Parent, Child, and Family Predictors of Dropout in Psychosocial Treatment for Pediatric Bipolar Disorder BY ASHLEY ISAIA B.A., Northwestern University, 2009 THESIS Submitted as partial fulfillment of the requirements for the degree of Master of Arts in Psychology in the Graduate College of the University of Illinois at Chicago, 2016 Defense Committee: Chicago, Illinois Amy West, Chair and Advisor Sally Weinstein, Psychiatry Stewart Shankman, Psychology
DEDICATION PAGE To my husband, Matt Isaia, my champion. ii
ACKNOWLEDGMENTS I would like to express my sincere appreciation and thanks to my advisor, Amy West, for her support and guidance in developing this manuscript. I am also grateful to Sally Weinstein and Stewart Shankman for contributing their insight and encouragement throughout this process. iii
TABLE OF CONTENTS CHAPTER PAGE I. INTRODUCTION... 1 A. Background... 1 B. Overview of the Present Study... 4 II. METHOD... 8 A. Participants... 8 B. Procedures... 8 1. Diagnosis and Randomization... 8 2. Study Design... 9 C. Measures... 10 1. Measures of Parent Functioning... 10 a. Parental Stress Scale... 10 b. Coping Health Inventory for Parents... 10 c. Therapy Outcome Parents Scale... 11 d. Symptom Checklist 90-Revised... 11 2. Measures of Child Symptom Severity... 12 a. Child Mania Rating Scale... 12 b. Child Bipolar Depression Rating Scale... 13 3. Measures of Family Functioning... 13 a. Family Adaptability and Cohesion Evaluation Scale... 13 b. Family Crisis Oriented Personal Evaluation Scales... 14 4. Outcome Measures... 14 D. Analytic Approach... 15 III. RESULTS... 16 A. Preliminary Analyses... 16 B. Descriptive Statistics... 17 C. Predictors of Pre-Treatment Dropout... 19 D. Dropout During Treatment... 20 E. Effects of Parent Functioning on Dropout During Treatment... 21 i. Parent Stress... 22 ii. Parent Coping Skills... 22 iii. Parent Self-Efficacy and Knowledge... 24 iv. Parent Psychopathology... 25 F. Effects of Child Symptom Severity on Dropout During Treatment... 27 i. Child Mania Symptoms... 27 ii. Child Depression Symptoms... 27 G. Effects of Family Functioning on Dropout During Treatment... 29 i. Family Adaptability and Cohesion... 29 ii. Family Coping... 29 IV. DISCUSSION... 33 iv
A. Baseline Predictors of Pre-Treatment Dropout... 33 i. Parent Functioning... 33 ii. Child Functioning... 34 iii. Family Functioning... 34 B. Baseline Predictors of Dropout During Treatment... 34 i. Parent Functioning... 35 ii. Child Functioning... 36 iii. Family Functioning... 36 C. Group Differences in Dropout During the Course of Treatment... 37 D. Limitations... 40 E. Conclusions... 41 CITED LITERATURE... 43 VITA... 51 v
LIST OF TABLES TABLE PAGE I. BASELINE DEMOGRAPHICS AND CLINICAL CHARACTERISTICS OF YOUTH WITH PEDIATRIC BIPOLAR DISORDER... 17 II. DESCRIPTIVE STATISTICS FOR PREDICTOR AND OUTCOME MEASURES... 18 III. RESULTS OF STANDARD LOGISTIC REGRESSIONS PREDICTING PRE-TREATMENT DROPOUT AS A FUNCTION OF BASELINE CHARACTERISTICS... 20 IV. RESULTS OF HIERARCHICAL COX REGRESSIONS PREDICTING DROPOUT AS A FUNCTION OF PARENT CHARACTERISTICS AND TREATMENT ASSIGNMENT... 26 V. RESULTS OF HIERARCHICAL COX REGRESSIONS PREDICTING DROPOUT AS A FUNCTION OF CHILD SYMPTOMS AND TREATMENT ASSIGNMENT... 28 VI. RESULTS OF HIERARCHICAL COX REGRESSIONS PREDICTING DROPOUT AS A FUNCTION OF FAMILY CHARACTERISTICS AND TREATMENT ASSIGNMENT... 31 VII. RESULTS OF HIERARCHICAL COX REGRESSIONS PREDICTING DROPOUT AS A FUNCTION OF PARENT CHARACTERISTICS AND TREATMENT ASSIGNMENT (CONTINUED)... 32 vi
LIST OF FIGURES FIGURE PAGE 1. Cumulative survival for youth in CFF-CBT and TAU... 21 vii
LIST OF ABBREVIATIONS ADHD ASRM BDI-II CBDRS CHIP CFF-CBT C-SSRS CMRS DBT DSM-IV-TR Attention Deficit Hyperactivity Disorder Altman s Self-Report of Mania Beck Depression Inventory II Child Bipolar Depression Rating Scale The Coping Health Inventory for Parents Child- and Family-Focused Cognitive-Behavioral Therapy Columbia Suicide Severity Rating Scale Child Mania Rating Scale Dialectical Behavior Therapy Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision FACES F-COPES FFT IPSRT KBIT-2 MF-PEP NOS PBD PSS RCT SCL-90-R The Family Adaptability and Cohesion Evaluation Scale Family Crisis Oriented Personal Evaluation Scales Family-Focused Treatment Interpersonal and Social Rhythm Therapy Kaufman Brief Intelligence Scale-Second Edition Multi-Family Psychoeducational Psychotherapy Not Otherwise Specified Pediatric Bipolar Disorder Parental Stress Scale Randomized Clinical Trial Symptom Checklist 90-Revised viii
TAU TOPS WASH-U-KSADS Treatment as Usual Therapy Outcomes Parents Scale Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia ix
SUMMARY Premature termination and dropouts are ongoing problems among children and adolescents receiving psychosocial treatment for mental health needs. A growing body of literature has identified parent, child, and family characteristics that contribute to poor treatment engagement among children seeking or utilizing mental health services across diagnoses. However, little is known about the role of these factors specifically among children with pediatric bipolar disorder (PBD). Thus, the present study explored baseline characteristics, including indicators of parent functioning (stress, coping, selfefficacy, and psychopathology), child symptom severity (mania and depression), and family functioning (coping, adaptability and cohesion), as predictors of dropout among a sample of 71 youth with PBD participating in family-based psychosocial treatment. In this study we chose to focus on characteristics that are likely to be impaired in families affected by PBD aspects of parent, child, and family functioning that we believe are modifiable through targeted treatment approaches. Results indicate that aspects of parent and family functioning demonstrated the greatest potential as predictors of dropout, while child symptomatology was not associated with dropout. In addition, our findings suggest that the influence of some aspects of parent and family coping behaviors on dropout may vary as a function of the type of treatment delivered. An intensive family-based treatment specifically developed to meet the needs of families affected by PBD may be particularly beneficial for engaging parents and families with poor coping behaviors. Results from this study have important implications for how we design and tailor interventions to meet the needs of families affected by PBD. Future work is needed to optimize treatment outcomes for these families. x
