; tel.
contacts or refresher meetings every
6–9 months
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Format/mode of delivery
One 2-h psychoeducation session. Covers
information on diagnosis, course, and
treatment of affective illness
1st 3 sessions: Symptoms, medications,
interpersonal and family issues. 2nd 3
sessions: Communication skills, problem
solving, general family issues, review
and termination
1st 3 sessions: slide presentation of
diagnosis, Tx modalities, and common
issues faced. 2nd 3 sessions: open-ended
discussions on typical problems families
encountered
Parents: 1st 3 sessions—didactic (slides,
workbooks), Q&A, skills building;
2nd 3 sessions—role-playing, ‘‘family
projects’’. Children: interactive group;
materials given; role play, anger
management, social skills building,
affect regulation
Materials given on mood disorders, risks,
resilience and decreased blame in children
group, clinicians linked materials to
family’s unique illness experience
Outcome measures Results
Survey questionnaire Significant improvement in knowledge in
consisting of 21 questions at least 8 questions out of 21 but with a
assessing family members’ decline in one
knowledge about depression
and suicide
Survey comprising open-ended Immediate outcome: Increased knowledge
questions and verbatim and perceived social support. 6-month
accounts. No child outcome FU: Shift in attitude toward child and
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measures examined illness became more prominent in 2/3
of families
ChIPS/P-ChIPS; DSM-IV MDD/DD benefited more from intervention
diagnoses; CDRS-R; MRS; than BPD. Both groups gained
MSI; C-GAS; UMDQ; knowledge, skills, support and positive
EEAC; FAD; CASA attitudes at immediate and 4-month
post-Tx
ChIPS/P-ChIPS; CDRS-R; Increase in: parental knowledge on
MRS; C-GAS administered childhood mood symptoms; positive
at baseline. UMDQ; EEAC; family interactions; children’s perceptions
SSS; CASA of parental support and utilization of
appropriate services by families. No
reduction in negative family interactions
Parents: SADS-L; SLICE; Significant change in child-related attitudes
C-GAS; SII. Children: and behaviors; increased understanding of
K-SADS-E-R; K-SLICE; parental illness in children; decreased
YSR; SCI; self-reports internalizing scores for all children with
time; more total change in clinician-
facilitated group due to linking cognitive
info presented to family’s illness
experience
813
 Table 1 continued
814

Authors/year/design Format/mode of delivery Outcome measures Results

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Miklowitz et al. (2004) Open Tx trial.
Family-focused treatment (FFT-A) with
ongoing mood stabilizer medication
Fristad (2006) RCT, Longitudinal.
(1) Immediate IFP + TAU: Alternating
parent-only and child-primary sessions
with parental ‘‘check-in’’ and ‘‘check-
out’’ segments. (2) 12-month wait-
list + TAU
Sanford et al. (2006) Unblinded, RCT.
(1) Experimental: Usual Tx + FPE.
(2) Control: Usual Tx
21 Outpatient sessions—educate,
communication enhancement, problem-
solving skills training. Sessions set at
weekly for 12 weeks, biweekly for
12 weeks and monthly for 3 months
16 50-min sessions, individual families.
Educational materials similar to MFPG
group. One session for crisis management
or review of topics. Additional unit on
Healthy Habits (sleep, nutrition, exercise)
Twelve 90-min sessions, individual
adolescent and family at home. Structured
and interactive. Session 1–4: Patient
education, Session 5–7: Communication
skills training Session 8–11: Family
problem-solving skills training with
homework
K-SADS-PL, CBCL, Cham. Improvements in depression symptoms,
Fam. Int. Cod mania symptoms and behavior problems
over 1 year
ChIPS/P-ChIPS, CDRS-R, Changes in IFP group with improvements
MRS, MSI, EEAC, in children’s mood immediately following
Medication Usage Grids, treatment and sustained over 12 months
Mental Health Grids post-IFP, better family climate and
possible treatment utilization
K-SADS-P, RADS, FAD Near significant improvements in depressive
general functioning, ACL, symptoms and MDD remission rate.
SSAI, C-GAS, CSQ Significant improvement in certain
domains of social and family functioning
and higher parent satisfaction with Tx
services

