Family problem solving interactions and 6-month symptomatic and functional outcomes in youth at ultra-high risk for psychosis and with recent onset psychotic symptoms: A longitudinal study
Introduction
Impaired social functioning is a diagnostic feature of schizophrenia and is present early in the course of illness (Addington et al., 2008). Many children and adolescents who go on to develop schizophrenia later in life show deficits in social skills from an early age (Schiffman et al., 2004). In a multi-site longitudinal study, greater social impairment was one of five features that contributed uniquely to the prediction of psychosis in youths at ultra high risk (UHR) (Cannon et al., 2008). Relatively little is known, however, about the nature of social deficits evaluated prospectively among UHR youth.
Studies indicate that interpersonal negativity and associated ineffective problem solving are related to poor adolescent social adjustment (McCombs et al., 1988), while prosocial problem-solving strategies and prosocial behavior predict social acceptance among adolescent peers (Pakaslahti et al., 2002). The inability to effectively solve everyday problems creates a significant challenge to healthy adolescent and family development (Coyne and Downey, 1991). Given the importance of interpersonal negativity and ineffective problem solving for adolescent social adjustment, these may be important skills to examine in vulnerable adolescent populations, such as UHR youth. Social problem solving skills may be a protective factor in the vulnerability-stress-protective factors model of schizophrenia (Kopelowicz et al., 2006).
Studies have found that individuals with schizophrenia are deficient in their ability to generate solutions to problems, to evaluate the effectiveness of solutions, and to implement solutions when compared to demographically matched healthy controls (Bellack et al., 1994, Stalberg et al., 2008). In turn, problem solving abilities are associated with social skills (Penn et al., 1995, Silverstein et al., 1998), successful functioning in the community (Jaeger and Douglas, 1992) and work performance (Bellack et al., 1999). In one of the few prospective studies of problem solving behavior among disturbed but non-psychotic adolescents, youth who used positive or neutral voice tones during a five minute problem solving discussion with their parent tended to show adequate psychosocial adjustment as young adults, while those using exclusively negative voice tones tended to show sufficient adjustment difficulties in early adulthood to warrant diagnoses within the extended schizophrenia spectrum (Asarnow et al., 1982).
The main goal of the current study was to examine prospectively the relationship between social problem solving behavior exhibited by youths at UHR for psychosis and with recent onset psychotic symptoms, and youths' future symptoms and social functioning. The current study utilizes observations of parent–adolescent interactions rather than relying on self- or other-report, so that youths' current skills can be measured directly in a highly relevant social context. We predicted that youths' social problem solving skills and constructive approach to problem-solving discussions with parents would be positively associated with social functioning with peers and with symptom improvement. Conversely, we predicted that youths' conflictual approaches to problem solving discussions would be associated with poorer social functioning with peers and with symptom exacerbation.
The second goal of the current study was to examine the relationship between parent problem solving behavior and UHR and early onset youths' symptoms and social functioning. Contemporary theories (for reviews see Kavanagh, 1992), as well as research evidence from adoption (Tienari et al., 2004), expressed emotion (Butzlaff and Hooley, 1998), and treatment studies (Pitschel-Walz et al., 2001, Smith and Birchwood, 1987) indicate that family environment plays a key role in the evolution of symptoms of psychosis. Research utilizing the Camberwell Family Interview (CFI) with key relatives of adolescent UHR patients found that positive family characteristics, such as parent warmth and involvement, predict reductions in adolescent negative symptoms and enhanced social functioning three months later (O'Brien et al., 2006). Although informative, these results are limited to attitudes expressed by family members and do not address actual family interactions. Observational methods have been crucial to the development of innovative family therapies for many youth disorders, such as externalizing behavior problems, substance abuse, depression, and ADHD (Patterson, 1982, Liddle, 2004, Danforth et al., 1991). Evaluations of the relationship between parents' problem solving approaches and youths' social functioning and symptom progression could inform early intervention efforts with UHR youth and their families. Despite the fact that problem solving skills training is included in many early interventions (McGlashan et al., 2007), to the best of our knowledge, this is the first study to examine the relationship between specific UHR/recent onset youth and parent problem solving behaviors demonstrated during interactions and the progression of youths' symptoms and functional outcome over time. We expected that parents' skillful and constructive approaches to discussions would be positively associated with youths' social functioning and symptom improvement, while parents' conflictual approaches would be associated with poorer social functioning and symptom exacerbation in at-risk adolescents.
Finally, we predicted that parent problem solving skills and constructive communication would be positively associated with adolescent problem solving skills and constructive communication given the large literature on family members' reciprocal influences on each other (Hamilton et al., 1999, Patterson, 1982, Patterson and Fisher, 2002) and previous work on the relationship between warm family interaction style and adolescents' constructive problem solving behavior (Rueter and Conger, 1995). Similarly, we expected positive associations between parent and adolescent conflictual communications.
Section snippets
Subjects
English speaking individuals, aged 12 to 35 years, were recruited to participate in the Staglin Music Festival Center for the Assessment and Prevention of Prodromal States (CAPPS), a clinical research center at the University of California, Los Angeles that identifies youth who are at high risk for developing psychosis, assesses them longitudinally, and offers psychiatric and psychosocial treatment. After anonymous phone screening, parents and patients signed informed consent/assent documents
Results
Pearson correlations were utilized to test hypotheses, and one-tailed tests were selected because all hypotheses predicted a particular direction to the relationship.
First, in order to evaluate the convergent validity of the problem solving interaction codes, Pearson correlations were conducted on the family assessment measures for each respondent. As presented in Table 3, adolescents were consistent in their communication across family interaction tasks. There was a significant positive
Discussion
As hypothesized, adolescents' social problem solving skills exhibited during problem solving discussions with their primary caregivers were associated with adolescents' enhanced social functioning six months later. In other words, adolescents' abilities to define problems, generate solutions, and move toward resolution when discussing issues that create tension between themselves and their parents were associated with more frequent social engagement with friends six months later. Similarly,
Role of funding source
This research was supported by the following grants: NARSAD Young Investigator Award (MPO), NARSAD Young Investigator Award (CEB), NIMH MH65079 (TDC), NIMH MH066286 (TDC), as well as donations from the Rutherford Charitable Foundation and Staglin Music Festival for Mental Health (TDC). These funding sources had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest
There are no conflicts of interest that influenced this work.
Contributors
Mary O'Brien, Jamie Zinberg, Alex Kopelowicz, and Ty Cannon designed the study and wrote the protocol. Mary O'Brien managed the literature searches, conducted the statistical analyses, and wrote the first draft of the manuscript. Carrie Bearden, Melita Daley, Lorena Ho, and Alexandra Rudd made major contributions to the data set. All authors contributed to and have approved the final manuscript.
Acknowledgements
The authors thank the patients and families who agreed to participate in this study. We are also indebted to the following project coordinators, treatment providers, interviewers, and research assistants: Sabrina Wright, Alison Greiner, LCSW, Caroline Miranda, LCSW, Derek Ott, MD, Joseph Pierre, MD, Zoe Martinez, MD, Jennifer Johnson, PhD, Stephanie Meyer, PhD, Rachel Loewy, PhD, Tara Niendam, PhD, Nicholas Breitborde, PhD, Christina Chang, PhD, Jorge Ramirez, PhD, Adrian Aguilera, MA, Anilga
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