I. Introduction A. Background Pediatric Bipolar Disorder (PBD) is a serious and debilitating disorder characterized by mood lability and significant psychosocial impairment. Youth with PBD experience difficulties in school, strained interpersonal relationships with peers and family members, and exhibit poor social skills (Geller et al., 2000). In addition, this earlyonset form of bipolar disorder is further complicated by psychiatric comorbidity, a more chronic and severe course, and poorer outcomes (Leverich et al., 2007). Though pharmacotherapy is the primary mode of treatment for these youth, medications do not address many of the functional impairments that lead to substantial difficulties in the daily lives of these youth and their families, justifying the importance of developing evidence-based psychosocial treatments for PBD and enhancing their utilization. Unfortunately, research indicates that the vast majority of children with psychiatric disorders a staggering 75% do not receive treatment (National Institute of Mental Health [NIMH], 2001). Even though there is a wealth of evidence-based treatments available, they are not readily delivered to the children who need them. Despite continued efforts to develop treatments for children that are efficacious, children often do not receive targeted or appropriate care. A study by Leaf et al. (1996) indicated that only 25% of youth with a psychiatric diagnosis and substantial functional impairment received specialized treatment services across four community-based sites. Among the small minority of youth who do access specialized mental health services, treatment engagement becomes a major issue. 1
Premature termination and dropouts are ongoing problems among children and adolescents receiving psychosocial treatment for mental health problems. With dropout rates ranging from 40-60% among children participating in outpatient treatment (Kazdin, 1996), there is a clear indication of significant problems with retention in this population. Further, this proves challenging for mental health service providers. Premature terminations place pressure on the mental health system and impact providers abilities to deliver services effectively and at a reasonable cost (Morrissey-Kane & Prinz, 1999). Service providers waste valuable time and resources, while the individual loses out on the benefits of treatment (Armbruster & Kazdin, 1994; Kazdin, 1996). Further, early termination may contribute to poor outcomes and ultimately becomes a public health concern, highlighting a need to enhance engagement and promote successful completion of treatment. At present, we are not aware of any previous studies investigating factors that contribute to dropout from psychosocial treatment among youth with PBD. However, given the significant issues with retention among children in treatment for psychiatric disorders more broadly, investigations into factors that predict dropout among youth in psychosocial treatment for PBD are warranted. The purpose of the present study is to understand whether indicators of parent, child, and family functioning contribute to dropout in psychosocial treatment among youth with pediatric bipolar disorder that could in turn be targeted to optimize outcomes for these youth. A growing body of literature has identified factors that contribute to poor treatment engagement among children seeking or utilizing mental health services across diagnoses (Gopalan et al., 2010; Kazdin, Holland, & Crowley, 1997; McKay & Bannon, 2004; Staudt, 2007). A variety of factors have predicted treatment engagement 2
across studies, including diagnostic and severity indicators, family factors (e.g. level of stress, family cohesion, parent-child interactions), parenting factors (e.g. effectiveness of discipline), sociodemographic variables (e.g. SES, single parent home), as well as logistical (e.g. lack of transportation, community violence) and perceptual barriers (e.g. poor therapeutic alliance, expectations and beliefs about treatment, stigma) (Gopalan et al., 2010). For the purposes of the present study, we will direct our attention to parent, child, and family characteristics, which are particularly relevant in the context of familybased psychosocial treatments for PBD. Parent, child, and family characteristics are well-established predictors of treatment engagement across studies of child treatment. When considering factors that contribute to engagement among youth in child treatment, it is especially important to consider the role of parent characteristics, since parents have the responsibility of finding mental health service providers for their child, bringing their child to treatment, and ensuring that aspects of the treatment are implemented at home and between sessions. A review by Morrissey-Kane and Prinz (1999) concluded that parental cognitions, including perceptions of barriers to treatment, expectations of treatment, and attributions of their child s behavior, contribute to treatment engagement. Aspects of parent functioning, including parent psychopathology, parenting difficulties, and stress, also serve as barriers to engagement in mental health services among youth (Staudt, 2007). Thus, evidence suggests that parents are key figures in the treatment process, and their functioning can have important implications for engagement and achievement of optimal treatment outcomes. 3