Note: ACL = Adjective Checklist; BL = Baseline; FU = Follow-up; MDD = Major Depressive Disorder; DD = Dysthymic Disorder; BPD = Bipolar Disorder; BPD-
NOS = Bipolar Disorder, Not Otherwise Specified; CASA = Child and Adolescent Services Assessment; CBCL = Child Behavior Checklist; CDRS-R = Children’s
Depression Rating Scale-Revised; C-GAS = Children’s Global Assessment Scale; Cham. Fam. Int. Cod. = Chamberwell Family Interview and Coding; ChIPS/P-
ChIPS = Children’s Interview for Psychiatric Syndromes-Child and Parent Forms. CRI-Y = Coping Response Inventory-Youth; CSQ = Client Satisfaction Question-
naire; EEAC = Expressed Emotion Adjective Checklist; FAD = The Family Assessment Device; FPE = Family Psychoeducation; GAS = Global Assessment Scale;
IFP = Individual family psychoeducation; K-SADS-E-R = Schedule for Affective Disorders and Schizophrenia for School-Age Children, Epidemiologic Version
Revised; K-SADS-PL = Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime; K-SLICE = Kiddie-Streamlines Longitudinal Interval
Continuation Evaluation; MRS = Mania Rating Scale; MSI = Mood Severity Index; RADS = Reynolds Adolescent Depression Scale; SADS-L = Schedule for
Affective Disorder and Schizophrenia-Lifetime Version; SCI = Semi-structured Child Interview; SII = Semi-structured interview about intervention;
SLICE = Streamlined Longitudinal Interval Continuation Evaluation; SSAI = Structured Social Adjustment Interview; SSS = Social Support Scale; Tx = Treatment;
UMDQ = The Understanding of Mood Disorders Questionnaire; YSR = Youth Self-Report
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education on mood symptoms and disorder, treatment, healthy/unhealthy family

responses to disorder, and mental health systems. Open-ended discussions were
incorporated with role-playing and ‘‘family projects’’ over subsequent three sessions
to address common problems encountered by families. Children and adolescents
also received some didactic and group materials but participated in more hands-on
and interactive teaching sessions that included role-play, anger management, social
skills building and affect regulation.
Results of the 3 MFPG studies indicated increases in four areas: parental
knowledge of illness symptoms, positive family interactions and child-perceived
parental support and utilization of appropriate services by families. In addition,
favorable clinical outcome were observed in one study (Fristad et al. 2002) across
the following measures: Children’s Depression Rating-Revised (CDRS-R; Poznan-
ski et al. 1984), Mania Rating Scale (MRS; Young et al. 1978), Mood Severity
Index (MSI) and Children’s Global Assessment Scale (C-GAS; Shaffer et al. 1983).
However, no child outcome measures were examined in the other two studies
(Fristad et al. 2003; Goldberg-Arnold et al. 1999). Reliable group comparisons were
also made more difficult for the reason that the same sampled subjects (N = 35)
were utilized in all three studies. According to Chambless and colleagues (1996,
1998), in order to be considered as an efficacious psychological treatment for a
specific disorder, independent replication in different randomized controlled trials is
necessary and such trials should be followed by research on effectiveness in clinical
settings and with various populations. MFPG is therefore considered as ‘‘probably
efficacious’’ in reducing symptoms, increasing illness knowledge, and improving
attitudes toward child and illness. An attempt in replicating the MFPG model by
Fristad and colleagues in a larger sample of 165 children with mood disorders is
in process.
In a separate pilot involving only individual families (i.e., not multi-family
groups), a randomized controlled trial of individual family psychoeducation (IFP)
yielded some preliminary data (Fristad 2006). Unlike MFPG, IFP spread over
16 weeks for 20 families with BPD youths (IFP + TAU, N = 10 or waitlist-
control condition plus TAU, N = 10) and was conducted in weekly 50-min
sessions, alternating between parent-only and child-primary sessions with parental
‘‘check-in’’ and ‘‘check-out’’ segments built into each child session. Out of the 16
sessions, one session was made available for crisis management or review of
previous psychoeducation materials. In contrast to MFPG which utilized group
games to facilitate learning and sharing, this was excluded in IFP. Instead, topic on
‘‘Healthy Habits’’ was given to focus on proper sleep hygiene, nutrition and
developmentally appropriate exercise routines. Using similar MFPG outcome
measures as well as the Medication Usage and Mental Health Grids (Davidson and
Fristad 2006; Goldberg-Arnold and Fristad 1999, Unpublished manuscript), the
pilot study reported improvements at 6-months follow up in mood and family
climate with possible improvements (non-significant degree) in treatment utiliza-
tion. These improvements were most pronounced at 12-month follow-up period.
However, the study’s small sample size and high dropout rate (7 out of 20 families)
before study completion may limit the confidence in the finding and reduce the
validity of its results.