Indicators of child and family functioning are also important for understanding whether families are likely to engage in treatment. Child characteristics have been found to influence treatment engagement. Male gender, a mental health diagnosis, and significant impairment in child functioning are associated with treatment engagement (McKay & Bannon, 2004). While male gender and a diagnosis are related to increased use of treatment services, there have been inconsistent findings regarding the direction of the relationship between severity of impairment and engagement (McKay & Bannon, 2004). In a study of predictors of engagement and dropout among children with antisocial behavior, child and family characteristics including higher levels of family adversity, lower socioeconomic status, and older children were associated with higher dropout rates (Prinz & Miller, 1994). Additional family characteristics, including families with a single-parent, a young mother, or a non-biological head of household, those with minority status or low income, and families with inadequate living arrangements or negative child-rearing practices, were associated with early dropouts from treatment among children with conduct problems (Kazdin & Mazurick, 1994). Taken together, these findings indicate that the characteristics that children and families bring to treatment have a significant impact on their ability to effectively engage in the treatment process. B. Overview of the Present Study Despite the available knowledge regarding factors that contribute to engagement among youth in psychosocial treatment, little is known about the role of these factors specifically among children with pediatric bipolar disorder, who represent a severe clinical population with extremely poor prognosis and documented difficulties with 4
retention in treatment (Horwitz et al., 2012). Thus, the present study aims to explore baseline parent, child, and family characteristics as predictors of dropout in familybased psychosocial treatment for PBD. This study uses data from a randomized clinical trial of Child- and Family-Focused Cognitive-Behavioral Therapy (CFF-CBT) compared to psychosocial treatment as usual (TAU) for PBD. CFF-CBT is a manual-based treatment that combines cognitive behavioral therapy techniques with psychoeducation, mindfulness-based approaches, and interpersonal/family therapy techniques for the treatment of youth ages 7-13 with a bipolar spectrum diagnosis. It incorporates 7 core ingredients reflected in the acronym RAINBOW that address specific areas of psychosocial and interpersonal functioning that are relevant to families affected by PBD, including: Routine (establishing predictable daily routines); Affect Regulation (psychoeducation about emotions; tracking and monitoring moods; building coping strategies to improve affect regulation); I Can Do It! (boosting child self-esteem and increasing parent self-efficacy); No Negative Thoughts/Live in the Now (cognitive restructuring to reduce negative cognitions and encouraging mindfulness techniques to increase awareness to the present moment); Be a Good Friend/Balanced Lifestyle (improving social skills and promoting parent balance and self-care); Oh How Do We Solve this Problem? (family problem-solving and promoting effective family communication); and Ways to Find Support (enhancing and utilizing social support networks in the family, neighborhood, and community) (West et al., 2014). CFF-CBT and two other family-based psychosocial treatments have demonstrated efficacy in the treatment of youth with bipolar disorders in randomized controlled trials (RCTs). Findings from our RCT of CFF-CBT indicated that youth in 5
CFF-CBT experienced greater reductions in mood symptoms and improved global psychosocial functioning relative to psychosocial treatment as usual (West et al., 2014). Multi-Family Psychoeducational Psychotherapy (MF-PEP; Fristad, Verducci, Walters, & Young, 2009), which is designed for children aged 8-12 with mood disorders, resulted in significant reductions in mood symptom severity; youth who completed treatment experienced even greater improvements in mood symptomatology than those who dropped out of treatment prematurely. In addition, Family-Focused Treatment (FFT; Miklowitz et al., 2008) demonstrated efficacy in reducing the rates of depression relapse among adolescents (aged 13-18) with bipolar disorder. Findings from pilot trials of two additional treatments that have been adapted for adolescents with bipolar disorder Dialectical Behavior Therapy (DBT; Goldstein et al., 2015) and Interpersonal and Social Rhythm Therapy (IPSRT; Hlastala, Kotler, McClellan, & McCauley, 2010) are also promising. Extant research suggests that these types of family-based psychosocial treatments are imperative to treat the range of symptoms and impairments at the child, parent, and family level that are associated with PBD (McClellan, Kowatch, & Findling, 2007; Washburn, West, & Heil, 2011). Thus, we believe the present research is particularly relevant as the parent, child, and family characteristics that are the focus of this study may significantly interfere with a family s ability to engage in the kinds of family-based treatment approaches that will help them. While the literature has reliably identified a number of stable characteristics (e.g. age, SES, single-parent status) that are predictive of treatment engagement, little is known about characteristics that might actually be modifiable through targeted treatment approaches. We have chosen to 6
examine characteristics that may be modifiable through treatment, including child mania and depression symptoms, indicators of parent functioning (i.e. psychopathology, stress, coping, and self-efficacy), and aspects of family functioning (i.e., coping, adaptability, and cohesion), to explore whether these factors predict dropout in psychosocial treatment. Once identified, child, parent, and family risk factors could be addressed early in the treatment process to enhance engagement in treatment, offset the negative impact of the static and unmodifiable barriers, and optimize treatment outcome for youth with PBD. To our knowledge, this is the first study to examine parent, child, and family predictors of dropout among youth in family-based psychosocial treatment for PBD. We hypothesized that baseline parent characteristics (stress, coping, self-efficacy, and psychopathology), child symptoms (mania and depression), and family characteristics (coping, adaptability, and cohesion) would be related to dropout in family-based psychosocial treatment for PBD. However, given that no prior studies have examined predictors of dropout from a psychosocial intervention for PBD, there were no specific hypotheses as to which baseline indicators of parent, child, or family functioning would be associated with dropout. The secondary aim was to assess if the effects of child, parent, and family characteristics on dropout varied as a function of the type of psychosocial treatment delivered. We predicted that CFF-CBT would be associated with greater retention in treatment among families with highly symptomatic children and those with poor family and parent functioning at baseline. 7
II. Method A. Participants The present study involves secondary data analysis of a randomized clinical trial of family-based psychosocial treatment for PBD in a pediatric mood disorders clinic in a large, urban academic medical center. Seventy-one participants who met eligibility criteria were included in the study. Participants were included if they met criteria for a bipolar spectrum disorder (BP-I, BP-II, and BP Not Otherwise Specified (NOS)) according to DSM-IV-TR diagnostic criteria and if they were between the ages of 7 and 13. Youth were excluded from the study if they met any of the following criteria: IQ < 70 via the Kaufman Brief Intelligence Scale-Second Edition (KBIT-2; Kaufman & Kaufman, 2004), active, severe suicidality requiring immediate hospitalization, determined by the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011), or current psychosis, serious medical or neurological conditions, or a current diagnosis of substance abuse or dependence as measured by the Washington University Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS; Geller et al., 2001). In addition, youth were excluded if, at the time of enrollment, their primary caregiver was experiencing severe symptoms of depression or mania, evidenced by a score 28 on the Beck Depression Inventory II (BDI-II; Beck, Steer, & Brown, 1996) and a score >6 on the Altman s Self-Report of Mania (ASRM; Altman, Hedeker, Peterson, & Davis, 2001). B. Procedures 1. Diagnosis and Randomization 8
Youth between the ages of 7-13 were screened for a bipolar spectrum diagnosis. After meeting initial eligibility criteria and completing informed consent procedures, youth and their parents were independently interviewed by trained professionals using the Washington University Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS; Geller et al, 2001). Following conformation of a bipolar spectrum diagnosis, youth were assessed for inclusion and exclusion criteria. After enrollment, families completed a large battery of baseline measures that assessed child and parent psychological symptoms, child global functioning, as well as child, parent, and family psychosocial functioning. 2. Study Design Youth were randomly assigned via Research Randomizer software (Urbaniak & Plous, 1997) to child- and family-focused cognitive-behavioral therapy (CFF-CBT; n =35) or to psychosocial treatment as usual (TAU; n = 36) and then proceeded with the study protocol. In the CFF-CBT treatment group, participants were assigned a clinician in the specialty mood disorders clinic who had been trained to administer the manual-based CFF-CBT treatment. Those in the TAU treatment group worked with a clinician from the general psychiatry clinic who was not trained in CFF-CBT. All participants, regardless of treatment group, received medication management from a psychiatrist at the clinic, but medication changes were not specifically made as part of the study design. Any changes in medication were documented throughout treatment. Both groups received a total of 12 weekly sessions of treatment (the acute phase) and 6 monthly maintenance sessions. Blind raters completed assessments at 4, 8, and 9
12 weeks and at the 6-month follow-up session. The present study utilizes baseline measures of child, parent, and family functioning. C. Measures 1. Measures of Parent Functioning a. Parental Stress Scale (PSS) The PSS (Berry & Jones, 1995) is a well-validated and reliable measure of parent stress that captures positive and negative aspects of parenting, including feelings about the parent-child relationship. Parents rate 18 items on a 5-point scale ranging from 1 ( strongly disagree ) to 5 ( strongly agree ), and responses are summed across the items to create a total score. Sample items include I enjoy spending time with my child and I feel overwhelmed by the responsibility of being a parent. Scores from the PSS were correlated with other commonly used parenting measures, such as the Parental Stress Index (Abidin, 1995). In our sample, internal consistency of the PSS was good (α =.89). b. The Coping Health Inventory for Parents (CHIP) The CHIP (McCubbin & Thompson, 1991) is a parent-report measure that assesses parents perceptions of their ability to manage family life in the context of caring for a child who is severely and/or chronically ill. All scores are summed to create a total coping score, and particular items are summed to create 3 subscales of coping skills: (1) maintaining family integration, cooperation, and an optimistic definition of the situation; (2) maintaining social support, self-esteem and psychological stability; and (3) understanding the 10
medical situation through communication with other parents and consultation with medical staff. Examples of items include Trying to maintain family stability and Becoming more self-reliant and independent. All responses are rated on a 4-point Likert scale ranging from 0 (not helpful) to 3 (extremely helpful). In our sample, internal consistency for the total coping score was excellent (α =.95), and good for the 3 coping subscales: Coping 1 (α =.89); Coping 2 (α =.89); and Coping 3 (α =.84). c. Therapy Outcome Parents Scale (TOPS) The TOPS (West et al., 2009) measures parents knowledge of their child s illness and their self-efficacy regarding their ability to cope with having a child with bipolar disorder. This 20-item face-valid measure was developed for this study. Parents rate each item on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Responses are summed with higher scores indicating greater perceptions of self-efficacy and knowledge. Sample items include: I feel confident in my ability to spot the early warning signs of out of control behavior in my child and I encourage the use of positive selfstatements in my child and try to discourage negative thoughts. This measure has demonstrated good internal consistency in this sample (α =.84). d. Symptom Checklist 90-Revised (SCL-90-R) The SCL-90-R (Derogatis, 1996) is a reliable and valid instrument for the assessment of a broad range of psychological problems and symptoms of psychopathology in adults. The SCL-90-R captures 9 symptom dimensions, 11