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In another format of patient and family psychoeducation, Miklowitz and

colleagues (2004) systematically studied the use of psychoeducation in adolescent
patient groups with BPD. It was an open treatment trial using the Family-Focused
Treatment-Adolescent (FFT-A) model on 20 adolescents with BPD and receiving
mood-stabilizing medications. The model utilized 21-outpatient sessions
(12 weekly, followed by biweekly for 12 weeks, then monthly for 3 months).
Sessions focused on educating adolescent patients taking mood stabilizers and their
families about bipolar illness and treatment modalities (9 sessions); communication
enhancement techniques (6 sessions); and problem solving skills training (6
sessions). In contrast to MFPG model, FFT-A spread over more sessions with
dedicated specific skills training sessions incorporated into their manualized
approach. Improvements in depressive symptoms, manic symptoms, and behavioral
problems were found on both diagnostic assessments and symptom reviews (CBCL
and K-SADS-PL) over 1 year. However, only 20 adolescents were studied.
Sanford and colleagues (2006) piloted an exploratory study of family psycho-
education (FPE) with 31 depressed adolescents (67% female, mean age 15.9 years)
and their families. A unique addition with this study was that FPE was conducted at
the adolescents’ homes. This in-home intervention consisted of twelve 90-minute
sessions over a 6-month period followed up by a booster session 3 months later. The
adolescents were randomized into an experimental group (usual treatment plus FPE)
and a control group (usual treatment). Comprising 5 phases, the sessions in the
experimental group were structured, interactive and involve, in one phase, direct
communication between the adolescent and other family members about the
experience of depression. Similar to the FFT-A model, FPE encompassed
communication skills training (identifying and minimizing unproductive interaction
patterns, enhancing positive interactions) and family problem-solving skills training
with weekly homework assignments in its other phases. The booster session
consisted of assessment of learned skills and strategies to sustain their use were
identified. Outcome measures included Reynolds Adolescent Depressive Scale
(RADS; Reynolds 1986), Structured Social Adjustment Interview (SSAI; McCleary
and Sanford 2002), Family Assessment Device (FAD; Epstein et al. 1983),
Adjective Checklist (ACL; Friedmann and Goldstein 1993), CGAS, and the Client
Satisfaction Questionnaire (CSQ; Larsen et al. 1979). Results showed a near
significant reduction in depressive symptoms during a 3-month period and higher
MDD remission rate in the experimental group at 3-month follow-up. Also,
significantly more positive family functioning and relationships in five domains of
social and family functioning outcomes and higher satisfaction among parents about
the program were registered. While providing a strong support for the use of FPE in
the clinical population, the study’s results were limited by its small sample size,
unblinded nature of study (participants were aware whether they were receiving
PFE or control conditions; C-GAS and FPE fidelity were not rated independently)
and the lack of standardization of psychosocial and drug treatments.
Brent et al. (1993) conducted a pre- and post-program survey on the acceptability
of a 2-h psychoeducation session to ascertain its acceptability and efficacy. The
abbreviated course was based on a manual, Living with Depression: A Survival
Manual for Families (Poling 1989). Given to 62 parents of affectively ill

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adolescents in a multi-family setting, it covered information provision on the

diagnosis of affective disorder, its course, and treatment. The single session brought
about a significant improvement in knowledge about depression of family members
based on 21 evaluation questions measuring changes in attitudes and knowledge
about affective illness. However, treatment utilization or outcome was not assessed.