including psychological symptoms of somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism, and also provides three global index scores that reflect global psychological distress (Global Severity Index), symptom intensity (Positive Symptom Distress Index), and the number of psychological symptoms (Positive Symptom Total). The Global Severity Index is used in the present study as an indicator of parent psychological distress. Parents rated 90 items on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). Items included: Feeling lonely and Worrying too much about things. Internal consistency for the Global Severity Index in this sample was excellent (α =.98). 2. Measures of Child Symptom Severity a. Child Mania Rating Scale (CMRS) The CMRS, parent version (West, Celio, Henry, & Pavuluri, 2011) measures the severity of child mania symptoms according to DSM-IV-TR diagnostic criteria. Parents rate their child on 21 items on a 4-point Likert scale ranging from 0 (never) to 3 (very often). Item content reflect symptoms of mania, including elevated, expansive, or irritable mood, excessive energy, decreased need for sleep, pressured speech, inflated self-esteem, racing thoughts, distractibility, and risky or hypersexual behavior. Responses are summed across all items to create a total score, and scores > 20 indicate clinically significant symptoms. In our sample, the alpha coefficient for the CMRS is.88, indicating good internal consistency. 12
b. Child Bipolar Depression Rating Scale (CBDRS) The CBDRS, parent version (West et al., 2014) is a parent-report measure of child depression symptoms based on DSM-IV-TR criteria. Parents rate their child on 22 items on a 4-point Likert scale ranging from 0 (never) to 3 (very often). Several examples of items include: Problems with sleeping too much, Appear to have lost weight or have a decreased appetite, and Feel depressed, sad or empty, or appear tearful or irritable for several days. This measure has strong reliability in our sample (α =.88). 3. Measures of Family Functioning a. The Family Adaptability and Cohesion Evaluation Scale (FACES) The FACES-IV (Olson, 2011) is a measure completed by the parent to assess aspects of family interactions, especially family flexibility and cohesion. The FACES is comprised of eight subscales that reflect dimensions of cohesion and flexibility within the family unit: (1) balanced cohesion, (2) balanced flexibility, (3) disengaged, (4) enmeshed, (5) rigid, (6) chaotic, (7) family satisfaction, and (8) family communication. Parents rate responses to 62 items on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Items include: It is hard to know who the leader is in our family and Our family tries new ways of dealing with problems. Internal consistency in this sample was excellent for the family satisfaction subscale (α =.93), good for the cohesion (α =.83), chaotic (α =.83), and family communication (α =.87) subscales, and acceptable for the flexibility (α =.75) 13
and disengaged (α =.77) subscales. The enmeshed (α =.55) and rigid subscales (α =.57) had poor internal consistency. b. Family Crisis Oriented Personal Evaluation Scales (F-COPES) The F-COPES (McCubbin, Olson, & Larsen, 1991) is a reliable and valid assessment of family problem-solving attitudes and behavioral strategies implemented in response to difficult situations. Parents rate each item on a 5- point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores are summed across all 30 items to create a total family coping score, and subscales are created by summing scores on items within each of the 5 subscales of family coping: (1) acquiring social support; (2) reframing of one s circumstances (3) seeking spiritual support; (4) mobilizing family to acquire and accept help; and (5) passive appraisal. Sample items include: Seeking encouragement and support from friends and Accepting stressful events as a fact of life. The total score and subscales demonstrated good or acceptable consistency in this sample: total family coping (α =.83); acquiring social support (α =.78); reframing of one s circumstances (α =.75); seeking spiritual support (α =.87); mobilizing family to acquire and accept help (α =.77); and passive appraisal (α =.70). 4. Outcome Measures For logistic regression analyses, the dependent variable was youth s pretreatment dropout status (0 = started treatment, 1 = dropped out pre-treatment). For survival analyses, the dependent variable in this analysis is the duration of treatment, measured as the number of weeks elapsed between the start and end 14
of treatment. Dropout from treatment was the event of interest, with dropouts coded as 1. Censored cases were youth who had not dropped out of the acute phase of treatment by the end of the study period. D. Analytic Approach Analyses were performed using SPSS 23.0 for Mac. Predictors included 2 child symptoms (mania and depression), 4 parent characteristics (stress, coping skills, psychological symptoms, and self-efficacy), and 2 family functioning measures (coping, adaptability and cohesion). To examine predictors of pre-treatment dropout, separate hierarchical logistic regression analyses modeled the effects of each predictor on pretreatment dropout (0=began treatment, 1=dropped out pre-treatment). All participants (n=71) were included in these analyses. In addition, survival analyses were completed to examine predictors of time to dropout during the course of treatment. Separate hierarchical Cox proportional hazard regressions analyses were performed to model the effects of each child, parent, and family characteristic, and their interactions with treatment assignment, on dropout among families who initiated treatment. All families who attended at least one treatment session (n=60) were included in survival analyses. We were interested in examining the unique contributions of baseline indicators of parent, child, and family functioning as predictors of dropout during the course of treatment. Therefore, these predictors were entered in step 1 of each model, treatment assignment was entered in step 2, and the predictor by treatment assignment interaction was entered in step 3 of each model. All predictors were centered at their means. Treatment assignment was dummy coded, and TAU was designated as the reference group. 15
III. Results A. Preliminary Analyses All variables were examined to determine if they were normally distributed. The Global Severity Index score of the SCL-90-R was positively skewed. This variable was transformed using a square root transformation, and the square root transformed variable was retained in all subsequent analyses. Chi-square, and t-tests were conducted to examine relationships between demographic variables (child age, gender, and race; family income) and treatment assignment. Age, gender, race, and family income were not related to treatment assignment (all p s >.39). In addition, analyses were conducted to examine associations between demographic variables and the two outcome measures. No significant associations emerged between demographic variables and pre-treatment dropout status (all p s >.06). Univariate Cox proportional hazard regression models examined demographic controls such as age, gender, and ethnicity on prediction of time to dropout. None of the demographic controls were significantly related to dropout (all p s >.19), and since there were no specific hypotheses about the relationship between demographic variables and time to dropout, these variables were not included in subsequent analyses. In addition, for Cox proportional hazards regressions, analyses were conducted to assess for violations of the proportional hazards assumption. Results indicated that the assumptions of proportional hazards were met for each predictor. 16
B. Descriptive Statistics Table I includes baseline demographic and clinical characteristics of the study sample by treatment assignment. Table II presents descriptive statistics for all predictor and outcome measures. Table I. Baseline Demographics and Clinical Characteristics of Youth with Pediatric Bipolar Disorder, n = 71 CFF-CBT (n = 35) TAU (n =36) M SD M SD Age 9.23 1.91 9.11 1.26 N % N % Sex (female) 16 46 13 36 Race White 19 54 19 53 Black 11 31 10 28 Hispanic 4 11 3 8 American Indian or Alaskan Native 0 0 3 8 Other 1 3 0 0 Family Income (<50, 000) 12 43 12 39 Diagnosis Bipolar I 8 23 15 42 Bipolar II 2 6 2 6 Bipolar NOS 25 71 19 53 Comorbid Diagnoses Anxiety Disorder 12 38 12 34 ADHD 23 70 31 89 ODD 12 38 13 37 CD 3 10 3 9 Note. Where data points were missing, percentages are calculated based on total number of available cases. *Denotes group differences, p <.05 on t-test or chi-square analyses. 17
Table II. Descriptive Statistics for Predictor and Outcome Measures, n = 71 CFF-CBT n = 35 TAU n = 36 Predictors M SD M SD Child Functioning Child Mania Rating Scale** 19.80 8.46 26.63 11.07 Child Bipolar Depression Rating Scale 17.75 9.63 20.45 10.45 Parent Functioning Parental Stress Scale 47.03 11.47 42.32 11.33 Coping Health Inventory for Parents 83.17 25.11 80.61 27.48 Total Coping 1 a 37.51 10.14 37.03 12.60 Coping 2 b 30.00 11.61 28.50 11.45 Coping 3 c 15.66 5.88 15.08 5.98 Therapy Outcome Parents Scale 69.61 10.37 71.77 11.59 Symptom Checklist 90-R.57.60.47.57 Family Functioning FACES Cohesion 27.68 4.43 29.06 4.66 Flexibility 25.79 4.25 25.71 5.47 Disengaged 15.38 4.08 13.32 5.13 Enmeshed 13.94 3.73 13.03 3.71 Rigid 21.06 3.82 20.22 4.16 Chaotic 15.47 5.21 14.50 5.41 Family Satisfaction 31.29 7.14 32.76 9.95 Family Communication 36.03 6.11 36.35 7.73 FCOPES 98.01 12.77 102.72 14.18 Acquiring Social Support 27.02 6.75 28.19 6.50 Reframing 27.90 4.93 28.43 5.52 Seeking Spiritual Support 12.81 4.83 13.91 4.20 Mobilizing Family for Help 15.12 3.28 15.57 3.44 Passive Appraisal 15.14 3.78 16.61 2.72 Outcome Measures N % N % Dropouts Pre-Treatment 3 9 8 22 Dropouts During Treatment d 5 16 10 36 + p <.10, * p <.05, **p <.01 a Coping 1 = maintaining family integration, cooperation, and optimism b Coping 2 = maintaining social support, self-esteem, and psychological stability c Coping 3 = communication with other parents and consultation with medical staff d Survival analyses included n = 60 youth (n CFF-CBT =32 ; n TAU =28) who started treatment 18
Among the full sample of 71 youth, treatment conditions were equivalent on baseline functioning measures with one exception: youth in TAU had significantly higher levels of manic symptoms relative to youth in CFF-CBT, which was reported previously (West et al., 2014). Among the 60 youth who initiated treatment, results indicated that treatment conditions were equivalent at baseline with 3 exceptions: (1) a greater proportion of youth in TAU had comorbid ADHD relative to CFF-CBT, χ 2 (1) = 5.75, p =.02; (2) baseline levels of parent stress were higher in CFF-CBT relative to TAU, t(57) = 2.38, p =.02; and (3) youth in TAU had significantly higher manic symptoms at baseline than those in CFF-CBT, t(57) = -3.46, p =.001. Analyses examined whether group differences in these measures at baseline (e.g. presence of comorbid ADHD, PSS scores, CMRS scores) were related to outcome. Neither the presence of comorbid ADHD, nor parental stress scores or child mania symptom levels were related to outcome (all p s >.21). Therefore, subsequent analyses did not control for these baseline differences. C. Predictors of Pre-Treatment Dropout A series of standard logistic regression analyses examined the effects of baseline indicators of parent, child, and family functioning on pre-treatment dropout across treatment conditions. Results are presented in Table III. There was a trend for parent psychopathology to positively predict the likelihood of dropout prior to treatment (OR = 4.56, 95% CI = 0.83, 25.13), indicating that for each unit increase in the parent s Global Severity Index score, the odds of dropping out prior to treatment increases by a factor of 4.56. No additional indicators of baseline parent, child, or family functioning predicted pre-treatment dropouts (all p s >.09). 19
Table III. Results of Standard Logistic Regressions Predicting Pre-Treatment Dropout as a Function of Baseline Characteristics, n = 71 Variable B SE OR 95% CI Parent Functioning PSS.04.03 1.04 0.98-1.09 CHIP -.01.01.99 0.96-1.01 Coping 1 -.02.03.98 0.93-1.03 Coping 2 -.05.03.96 0.91-1.01 Coping 3 -.02.05.98 0.88-1.09 TOPS -.04.03.96 0.90-1.02 SCL-90-R GSI + 1.52.87 4.56 0.83-25.13 Child Functioning CMRS.01.03 1.01 0.95-1.07 CBDRS.03.03 1.03 0.96-1.10 Family Functioning FACES Cohesion.10.09 1.11 0.94-1.31 Flexibility.01.07 1.01 0.88-1.16 Disengaged -.09.08 0.91 0.77-1.07 Enmeshed.03.09 1.03 0.87-1.22 Rigid.01.08 1.01 0.86-1.19 Chaotic -.02.06.99 0.87-1.12 Family Satisfaction -.02.04.98 0.91-1.05 Family Communication.02.05 1.02 0.93-1.13 FCOPES.00.02 1.00 0.96-1.05 Acquiring Social Support -.02.05.98 0.89-1.08 Reframing -.08.06.93 0.82-1.05 Seeking Spiritual Support.04.08 1.05 0.90-1.21 Mobilizing Family for Help.19.12 1.21 0.95-1.54 Passive Appraisal.13.12 1.14 0.90-1.44 + p <.10, * p <.05, D. Dropout During Treatment Comparison of survival curves using Kaplan-Meier survival analysis was used to estimate patterns of dropout among youth in CFF-CBT and TAU during the acute phase of treatment. Among the 60 youth who began treatment, 15 youth (25%) dropped out during the course of treatment (n TAU = 10; n CFF-CBT = 5). As depicted in Figure 1, youth in CFF-CBT had a marginally lower likelihood of dropout during the acute phase of 20