Psychoeducation Programs as Prevention

There is only one randomized controlled study that focused on family psychoed-
ucation as a prevention strategy. The recipients are children and adolescents who
had been identified as at risk of developing a mood disorder by virtue of their
parents’ mood disorder or that they may have symptoms that did not meet diagnostic
criteria for a mood disorder. Beardslee et al. (2003) studied a family-based
psychoeducation approach to the prevention of depressive symptoms in 121
children, aged 8–15 years, who were at risk for depression by virtue of their parent’s
depression status. The trial was performed longitudinally to study whether
enhancing children’s self-understanding would reduce onset of mood disorder.
Families were randomized into a lecture group format (without clinician’s presence)
or a clinician-facilitated group format. The former group had 2 separate ‘‘parents-
only’’ group meetings involving several families while the latter group involved
6–11 sessions with individual families in addition to separate meetings with parents
and children, family meetings, and telephone contacts or refresher meetings at
6–9 month intervals. Both groups were given similar psychoeducational materials
about mood disorders, risk and resilience. Efforts were made to decrease guilt
feelings and self-blame in children. In addition, parents were assisted in helping
their children to forge relationships both within and outside the family facilitating
independent functioning. However, in the clinician-facilitated group, the clinicians
linked materials taught to the family’s unique experience of the illness. The results
of the study found that both child and parents groups reported experiencing a
significant change in child-related attitudes and behaviors. Besides an increase in
understanding the parental illness, the internalizing scores for all children also
decreased over time. However, more total change was noted in the clinician-
facilitated group, which the authors postulated as possibly due to linking cognitive
information presented to family’s illness experience. This study had the largest
sample of adolescents (N = 121).

Discussion

In our reviewed studies of family-based psychoeducation treatment and prevention

models, children and their parents or immediate family members were involved in
the psychoeducation, except for the study by Brent and colleagues (1993) in which
only parents attended psychoeducation. When both parents and children were
involved, they attended separate sessions of psychoeducation, so as to cater for
age-appropriate teachings relevant to enhancing the children’s understanding,

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participation level and enthusiasm. Only one study had psychoeducation delivered
in a home setting which included the adolescent and his/her family members
together (Sanford et al. 2006). When applied to multiple families groups (Miklowitz
and Hooley 1998), psychoeducation may have an added advantage of increasing
sharing and support among various families and enhancing the families’ coping
abilities. Running multi-family groups is a relatively cost-effective way of
delivering psychoeducation, as each session could comprise a few families at one
time. Conversely, individual family psychoeducation could be particularly useful
for certain community-based practices set in the more remote localities, when
scheduling flexibility for sessions is needed and when families do not feel
comfortable sharing personal information in a group setting.
The commonly used format in the reviewed psychoeducation models comprised
both didactic and interactive ‘‘workshop’’ approach supplemented with oral
presentations and printed materials on facts about mood disorders. Specific skills
training, in the form of communication enhancement and problem solving, during
dedicated sessions of the psychoeducation program is widely used in several of the
reviewed models, e.g. FFT-A and FPE, and serves as practical additions to the core
psychoeducational materials. These skills were also taught indirectly through family
projects and role-playing in MFPG and IFP. Different media and teaching formats,
such as video and slide presentations and role-playing, have been used to engage the
younger children and to improve their understanding of difficult concepts. Many
children, including those who are preliterate, might understand unfamiliar medical
concepts and respond well to modeling through visual demonstration instead of the
written words. Family projects during joint sessions were further used to enhance
family cohesion and communication. Linking didactic materials to family’s unique
illness experience has been found to be particularly beneficial in one study
(Miklowitz et al. 2004). The absence of cross-comparisons between different multi-
family psychoeducation programs and the lack of proper control groups greatly limit
the generalizability of our findings. Overall, the psychoeducation programs described
in our current review are ‘‘probably efficacious’’ in bringing about changes in
attitudes and behavior of parents on their children and their mood disorders, as well
as reduction of mood symptoms in the short and intermediate term. Two
psychoeducation programs (MFPG and Brent et al.) however have demonstrated
actual knowledge learned about the illness. During our review of the available
literature, we noted the paucity of robust studies examining psychoeducation use
in treating childhood mood disorders. There was also a lack of comparable study
methodologies, outcome measures and efficacy data. Consequently, a narrative
approach was adopted in our review as opposed to a meta-analysis, which would be
premature at this point in the development of psychoeducation literature.
There are no randomized controlled trials to compare the efficacy or examine the
different effects of psychoeducation administered by different health practitioners,
i.e. mental health professionals, primary care physicians, registered nurses or allied
health staff. However, Hauenstein (2003) illustrated how the school nursing staff
could be used to deliver psychoeducation to a group or adolescents diagnosed with
depression. The usefulness of nurses in general practice for purpose of rendering
support and patient education has also been documented in CBT intervention