treatment than youth in TAU (Log-Rank [1 df ] = 3.40, p =.07). Because the survival probability did not drop below 0.5 in either treatment, the median week of dropout could not be reliably estimated among youth in CFF-CBT or TAU. Figure 1. Cumulative Survival for youth in CFF-CBT and TAU. E. Effects of Parent Functioning on Dropout During Treatment Results of models examining the effects of parent functioning, and their interactions with treatment assignment, as predictors of dropout are presented in Table IV, including the change in -2 log likelihood for each step of the models. 21
1. Parent Stress. A hierarchical Cox regression analysis was conducted to model the effects of baseline parent stress on likelihood of dropout. In step 1, baseline PSS scores were not a unique predictor of dropout before controlling for the significant group differences in these scores. In step 2, a significant relationship between treatment assignment and dropout emerged (HR =.22; 95% CI = 0.06, 0.78), indicating that families in CFF-CBT had a lower probability of dropout compared to families in TAU. Controlling for group differences in baseline PSS scores, families with higher levels of parent stress were marginally more likely to dropout of treatment (HR = 1.04; 95% CI = 0.99, 1.10). In step 3, the interaction between parent stress and treatment assignment was not significant, indicating that baseline levels of parent stress influenced dropout similarly across treatments. 2. Parent Coping Skills. A hierarchical Cox proportional hazard regression analysis modeled the effects of total parent coping skills at baseline on likelihood of dropout. In step 1, parent coping skills, as measured by the CHIP, were not independently associated with dropout. In step 2, assignment to CFF-CBT was marginally associated with a decreased probability of dropout (HR =.32; 95% CI = 0.10, 1.04). In step 3, the interaction of parent coping skills and treatment assignment was significant (HR = 1.07; 95% CI = 1.00, 1.15), indicating that among parents in CFF-CBT, the probability of dropout increased as parent coping skills increased. There was no effect of parent coping skills on likelihood of dropout among parents in TAU. 22
We also explored the effects of three specific patterns of parent coping behaviors using the subscales of the CHIP as predictors of dropout. In step 1, the inclusion of the coping subscale of family integration, cooperation, and optimism (Coping 1) was not statistically significant, indicating that this pattern of parent coping behaviors at baseline was not independently related to dropout. In Step 2, the main effect of treatment assignment was marginally significant (HR =.35, 95% CI = 0.11, 1.13). In step 3, the interaction term was marginally significant (HR = 1.16; 95% CI = 0.98, 1.38), indicating a possible positive relationship between parent s perception of family integration, cooperation, and optimism and likelihood of dropout among families in CFF-CBT. There was no association between these coping behaviors and dropout in TAU. In the second Cox regression model, parent s coping skills as evidenced by their ability to maintain social support, self-esteem, and psychological stability (Coping 2) did not demonstrate a significant main effect on time to drop out in step 1. In Step 2, treatment assignment was marginally significant (HR =.31, 95% CI = 0.10, 1.00), indicating that families in CFF-CBT were marginally less likely to drop out from treatment. In step 3, there was a trend for an interaction between parent s perceptions of their ability to maintain social support, selfesteem, and psychological stability and treatment assignment on dropout (HR = 1.15, 95% CI = 0.98, 1.36). This finding suggests that as parent s perceptions of their ability to maintain social support, self-esteem, and psychological stability increased, families in CFF-CBT were marginally more likely to dropout of treatment relative to TAU families. 23
The third Cox regression model for parent coping examined the CHIP subscale that assesses parents understanding of the medical situation through communication with other parents and professionals (Coping 3). In Step 1, Coping 3 was not related to dropout. In Step 2, assignment to CFF-CBT was associated with a marginally lower probability of dropout (HR =.31; 95% CI = 0.10, 1.00). In Step 3, the interaction between Coping 3 at baseline and treatment assignment was borderline statistically significant (HR=1.41, 95% CI = 0.95, 2.10), indicating that among parents in CFF-CBT, increases in parents perceptions of their ability to understand the medical situation through communication with others were associated with a marginally greater likelihood of dropout, but this relationship was not significant among parents in TAU. 3. Parent Self-Efficacy and Knowledge. An analysis using Cox proportional hazard regression modeled the effects of parents perceptions of their knowledge and self-efficacy regarding their child s illness at baseline on dropout. In step 1, results from the TOPS indicated that the effect of parent's perceptions of their self-efficacy and knowledge on dropout was not significant. In step 2, the main effect of treatment assignment was marginally significant (HR =.32; 95% CI =.10, 1.02), indicating that families in CFF-CBT were marginally less likely to dropout of treatment relative to families in TAU. In step 3, the interaction of treatment assignment and parent self-efficacy and knowledge was not significant, indicating that parents perceptions of their self-efficacy and knowledge at baseline influenced the likelihood of dropout similarly in both treatments. 24
4. Parent Psychopathology. Hierarchical Cox proportional hazard regression analysis modeled the effects of baseline parent psychological distress on dropout. In step 1, parent global psychological distress, as measured by the Global Severity Index of the SCL-90-R, was not a significant predictor of dropout. In step 2, there was a marginally significant main effect of treatment assignment (HR =.34; 95% CI = 0.11, 1.11), again indicating that assignment to CFF-CBT is associated with a marginally lower likelihood of dropout compared to TAU. In step 3, dropout was not significantly predicted by the interaction of global psychological distress and treatment assignment. 25
Table IV. Results of Hierarchical Cox Regressions Predicting Dropout as a Function of Parent Characteristics and Treatment Assignment, n = 60 Step 1 Step 2 Step 3 Variable B HR 95% CI B HR 95% CI B HR 95% CI Parent Stress (PSS) PSS Total.02 1.02 0.98-1.06.04 + 1.04 0.99-1.10.07* 1.07 1.00-1.14 Treatment Assignment -1.53*.22 0.06-0.78-1.29*.28 0.08-0.93 PSS Total x Tx Assignment -.06.94 0.85-1.05-2 Log Likelihood 101.59 95.33* 94.08 Parent Coping Skills (CHIP) CHIP Total.02 1.02 1.00-1.05.02 + 1.02 1.00-1.05.01 1.01 0.98-1.04 Treatment Assignment -1.13 +.32 0.10-1.04-2.20*.11 0.02-0.84 CHIP Total x Tx Assignment.07* 1.07 1.00-1.15-2 Log Likelihood 100.74 + 96.72* 92.25* Coping 1.03 1.04 0.98-1.09.03 1.03 0.98-1.09.01 1.01 0.96-1.07 Treatment Assignment -1.04 +.35 0.11-1.13-1.78 +.17 0.03-1.02 Coping 1 x Tx Assignment.15 + 1.16 0.98-1.38-2 Log Likelihood 101.99 98.55 + 94.99 + Coping 2.04 1.05 0.99-1.10.05 + 1.05 1.00-1.11.03 1.03 0.97-1.10 Treatment Assignment -1.18 +.31 0.10-1.00-2.13*.12 0.02-0.90 Coping 2 x Tx Assignment.14 + 1.15 0.98-1.36-2 Log Likelihood 100.96 96.63* 93.39 + Coping 3.10 1.10 0.98-1.23.11 + 1.12 0.99-1.27.05 1.05 0.93-1.19 Treatment Assignment -1.17 +.31 0.10-1.00-2.58 +.08 0.01-1.09 Coping 3 x Tx Assignment.34 + 1.41 0.95-2.10-2 Log Likelihood 100.51 + 96.24* 92.08* Parent Knowledge & Self-Efficacy (TOPS) TOPS Total -.01.99 0.94-1.04 -.01.99 0.94-1.04 -.01.99 0.94-1.04 Treatment Assignment -1.14 +.32 0.10-1.02-1.14 +.32 0.10-1.03 TOPS Total x Tx Assignment.00 1.00 0.90-1.12-2 Log Likelihood 102.19 98.05* 98.05 Parent Psychopathology (SCL-90-R) SCL-90-R -1.24.29 0.05-1.82-1.05.35 0.05-2.58-1.69.18 0.01-3.48 Treatment Assignment -1.07 +.34 0.11-1.11-1.01.37 0.10-1.24 SCL-90-R x Tx Assignment 1.30 3.65 0.06-209.36-2 Log Likelihood 99.86 96.35 + 95.96 + p <.10, * p <.05, ** p <.01, *** p <.001 26
F. Effects of Child Symptom Severity on Dropout During Treatment The results of hierarchical Cox proportional hazard analyses examining the effects of child symptoms, and their interactions with treatment assignment, on prediction of time to dropout are presented in Table V, including the change in -2 log likelihood for each step of the models. 1. Child Mania Symptoms. A hierarchical Cox regression modeled the effects of baseline parent-reported child mania symptoms on the likelihood of dropout. In step 1, baseline CMRS scores were not associated with dropout. In step 2, treatment assignment was not a significant predictor of dropout. With the inclusion of treatment assignment to control for group differences in baseline CMRS scores, the level of child mania symptoms was still not a significant predictor of dropout. Finally, in step 3, the interaction of treatment assignment and baseline CMRS scores did not significantly predict dropout, indicating that the effect of CMRS scores on dropout was consistent across treatments. 2. Child Depression Symptoms. An analysis using hierarchical Cox regression examined the effects of baseline parent-reported child depression symptoms on dropout. In step 1, baseline CBDRS scores were not significantly associated with dropout. In step 2, treatment assignment was marginally associated with dropout (HR =.33; 95% CI = 0.10, 1.07), indicating that families in CFF-CBT were marginally less likely to dropout of treatment than those in TAU. In step 3, dropout was not significantly predicted by the interaction of baseline CBDRS scores and treatment assignment, indicating that child depression symptomatology influenced dropout similarly in CFF-CBT and TAU. 27
Table V. Results of Hierarchical Cox Regressions Predicting Dropout as a Function of Child Symptoms and Treatment Assignment, n = 60 Step 1 Step 2 Step 3 Variable B HR 95% CI B HR 95% CI B HR 95% CI Child Mania Symptoms (CMRS) CMRS.03 1.03 0.98-1.09.01 1.01 0.96-1.07.02 1.02 0.96-1.08 Treatment Assignment -1.02.36 0.11-1.25-1.04.35 0.10-1.28 CMRS x Tx Assignment -.02.98 0.86-1.12-2 Log Likelihood 100.79 98.00 + 97.89 Child Depression Symptoms (CBDRS) CBDRS.02 1.02 0.97-1.08.01 1.01 0.96-1.07.02 1.02 0.96-1.08 Treatment Assignment -1.10 +.33 0.10-1.07-1.09 +.34 0.10-1.10 CBDRS x Tx Assignment -.01.99 0.87-1.11-2 Log Likelihood 101.84 98.03 + 97.98 + p <.10, * p <.05, ** p <.01, *** p <.001 28
G. Effects of Family Functioning on Dropout During Treatment The results of hierarchical Cox proportional hazard analyses examining indicators of family functioning, and their interactions with treatment assignment, on dropout are presented in Tables VI and VII, including the change in -2 log likelihood for each step of the models. 1. Family Adaptability and Cohesion. Hierarchical Cox proportional hazard regression analyses examined the effect of each subscale of the FACES on dropout. In step 1, results from each of the FACES subscales indicated that none of the dimensions of family adaptability and cohesion significantly predicted dropout. In step 2, treatment assignment was marginally associated with dropout in each analysis, with the exception of the Chaotic subscale of the FACES. In analyses involving the Chaotic subscale, treatment assignment significantly predicted dropout (HR = 0.31; 95% CI = 0.10, 0.99), indicating that assignment to CFF-CBT is associated with a lower likelihood of dropout relative to TAU. In step 3, interactions of treatment assignment and each of the subscales were not significant, indicating that aspects of family flexibility and cohesion at baseline influenced dropout similarly across treatments. 2. Family Coping. A series of Cox regression analyses examined the effects of total family coping abilities, as well as specific dimensions of family coping skills at baseline, on dropout. In step 1, results from the F-COPES indicated that total family coping (F-COPES total), and the mobilizing family for help, passive appraisal, seeking spiritual support, and acquiring social support subscales were not unique predictors of dropout. However, results from the reframing subscale of 29