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programs such as ‘‘Teaching Kids to Cope’’ (Puskar et al. 1997, 2003) and ‘‘Coping
with Depression’’ course (Clarke et al. 1990; Lewinsohn et al. 1985). So far, no
studies were done to look at advantages and disadvantages or differences between
psychoeducation delivered by various health or teaching professionals. Given the
relative lack of child-focused psychologists and psychiatrists, examination of the
implementation of mood disorder psychoeducation programs by nurses and other
professionals could serve a great need.
Psychoeducation offers itself as part of a multi-modal approach to treating
childhood mood disorders. Engaging parents and other key adult caregivers into
family psychoeducation may enhance the rehabilitative and recovery processes of
mood disorders. Psychoeducation for the parents of children with mood disorders is
even more relevant for pediatric patients, given children’s physical and emotional
reliance on them. The goal is for parents of affectively ill children to become more
involved in the treatment process of their children and learn to be advocates for
themselves as parents and for the needs of their children. A psychoeducational
program for children and adolescents can therefore be similar to that used in adults
as the basic assumptions—connecting with families and patients, information giving
and ongoing psychosocial interventions—still hold (Holder and Anderson 1990).
The present trend is for psychoeducation to be blended with other treatment
modalities such as CBT, which would entail more expertise, time and training of
staff. Psychoeducation alone therefore may be a more viable and cost-effective
option for treating children and adolescents with mood disorders. In a way,
psychoeducational interventions have been seen also to possess the ability to change
or shift cognitions for depressed patients and their families. Though definite
conclusions about the true efficacy of psychoeducation programs could not be
drawn presently, the generalizability of psychoeducational principles should aid
general clinicians and allied health workers in delivering effective patient education,
specific skills training and supportive counseling in other non-psychiatric settings.
With an increased trend of incorporating other treatment modalities, specific skills
training and forms of self-help activities into psychoeducation, the value and long-
term effects of these integrations need to be explored. Given the promising results of
symptom reduction with the use of psychoeducation in some reviewed studies (e.g.,
Miklowitz et al. 2004), future research should evaluate psychoeducation alone as a
treatment approach compared to other existing empirically-supported treatments,
particularly when there are therapist or client-related barriers to implementing the
latter treatments. However, it is imperative to recognize that while psychoeducation
could serve as an invaluable treatment option, it may often not be sufficient as a
stand-alone treatment for childhood mood disorders.
Due to the paucity of studies done on psychoeducational programs for children
and adolescents with mood disorders and a lack of clear definition as to what
psychoeducation is for childhood psychiatric disorders, direct comparisons between
individual programs is difficult. It is also hard to determine whether any
improvement made during psychoeducation delivered in a workshop format for
treatment or for prevention of mental illnesses is due to the knowledge gained or
due to the unique situation of a group-setting environment. One needs to consider
the many factors which exist in therapeutic group settings e.g. group support and

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cohesion, group sharing, modeling from other group members and other non-
specific interactions etc., that could possibly have an impact on outcome effects. A
suitable research design, e.g. group psychoeducation versus support group or group
activity (without psychoeducation given) would perhaps help to address this query.
Further studies involving component analyses that examine different active
components of psychoeducation could help determine the effect of group variables
that bring about change in attitude and behavior toward disease. To answer the
question on which format of psychoeducation works best, there is a need for future
research to analyze the various psychoeducation delivery methods, such as parent-
only, child-only, single-family or multiple-families formats, and to incorporate
major findings from adult literature. Further examinations of psychoeducation
programs by independent investigatory groups in various clinical settings and
populations would help elucidate their true efficacy in the treatment of mood
disorders in children and adolescents.

Acknowledgments This work was funded by Advanced Center for Intervention and Services Research
(ACISR) grant number 5P30-MH071478, from NIMH and Columbia University, NY, USA. The first
author would like to also acknowledge National Healthcare Group (Singapore) for funding a research
fellowship in New York State Psychiatric Institute.

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